How many inspection deficiencies does BELMONT TERRACE have?

BELMONT TERRACE has 92 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at BELMONT TERRACE?

BELMONT TERRACE has a three-star staffing rating from CMS with 0.85 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is BELMONT TERRACE located?

BELMONT TERRACE is located in BREMERTON, WA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does BELMONT TERRACE have?

BELMONT TERRACE has 102 certified beds.

Who owns BELMONT TERRACE?

BELMONT TERRACE is a for profit - limited liability company facility and is part of the THE ENSIGN GROUP chain.

What questions should families ask when visiting BELMONT TERRACE?

Families visiting BELMONT TERRACE should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does BELMONT TERRACE compare to other nursing homes?

BELMONT TERRACE has a 1-star overall rating, which is below average compared to other nursing homes in WA. Families should carefully review inspection findings and consider alternatives.

BELMONT TERRACE

Name: BELMONT TERRACE
Address: 560 LEBO BOULEVARD, BREMERTON, WA, 98310, US
Telephone: (360) 479-1515
Rating: 1.0

560 LEBO BOULEVARD, BREMERTON, WA 98310 · (360) 479-1515

For profit - Limited Liability company 102 Beds THE ENSIGN GROUP Data: November 2025

Trust Grade

33/100

#168 of 190 in WA

Share this report:

BELMONT TERRACE nursing home in BREMERTON, WA - Photo 1 of 5

BELMONT TERRACE nursing home in BREMERTON, WA - Photo 2 of 5

Photo by Ahavah Kaur

BELMONT TERRACE nursing home in BREMERTON, WA - Photo 3 of 5

Photo by Ahavah Kaur

BELMONT TERRACE nursing home in BREMERTON, WA - Photo 4 of 5

Photo by Belmont Terrace

BELMONT TERRACE nursing home in BREMERTON, WA - Photo 5 of 5

1 / 5 photos

View 360° on Google Maps

Last Inspection: November 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Belmont Terrace in Bremerton, Washington, has received a Trust Grade of F, indicating significant concerns about the facility's overall quality and care. Ranking #168 out of 190 facilities in Washington places it in the bottom half, and #7 out of 9 in Kitsap County shows there are only two local options that are worse. Although the facility is trending towards improvement, reducing issues from 40 to 6 over the past year, it still exhibits serious concerns. Staffing is rated average with a 3/5 star rating and a turnover rate of 50%, which is close to the state average. However, there have been troubling incidents, such as a resident who fell and fractured a hip due to being left unattended in the bathroom and failures in infection control practices that put residents at risk for COVID-19. Overall, while there are some areas of improvement, the facility's serious deficiencies and poor ratings make it a concerning option for families.

Trust Score: F
In Washington: #168/190
Safety Record: Moderate
Inspections: Getting Better
Staff Stability: 50% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $9,750 in fines. Lower than most Washington facilities. Relatively clean record.
Skilled Nurses: Each resident gets 50 minutes of Registered Nurse (RN) attention daily — more than average for Washington. RNs are trained to catch health problems early.
Violations: 92 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★☆

4.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 40 issues

2025: 6 issues

The Good

4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

1-Star Overall Rating

Below Washington average (3.2)

Significant quality concerns identified by CMS

Staff Turnover: 50%

Near Washington avg (46%)

Higher turnover may affect care consistency

Federal Fines: $9,750

Below median ($33,413)

Minor penalties assessed

Chain: THE ENSIGN GROUP

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 92 deficiencies on record

1 actual harm

Apr 2025 6 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0660 (Tag F0660)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to develop a personalized discharge plan based on each residents' identified needs, goals, and preferences and implement it timely for 2 of 3 residents (6 & 8) reviewed for discharge planning. This failure placed residents at risk for delayed discharge, unmet care needs after discharge and a diminished quality of life. Findings included . <Resident 6> Resident 6 was admitted to the facility on [DATE] with diagnoses including a cognitive communication deficit. The quarterly Minimum Data Set (MDS/An assessment tool), dated 02/06/2025, documented Resident 6 had no cognitive impairment Care Plan, dated 07/31/2024, documented Resident 6 wished to return home with their son. Care Plan, dated 12/20/2024, document Resident 6 was waiting to discharge with their son until the Medicaid application was complete. Progress notes, dated 02/03/2025, showed Resident 6 was wanting to know discharge plans. The resident was told the Medicaid application was approved. No mention was made of discharge plans. Progress notes, dated 02/10/2025, documented Resident 6 wanted to go to an assisted living facility. The plan to go home with their son was not in their best interest, as their son had many health issues himself. The note showed social services would work with the State Agency to finding a location. On 04/01/2025 at 3:10 PM, Resident 6 said they did not know what their discharge plan was and wished staff would communicate the status of a community discharge location. Resident 6 was aware the State Agency was working to help find a location, but there had not been updates on when Resident 6 could discharge. Resident 6 said they did need some assistance but could do many things for themselves. At 4:22 PM, Staff C, Social Services, said they were working with the State Agency and the resident's Medicaid application had been approved. Staff C said they probably needed to update the resident more often and they would do this. Staff C said Resident 6's care plan should have been updated with the current discharge plans. At 4:35 PM, Staff B, Registered Nurse (RN) and Director of Nursing (DNS), said discharge care plans should have been updated. <Resident 8> Resident 8 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a lung disease with limits air flow and breathing) and respiratory failure. The significant change MDS, dated [DATE], documented Resident 8 has no continued impairment and required set up or was independent with activities of daily living (ADLs). Care plan, dated 01/29/2025, documented Resident 8 planned to stay long-term at the facility. On 02/28/2025 at 9:30 AM, Resident 8 said they wished to discharge home. Resident 8 feelt urgent about this as they were on hospice and did not want to die at the facility. Resident 8 appeared anxious and worried. Resident 8 said they would like to go home with their daughter. The resident had spoken with their daughter but needed help coordinating the discharge. Resident 8 said they would like staff at the facility to help them with the discharge. At 10:00 AM, Staff B, was informed of Resident 8's wishes to discharge home. At 10:30 AM, Staff A, Administrator, was informed of Resident 8's wishes to discharge home. No progress notes regarding Resident 8's wishes to discharge home were found. No discharge planning notes were made since the resident's statements. On 04/01/2025 at 4:22 PM, Staff C, social services, said she was not made aware of statements made by the resident. Staff C said she would have followed up had she known. Staff C said Resident 8's care plan and discharge plan should have been updated with the resident's current wishes. At 4:35 PM, Staff B, said he should have put a note in the record regarding Resident 8's discharge wishes. The resident should have discharge notes in the medical record and the care plan should have been updated. Reference WAC 388-97-0080 .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to accurately assess and identify a change in urinary incontinence, ensure a plan for treatment and services to restore as much normal bladder and/or bowel function as possible for 2 of 3 residents (5 & 6) reviewed for urinary incontinence. Failure to identify and assess/determine causative factors of urinary incontinence placed residents at risk for unmet care needs and decreased quality of life. Findings included . <Resident 5> Resident 5 was admitted to the facility on [DATE] with diagnoses including a fracture of the arm. The admission Minimum Data Set (MDS/an assessment tool), dated 01/28/2025, documented Resident 5 had no cognitive impairment and was frequently incontinent of urine. The Bowel and Bladder Evaluation, dated 01/31/2025, documented Resident 5 was continent of urine. No further assessment or interventions were implemented. Care Plan, dated 02/25/2025, documented Resident 5 was occasionally incontinent of bladder related to diuretic (medication that draws excess fluid from the body via urine) use, muscle weakness, urgency, and frequency. Staff will provide briefs for the resident and check the resident for incontinence. Progress notes, dated 01/31/2025, documented Resident 5 voiced concerns about staff assisting them to the toilet. The resident was able to maintain continence and brought themselves to the toilet. Progress note, dated 02/03/2025, documented Resident 5 was started on oxybutynin (a medication used to treat an overactive bladder) for frequent urination and bladder spasms. Progress notes, dated 02/04/2025, documented the resident was voiding nine times a shift. Progress notes, dated 02/19/2025, documented Resident 5 asked to discontinue the oxybutynin. During the resident's stay, no new reassessment or monitoring was implemented nor were appropriate interventions initaited for the resident. On 04/01/2025 at 4:35 PM, Staff B, Registered Nurse (RN) and Director of Nursing (DNS), could not indicate Resident 5's type of incontinence. Staff B said the facility did not reassess the resident or address the inconsistencies in Resident 5's bladder incontinence. <Resident 6> Resident 6 was admitted to the facility on [DATE] with diagnoses including a cognitive communication deficit. The quarterly MDS, dated [DATE], documented Resident 6 had no cognitive impairment and was frequently incontinent of urine. The Bowel and Bladder Evaluation, dated 02/06/2025, documented Resident 6 was continent of urine. No further assessment or interventions were implemented. Care Plan, dated 01/24/2025, lacked documentation related to Resident 6's bladder status. Progress notes, dated 02/10/2025, documented Resident 6 had a urinary tract infection requiring treatment. On 04/01/2025 at 3:50 PM, Staff D, Nursing Assistant, said Resident 6 was incontinent of urine. Sometimes the resident dribbled a small amount of urine and other times it was large amounts. The resident could bring themselves to the bathroom, but staff checked on Resident 6 due to incontinence. At 4:35 PM, Staff B, Registered Nurse (RN) and Director of Nursing (DNS), could not indicate Resident 6's type of incontinence. Staff B said the care plan was not updated. The facility did not reassess the resident nor address the inconsistencies in Resident 6's bladder incontinence. Reference WAC 388-97-1060 (3)(c) .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide pain management to adequately control residents pain for 1 of 3 sampled residents (1) when reviewed for pain management. This failure put residents at risk of uncontrolled pain and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with respiratory failure and chronic obstructive pulmonary disease (a lung disease with limits air flow and breathing). On 02/27/2025 at 3:46 PM, Resident 1 said when they were discharged , the facility sent them with a large bag full of medication. It was very overwhelming for Resident 1 to be given a bag with many different medications. Because Resident 1 was so overwhelmed, they did not notice any concerns with their pain medication. Resident 1 discovered once home they were sent home with only three oxycodone (a narcotic pain medication). Resident 1 experienced pain until they could get to the appointment with their community provider. No prescription was sent with the resident, and they were not told they would only have three tablets of oxycodone. Physician orders, dated 01/15/2025, documented Resident 1 could take oxycodone every eight hours as needed. Progress notes, dated 01/16/2025, documented Resident 1 received oxycodone for back and abdominal pain. Provider notes, dated 01/17/2025, documented Resident 1 reported abdominal pains with some relief from oxycodone. Tenderness was found upon abdominal exam. The provider increased administration of oxycodone to every six hours as needed. Progress notes, dated 01/17/2025, documented Resident 1's pain originated in the chest from coughing. Provider notes, dated 01/20/2025, documented Resident 1 continued to complain of abdominal pain. Oxycodone was continued every six hours as needed. Progress notes, dated 01/20/2025, documented Resident 1's pain originated from osteoporosis. Doing art projects in room eased pain. The care plan, dated 01/25/2025, documented Resident 1 had acute pain from osteoporosis. Staff wwere to assess pain each shift, monitor pain quality and severity of pain, and document side effects from pain medication. The January 2025 Medication Administration Record (MAR), documented Resident 1 received one tablet of oxycodone two to three times a day during their stay the facility. The resident's pain ranged from a 4-7 on a scale of 1-10 (1 is mild pain and 10 is severe pain). The Discharge Resident Medication Transfer Record, dated 01/22/2025, documented Resident 1 was sent home with three oxycodone. No prescription was provided to the resident to ensure they had sufficient oxycodone until Resident 1 was assessed by their community provider. On 04/01/2025 at 4:35 PM, Staff B, Registered Nurse (RN) and Director of Nursing (DNS), said the resident did not get sufficient oxycodone upon discharge. Staff B said a prescription should have been sent with the resident, but Staff B was unable to locate a prescription. Staff B said a new staff member discharged Resident 1 and may have missed this. Reference WAC 388-97-1060 (1) .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to repeatedly implement antibiotic protocols to ensure antibiotics were appropriately prescribed for 1 of 3 sampled residents (1), reviewed for antibiotic use. This failure placed residents at risk of development of antibiotic-resistant organisms, adverse side effects, and diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with respiratory failure and chronic obstructive pulmonary disease. On 02/27/2025 at 3:46 PM, Resident 1 said when they were sent home they were sent with a large bag full of medications. They did not know what all of the medications were for, and it was very confusing. Resident 1 went to their doctor and went through everything. They found two antibiotics that had many pills left. Resident 1 said they were never told to discontinue the medication but thinks they should have since they were getting these medications in the hospital. Resident 1 said it was very confusing. The Hospital Discharge summary, dated [DATE], documented Resident 1 should take cefuroxime (antibiotic), twice daily, for 14 doses. Resident 1 should take metronidazole (antibiotic), two times daily, for 14 doses. The Order Summary Report, dated 01/15/2025, documented the resident would receive cefuroxime twice daily and metronidazole two times daily. The medications did not have a date noted when the medications should be continued. The Discharge Resident Medication Transfer Record, dated 01/22/2025, documented Resident 1 was sent home with 46 tablets of cefuroxime and metronidazole. On 04/01/2025 at 4:35 PM, Staff B, Registered Nurse (RN) and Director of Nursing (DNS), said cefuroxime and metronidazole should have an end date noted and this should have been communicated upon discharge. No associated WAC. .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure the pneumococcal vaccine (used to prevent pneumonia and sepsis), was provided for 1 of 3 residents (1), reviewed for immunizations. This failure placed the resident at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from influenza disease. Findings included . Resident 1 was admitted to the facility on [DATE] with respiratory failure and chronic obstructive pulmonary disease. The Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination, dated 01/15/2025, documented Resident 1 wished to receive the pneumococcal vaccine. The documents were signed by the nurse on the same day. Review of Resident 1's electronic health record showed no documentation that Resident 1 was provided a pneumococcal vaccination. On 04/01/2025 at 4:35 PM, Staff B, Registered Nurse (RN) and Director of Nursing (DNS), said there was a consent signed from the resident indicating they would like the vaccine. Staff B said the vaccine was not given. Staff B said the vaccine should have been given. Reference (WAC) 388-97-1340 (1)(2) .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure the COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) vaccine was provided for 1 of 3 residents (1), reviewed for immunizations. The failure to provide the COVID-19 vaccination placed the resident at risk for contracting the COVID-19 virus and related complications. Findings included . Resident 1 was admitted to the facility on [DATE] with respiratory failure and chronic obstructive pulmonary disease. The Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination dated 01/15/2025, documented Resident 1 wished to receive the COVID-19 vaccine. The documents was signed by the nurse on the same day. Review of Resident 1's electronic health record showed no documentation that Resident 1 was provided a COVID-19 vaccination. On 04/01/2025 at 4:35 PM, Staff B, Registered Nurse (RN) and Director of Nursing (DNS), said there was a consent signed from the resident indicating they would like the vaccine. Staff B said the vaccine was not given. Staff B said the vaccine should have been given. No reference WAC .

Nov 2024 32 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and interview, the facility failed to respect and value the residents' private space by not knocking and/or announcing themselves for 3 of 4 sampled residents (Resident 19, 48 & 63) reviewed under resident rights for dignity. This failure placed residents at risk for being treated with lack of dignity and a diminished quality of life. Findings included . Facility policy titled Residents Rights, revised 11/23/2016, documented, The resident has a right to dignified existence, self-determination and communication with, and access to individuals and services inside and outside the Facility. On 11/04/2024 at 10:34 AM, Staff F, Certified Nursing Assistant (CNA), walked into room [ROOM NUMBER]B without knocking or announcing themself. At 10:46 AM, when asked about how staff show dignity to residents before entering a resident room, Staff F said knocking on the door and introducing myself. When asked if it was acceptable to walk in without knocking or announcing themselves, Staff F said no, I should have knocked. At 11:05 AM, Staff G, Housekeeping, walked into room [ROOM NUMBER]A without knocking or announcing themself. When asked about knocking and announcing, Staff G said I forgot. At 11:30 AM, while in an interview with Resident 19, Staff H, CNA/Shower Aid, walked into the room without knocking or announcing themself. Staff H observed Resident 19 in an interview, turned around and walked out of the room. At 3:12 PM, Staff G, Housekeeping, walked into to room [ROOM NUMBER] without knocking or announcing themself. On 11/12/2024 at 10:05 AM, Staff E, Resident Care Manager, said it is expected staff are knocking and/or announcing themselves before entering a resident's room. When multiple incidents reported of failure to knock and/or announcing before walking into a residents room, Staff E said that was not acceptable and we need to retrain. At 12:45 PM, Staff B, Director of Nursing Services, said staff were expected to knock and announce themselves before entering a resident's room. Staff B said this was not acceptable. WAC 388-97-0180 (2) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and interview, the facility failed to ensure that residents had signed consent prior to psychotropic (group of drugs to treat mental health conditions) medication administration and that residents had the correct risks and benefits provided, for 1 of 5 residents (Resident 21) reviewed for unnecessary medications. This failure placed residents at risk of receiving medication without knowledge of the medication or correct side effects, and a decreased quality of life. Findings included . Review of the Electronic Health Record (EHR) showed Resident 21 was admitted to the facility on [DATE]. Resident 21 had diagnoses of depression (overwhelming feeling of sadness and hopelessness) and dementia (condition affecting memory and thinking) with psychosis (detachment from reality). Review of the Annual Minimum Data Set, an assessment tool, dated 08/26/2024, showed Resident 21 was dependent on staff for care. <Consent Form> Resident 21 was prescribed risperidone, which is an antipsychotic medication (decreases thoughts and feelings that are not based on reality). Review of the EHR showed that consent was signed on 08/31/2023 for risperidone using an anticonvulsant (decreases seizure activity) form, 12/12/2023 for risperidone on an antianxiety (decreases stress) form, and then 05/3/2024 for risperidone on an antipsychotic form. Review of the three consent forms used for risperidone showed different common side effects were listed based on drug classification. The anticonvulsant consent form for Resident 21 listed most common side effects being: nausea/vomiting, appetite changes, sedation/drowsiness, dizziness, blurred vision. The antianxiety consent form listed frequent side effects being: drowsiness, dizziness, drunken walk, and disorientation. The antipsychotic consent form listed frequent side effects being: drowsiness, jaundice (yellowing of the skin), shakiness, blurred vision, restlessness, skin rash, dizziness, and urinary retention. During an interview on 11/13/2024 at 1:44 PM, Staff C, Resident Care Manager (RCM), said that Resident 21's consent forms with different classifications did not review the correct risks and benefits for risperidone. During an interview on 11/13/2024 at 9:04 AM, Staff B, Director of Nursing Services (DNS), said their expectation was that risperidone would be classified as an antipsychotic and that consent would have been signed for Resident 21 based on this classification. < Medication before Consent> Review of the EHR showed that Resident 21 signed consent for venlafaxine (an antidepressant) on 05/17/2024. Review of the administration record showed that Resident 21 had doses of venlafaxine before consent was signed, with administration starting on 05/03/2024. During an interview on 11/13/2024 at 1:44 PM, Staff C, RCM, reviewed the EHR, said Resident 21 received venlafaxine on 05/03/2024 and their expectation was that consent would have been obtained before the first dose of venlafaxine. During an interview on 11/13/2024 at 9:04 AM, Staff B, DNS, said their expectation was that prior to giving venlafaxine, the facility would have obtained consent for Resident 21. Reference WAC 388-97 -0300(3)(a), -0260, -1020(4)(a-b) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure resident choices regarding bathing frequency were honored for 2 of 4 residents (Residents 376 and 176) reviewed for choices. The facility's failure to accommodate resident preferences related to frequency and type of bathing placed residents at risk for feelings of un-cleanliness, powerlessness, diminished self-worth, and a decreased quality of life. Findings included . 1) Resident 376 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 11/05/2024, showed the resident was cognitively intact, required physical assistance with bathing, and choices related to bathing were identified as Very Important. On 11/04/2024 at 2:59 PM, Resident 376 reported that they were not asked how many or what type of bathing they preferred. Rather, upon admission they were informed they would get one shower a week on Sundays. Since I have been here, I have had one shower (resident made air quotes with her fingers.) All she did was put some stuff in my hair, didn't wash my back or legs or use soap. They just ran the water over me and that is it. That is not a shower. Resident 376 said they showered daily at home but indicated it would be acceptable if they were showered three times a week while at the facility. An activities of daily living (ADL) care plan, initiated 10/30/2024, directed staff to provide one person assistance with bathing weekly and as necessary. Resident 376's bathing record showed they were scheduled to be bathed/showered once a week on Sundays. Review of the electronic health record (EHR) showed there was no documentation present to show the facility promote or attempted to facilitate resident self-determination through support of resident choice. 2) Resident 176 admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively intact, required physical assistance with bathing, and choices related to bathing were identified as Very Important. On 11/04/2024 at 3:38 PM, Resident 176 said they were not asked about the type or frequency of bathing they preferred. The resident reported staff just informed them that they would be showered one day per week. Resident 176 said they preferred daily showers but while at the facility, they wanted one at least every three days. An ADL care plan, revised 10/30/2024, showed the resident required substantial assistance with bathing. The care plan did not identify the frequency of bathing. Resident 176's bathing record showed they were scheduled to be bathed/showered once a week. Review of the EHR showed there was no documentation present to show the facility promoted or attempted to facilitate resident self-determination through support of resident choice. On 11/12/2024 at 1:18 PM, Staff C, Resident Care Manager, said initially all residents were assigned one shower a week upon admission, but the frequency could be changed at resident request or during the initial care conference to their desired frequency. On 11/13/2024 at 12:41 PM, Staff B, Director of Nursing Services, said residents should be asked their desired method and frequency of bathing. When asked why Staff C, who was performing admissions, said residents were initially assigned one shower a week upon admission, but could be changed later if requested Staff B explained the facility had identified problems with the shower schedules so they went through and revised the schedules and used a default of one shower per week as a start off point. Then they would personalize the schedules over time based on residents' feedback. Reference WAC 388-97-0900 (1)(3) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of the EHR showed Resident 56 was admitted to the facility on [DATE]. Resident 56 had no active diagnosis of depression or mood disorders. Review of Resident 56's admission Level 1 PASRR, dated 09/13/2024, showed no serious mental illness indicators. Review of Resident 56's updated Level 1 PASRR, dated 09/18/2024, showed Resident 56 had a serious mental illness indicator, with mood disorder- depressive or bipolar selected. During an interview on 11/08/2024 at 8:39 AM, Staff C, RCM, said that Resident 56 did not have a diagnosis of depression on the diagnosis list and the Level 1 PASRR from 09/18/2024 was coded incorrectly. During an interview on 11/12/2024 at 4:14 PM, Staff B, DNS, said that the updated Level 1 PASRR for Resident 56, dated 09/18/2024, was not accurate. Reference WAC 388-97-1915 (1)(2)(a-c) Based on interview and record review the facility failed to ensure that the Pre-admission Screening and Resident Review (PASRR, a screening tool used to identify mental health needs) was accurate and a referral for Level II PASRR was sent in a timely manner for 2 of 5 sampled residents (Residents 60 and 56) reviewed for PASRR. This failure placed residents at risk for not receiving specialized mental health services, and a decreased quality of life. Findings included . 1) Resident 60 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool) dated 09/25/2024 documented that Resident 60 was cognitively intact and had a diagnosis of depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.) A Level I PASRR, dated 09/05/2024 documented that Resident 60 was diagnosed with anxiety disorders (mental health disorders characterized by intense, excessive, and persistent worry and fear about everyday situations.) Review of the Electronic Health Record (EHR) documented that Resident 60 was not diagnosed with anxiety but did have a diagnosis of depression. The Level I PASRR indicated that Resident 60 had an exempted hospital discharge which would not require a Level II evaluation due to anticipated stay of less than 30 days at the facility resident was to be transferred to. The Level I PASRR indicated that a Level II evaluation must be completed if discharge does not occur in 30 days. On 11/08/2024 at 12:24 PM, Staff I, Patient Advocacy Resource, said that a Level II PASRR referral was not sent until 11/06/2024 and it should have been sent 30 days after resident's admission on [DATE]. On 11/14/2024 at 2:42 PM, Staff C, Resident Care Manager (RCM), said that Resident 60 did not have a diagnosis of anxiety, but did have a diagnosis of depression. When asked if the Level I PASRR was accurate, Staff C said according to the EHR the Level I PASRR was inaccurate and it did not meet expectations that this was not identified. On 11/14/2024 at 2:48 PM, Staff B, Director of Nursing Services (DNS), said she did not see a diagnosis of anxiety in the EHR, but did see a diagnosis of depression and her expectation was for the Level I PASRR to match the diagnosis.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 25 sampled residents (Resident 56 and 126). This failure placed residents at risk for unidentified/ unmet care and safety needs, and a diminished quality of life. Findings included . 1) Review of the Electronic Health Record (EHR) showed Resident 56 was admitted to the facility on [DATE]. Resident 56 had diagnoses that included surgical amputation (removal of a limb), muscle weakness, and hypertension (high blood pressure). The Medicare 5-day Minimum Data Set Assessment (MDS, an assessment tool), dated 11/04/2024, showed Resident 56 needed assistance from staff for activities such as transferring to and from bed to a wheelchair or going from a sitting to a standing position. <Activities> Review of Resident 56's Activity Assessment, dated 09/26/2024, showed that Resident 56 enjoyed various activities including exercise groups, puzzles, and men's group. During an interview on 11/04/2024 at 2:34 PM, Resident 56 said they liked to exercise and were interested in the facility's more active programs. During an interview on 11/08/2024 at 1:01 PM, Staff C, Resident Care Manager (RCM), said the care plan should include resident specific likes or preferences for certain activities. Staff C said there was not an activity care plan for Resident 56. During an interview on 11/12/2024 at 4:06 PM, Staff B, Director of Nursing Services (DNS), said their expectation was for Resident 56 to have had a care plan for activities. <Edema> Review of Resident 56's progress notes showed that Resident 56 had documented edema. Review of Resident 56's care plans showed there was not a triggered care plan for edema with interventions or goals. During an interview on 11/12/2024 at 9:44 AM, Staff C, RCM, said Resident 56 had edema that was being noted in the progress notes. Staff C reviewed Resident 56's care plan and stated that their expectation was that Resident 56 would have had a care plan on edema, or have had an existing care plan expanded to include interventions for edema. During an interview on 11/12/2024 at 4:06 PM, Staff B, DNS, said a care plan should include sections on focus, interventions, and goals. Staff B said they would expect an edema care plan for Resident 56. <Negative Pressure Wound Treatment> Review of Resident 56's care plan for alteration in skin integrity showed an intervention initiated on 11/06/2024 for negative pressure wound treatment (a technique that uses suction to promote wound healing) to the left plantar foot wound. During an interview on 11/12/2024 at 9:44 AM, Staff C, RCM, said that Resident 56 had a care plan with the wrong extremity listed, and that it was Resident 56's right side (amputation wound) not left side that was receiving negative pressure treatment. During an interview on 11/12/2024 at 4:08 PM, Staff B, DNS, said it did not meet expectation the wrong extremity was listed in the care plan for Resident 56. 2) Review of the EHR showed Resident 126 was admitted to the facility on [DATE]. Resident 126 had diagnoses of sepsis (bloodstream infection) and cellulitis (bacterial skin infection). Review of the Medicare-5 Day MDS, dated [DATE], showed that Resident 126 received intravenous (through a vein) antibiotics. Review of the EHR showed that Resident 126 had a single lumen peripherally inserted central catheter (PICC, a thin long tube that goes through a vein in the arm and goes to the larger veins near the heart for giving medications). During an interview on 11/08/2024 at 7:49 AM, Staff C, RCM, reviewed Resident 126's care plans and said they were unable to find a care plan for Resident 126's PICC. Staff C said their expectation was that there would be a care plan that addressed the PICC. During an interview on 11/12/2024 at 4:30 PM, Staff B, DNS, said their expectation for a resident with a central line was for it to be care planned, and it did not meet expectations that Resident 126 did not have this care planned. Reference WAC 388-97-1020(1), (2)(a)(b) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 176) reviewed for communication, were provided appropriate treatment and services to maintain hearing. The failure to complete Resident 176's earwax removal treatment, resulted in Resident 176 indicating their ears remained clogged with wax and they still had difficulty hearing. This placed the resident at risk for feelings of frustration, diminished self-worth and decreased quality of life. Findings included . Resident 176 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 10/24/2024, showed the resident was cognitively intact, had moderate difficulty hearing in some environments and did not have hearing aids or other hearing devices. On 11/04/2024 at 4:05 PM, Resident 176 reported they were experiencing ear pain and could not hear very well due to earwax build-up. The resident said he asked staff to declog their ears. The resident said the nurses put Debrox (ears drops that soften/loosen earwax build-up) drops in their ears for several days, but never flushed their ears when the treatment was completed. Resident 176 said the ear wax was still there and stated, I still can't hear very well. An At Risk For Impaired Communication care plan related to hearing loss, revised 11/01/2024, directed staff to administer ear drops as ordered and to moderately elevate tone and speak directly to Resident 176. The October and November 2024 medication administration records showed a 10/28/2024 order for Debrox (ear drops used to soften and loosen ear wax) three drops in both ears two times a day for seven days alternating with acetic acid ear drops, 3 drops to both ears two times a day. There was no instruction provided to flush the resident's ears when the treatment was completed. Review of the administration instructions on the Debrox (Carbamide Peroxide) package insert read as follows: Step 1- Place 5-10 drops in ear, wait several minutes with head tilted. Step 2- Repeat step one, two times daily for up to four days if needed. Step 3- Gently flush ear with warm water, using soft rubber bulb syringe, to remove remaining wax after final day of treatment. On 11/14/2024 at 7:48 AM, Staff B, Director of Nursing Services, said upon completion treatment with debrox ear drops, the ears should be flushed with warm water. When asked if there was documentation to show that occurred for Resident 176, Staff B said no and indicated facility nurses should have identified the order was incomplete and clarified it. Reference WAC 388-97-1060 (2)(a)(ii) .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interviews and record review, the facility failed to consistently provide treatments as ordered, and implement timely and appropriate interventions to prevent the worsening of PU (PU/PI, injury to the skin and underlying tissue due to prolonged pressure) for 1 of 3 sampled residents (Resident 64), reviewed for pressure ulcers. This failure may have contributed to worsening/deterioration of the PU to the sacrum (the triangular bone at the base of the spine that connects the lower back to the pelvis). This failure placed residents at risk for skin injuries, PUs/PIs, and a diminished quality of life. Findings included . <Policy> Facility policy titled, Skin Care Policy/Procedure, revised 06/2016, stated, It is the policy of the facility that: 1. A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and 2. A resident having pressure injuries receives necessary treatment and services to promote healing, prevent infection and prevent new, avoidable pressure injuries from developing. Procedures: Resident Assessment. 1. The nurse responsible for assessing and evaluating the residents' condition on admission and readmission is expected to take the following actions: a. Completed Initial admission Records and Braden Scale to identify risk and to identify any alterations in skin integrity noted at that time. b. Braden Scale should be completed on admission, quarterly and following a change in the resident's condition. c. Identify risk factors which relate to the possibility of skin breakdown and or the development of pressure injury which include . d. All risk factors identified on assessment should be documented in the resident's clinical record and, when appropriate, be addressed through a care plan designed to minimize the possibility of skin breakdown. e. Develop comprehensive care plan if indicated following the evaluation/assessment. Care plans must be individualized and designed to meet the needs of the particular resident for whom they are being developed. f. Assessment of wounds upon admission and readmission: g. Assessment of wounds identified after admission: h. A licensed nurse will assess/evaluate at least weekly each area of alteration/injury, whether present on admission or developed after admission, which exists on the resident, . i. It is understood that a resident may experience pain associated with the presence of a skin injury and/or any form of skin compromise. j. Once an area of alteration in skin integrity has been identified, assessed and documented, nursing shall administer treatment to each affected area as per the Physician's Order. Resident 64 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated 04/22/2024, documented Resident 64 was moderately cognitively impaired and required extensive assistance for some activities of daily living (ADLs). The MDS also documented Resident 64 had one Stage II PU and interventions included a pressure reducing device for the resident's bed and wheelchair and for pressure ulcer/injury care and applications of ointments/medications Review of the LN [Licensed Nurse]-Initial admission Record, dated 04/15/2024, documented Resident 64 had skin problems, yes and showed two areas, identified as pressure related to the sacrum and documented: 1. Site: 53) Sacrum. Type: Pressure. Length (L) 0.5 x Width (W) 0.5 x Depth (D) 0.1 centimeters (cm). Stage II 2. Site: 53) Sacrum. Type: Pressure. L 1 x W 1.2 x D 0.3 (cm). Stage II. Review of a Braden Scale evaluation (a skin assessment that evaluates the risk of skin breakdown), dated 04/15/2024, documented Resident 64 was at low risk for developing PU. Review of Resident 64's Skin Care Plan, dated 04/15/2024, documented Resident 64 had two open areas on the sacrum but did not identify them as pressure related. Review of a physician's order, dated 04/15/2024, documented Resident 64 had two open areas on the sacrum. The area was to be cleaned with warm soap and water, patted dry and then Zinc ointment applied (treats or prevents skin irritation like cuts, burns or diaper rash), every day and evening shift until resolved. Review of the Electronic Health Record (EHR) had missing entries for completion of the above order on: 04/16/2024 PM shift, 04/17/2024 PM shift, 04/22/2024 AM shift, 04/25/2024 PM shift, 04/26/2024 PM shift, 04/30/2024 PM shift, 05/01/2024 PM shift, 05/10/2024 PM shift, and 05/17/2024 AM shift. The physician order was then discontinued on 05/23/2024. Review of the first LN- Skin Pressure Ulcer Weekly, dated 05/08/2024 (started 3 &1/2 weeks after admission), documented: Site 1: Present on admission: No. Onset date 05/08/2024. Coccyx/buttock. SDTI (Suspected deep tissue injury) 1.2 x 1.2 cm. Site 2: Present on admission: No. Onset date 05/08/2024. Coccyx/right buttock (No measurements included). No weekly skin check was completed on 05/15/2024. Review of the LN- Skin Pressure Ulcer Weekly, dated 05/23/2024, documented only one PU on the coccyx, and identified it as a SDTI with measurements of 1.8 x 2.7 cm. No second site was documented in the assessment. Review of a physician's order, dated 05/23/2024, documented a Deep Tissue Injury (DTI) was to be cleaned with warm soap and water, patted dry and phytoplex (a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) applied every day and evening shift until wound had resolved. Review of the EHR had a missing entry for completion of the above order on 05/28/2024. The above physician's order was discontinued on 05/29/2024. Review of the LN- Skin Pressure Ulcer Weekly, dated 05/28/2024, documented the left buttock had a 2 x 2 cm round wound with slough (a soft, yellow or white substance that can appear in a wound bed and is made up of dead cells, debris, and other substances) wound bed and draining pus. The adjacent (nearby) wound was beefy red, measured 2 x 4 cm and was identified as unstageable. On 05/28/2024, the physician was notified of the worsening PU. Review of a wound care provider note, dated 05/29/2024, documented an initial assessment that showed, Location-left buttock. Pressure stage: Stage 4. Review of the LN- Skin Pressure Ulcer Weekly, dated 05/29/2024, documented the area had increased in size and the facility had ordered an air mattress with bolsters. There was no documentation regarding the stage or condition of the wound with this assessment. Review of a physician's order dated 05/29/2024, documented orders for Resident 64's coccyx left buttock to be cleaned with normal saline, patted dry and calcium alginate (is a gelatinous, cream-colored substance with many uses, including wound healing) applied to the open area and covered with a 4 x 8 dressing, every day and evening shift until resolved. Review of the EHR had missing entries for completion of the above order on: 06/01/2024 PM shift, 06/05/2024 PM shift, 06/08/2024 PM shift, 06/10/2024 AM shift, And the resident refused care 06/11/2024 AM shift. The above physician's order was discontinued 06/13/2024. Review of a physician's order dated 06/13/2024, documented orders for Resident 64's coccyx left buttock to be cleaned with normal saline, patted dry, packed with Iodoform gauze packing strip (a sterile, antiseptic, and absorbent gauze that is used to treat infected wounds, reduce bleeding, and remove necrotic/dying tissue) to open area and cover with dressing every day and evening shift until resolved. Review of the EHR had missing entries for completion of the above order on: 06/15/2024 PM shift, 06/16/2024 PM shift, And 06/17/2024 PM shift. The above physician's order was discontinued 06/20/2024. Review of a physician's order dated 06/20/2024, documented orders for Resident 64's coccyx left buttock to be cleaned with normal saline, patted dry, pack with Dakins half strength Kerlix (a diluted solution of Dakin's Solution, used to treat a variety of wounds and infections) and cover with a foam dressing every dayshift. Review of the EHR had a missed entry for completion of the above order on 06/21/2024 and showed Resident 64 refused on 06/25/2024. The above physician's order was discounted on 06/26/2024. Review of the LN- Skin Pressure Ulcer Weekly, dated 06/20/2024, documented no other PU's on Resident 64. Review of wound care provider note, dated 06/26/2024, showed a left ear helix Stage 4 PU and a chronic, non-healing, left buttock wound with significant undermining (tunneling wound under the skin) and documented: Wound 1: (coccyx): Size 6.5 x 4 x 2.3 cm Wound 2: Left Ear Helix Pressure. Stage 4. Size: 0.5 x 0.5 x 0 cm. Review of the LN- Skin Pressure Ulcer Weekly, dated 07/10/2024, documented no other PU's on Resident 64. A Braden Scale evaluation, dated 07/15/2024, documented Resident 64 was at low risk for developing a PU, contrary to how the resident should have scored due to having numerous PUs and risk factors. On 11/14/2024 at 9:54 AM, Staff B, Director of Nursing Services, said when a resident admits with a pressure ulcer, it was the expectation that the facility would treat and monitor the pressure ulcers. Staff B said the facility would add the resident to the wound care provider committee to be discussed and put additional interventions in place. At 11:02 AM, Staff B, said Resident 64 entered the facility with a Stage II pressure ulcer to the sacrum and it progressed and worsened, but their contracted wound provider was treating Resident 64. Staff B provided wound provider notes regarding each visit. Staff B said the notes had not been scanned into the EHR and should have been. Staff B said Resident 64 was assessed to have a Stage II PU, the physician had placed orders for treatment and then the wound specialist providers started following Resident 64 weekly. Staff B said Resident 64's diagnoses turned to Terminal Skin Failure in June. Resident 64 was attending dialysis, but no longer qualified for dialysis and stopped attending. Staff B said a Braden Scale was completed. When asked what the results of the Braden Scale were, Staff B said, the Braden Scale showed Resident 64 was at low risk for pressure ulcers. When asked if the Braden scale was correct, Staff B said the assessments were incorrect due to Resident 64 admitting with a Stage II PU. When asked about interventions for Resident 64, Staff B said medication, physician ordered treatments, monitoring and assessing, and turning and repositioning were used for Resident 64. When asked about Resident 64's change/worsening PU, Staff B said she was unable to provide specifics about the events that caused the PU to worsen. Staff B said the physician was notified on 05/28/2024 regarding the worsening PU. When asked about missing entries in the treatment orders, Staff B said residents did have the right to refuse care. Staff B said the missing entries should have noted why the treatment were not completed. Staff B said it was reported to her that Resident 64 had refused on occasion, but acknowledged the record did not show documentation for follow up with the refusals. Staff B said staff should have been asking why the resident was refusing and should have been documenting it. Reference WAC 388-97-1060 (3)(b) Reference F692. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to administer parenteral (routes other than the digestive system to give fluids or medication) medication in a manner consistent with professional standards for 1 of 1 sampled residents (Resident 126) reviewed for antibiotics. This failure placed residents at risk for complications, infections, and a diminished quality of life. Findings included . Review of the Electronic Health Record (EHR) showed Resident 126 was admitted to the facility on [DATE]. Resident 126 had diagnoses including sepsis (bloodstream infection) and cellulitis (bacterial skin infection). Review of the Medicare-5 Day Minimum Data Set Assessment, dated 10/28/2024, showed Resident 126 received intravenous (IV, through a vein) antibiotics. Review of the EHR showed Resident 126 had a single lumen peripherally inserted central catheter (PICC, a thin long tube that goes through a vein in the arm and goes to the larger veins near the heart for giving medications). Review of the EHR showed Resident 126 did not have orders specific to having a central line (the PICC). The EHR also showed Resident 126 did not have a central line or PICC care plan. Review of Resident 126's IV medications showed the orders did not specify the rate of the antibiotics. Resident 126 was receiving IV vancomycin (antibiotic) every 24 hours and IV piperacillin tazobactam (antibiotic) every 8 hours. During an interview on 11/08/2024 at 7:27 AM, Staff E, Resident Care Manager/Registered Nurse (RCM/RN) said for PICCs, the facility would check the measurement of the external catheter length from the skin to the hub (attachment on the end of the PICC tubing where medications are given). Staff E was unable to find a previous measurement and obtained a new measurement on Resident 126. During an interview on 11/08/2024 at 7:49 AM, Staff C, RCM, said they were unable to find an order for Resident 126 for frequency of dressing change that was per central line guidance. Staff C was unable to find rates on the two IV antibiotic orders. Staff C said their expectation was for staff to confirm the rate with every administration with the order, and the orders should have detailed instructions. During an interview on 11/12/2024 at 4:30 PM, Staff B, Director of Nursing Services, said their expectation for staff on obtaining the external catheter length for a resident with a central line was on admission and with dressing changes, and this should be care planned. Staff B said it did not meet expectations that Resident 126 was admitted on [DATE] and did not have a measurement of the external catheter length of their PICC until 11/08/2024. Staff B said their expectation was for the rate to be listed in the medication order, and central line dressing changes would be ordered and accurate for the central line. Reference F656 Reference WAC 388-97-1060 (3)(j)(ii) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure orders were followed for 2 of 2 residents (Residents 72 and 10) reviewed for dialysis. This failure put residents at risk for medical complications and a decreased quality of life. Findings included . Resident 72 admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool) documented Resident 72 was cognitively intact. Resident 72's diagnosis included End Stage Renal Disease (ESRD, a condition in which the kidneys lose the ability to remove waste and balance fluids) and dependence on renal dialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are no longer functioning properly). Resident 72 had a dialysis fistula (a surgically created connection between an artery and a vein that allows for direct access to the bloodstream for dialysis) to their left arm. Review of the Electronic Health Record (EHR) showed that Resident 72 was going to dialysis three times a week from 5 AM to 9 AM. A physician's order, dated 09/21/2024, instructed post dialysis fistula access care to include removal of pressure dressing(s) two hours after dialysis The Renal (kidney) System Care Plan, dated 09/21/2024, instructed staff for post dialysis fistula access care: Remove pressure dressing two hours after dialysis. On 11/04/2024 at 11:15 AM, Resident 72 said after dialysis ended (around 9 AM) they removed the pressure dressing themself and often would wait until 7 or 8 PM to take the pressure dressing off. Resident 72 reported they had removed their own pressure dressing too early one time and there was bleeding from their fistula site resulting in transfer to the hospital. On 11/07/2024 at 3:20 PM, Staff R, Registered Nurse, said Resident 72 liked to wait to remove their own pressure dressing after dialysis, usually removing it themself. On 11/12/2024 at 10:02 AM, Staff C, Resident Care Manager (RCM), said for a resident to remove their own pressure dressing there would need to be training and teaching documented in the EHR. When asked to provide training or teaching documentation for Resident 72's abilities to change their own pressure dressing, Staff C said he could not locate the documentation. At 2:21 PM, Staff B, Director of Nursing Services (DNS), said for Resident 72 to remove their own pressure dressing her expectation was they would have a self-administration form in the EHR, it would be addressed on the care plan and there would be a physician order for Resident 72 to remove their own dressing. No documentation that these steps were taken was provided. Reference WAC 388-97-1900 (1)(6)(a-c) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure that the pharmacist's Medication Regimen Review (MRR) recommendations were acted upon for 1 of 5 residents (Resident 21) reviewed for unnecessary medications. This failure placed residents at risk of decreased effects of medication, medication complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Medication Regimen Review, revised 08/2017, showed the MRR recommendations were to be provided to the responsible physician, facility's Medical Director, and the Director of Nursing within a week of the review. The provider would then document in the resident's medical record what was reviewed and if any actions needed to be taken. Nursing was responsible for providing a written response to the review, to be given to the pharmacist and to the facility to be filed. Review of the Electronic Health Record (EHR) showed Resident 21 was admitted to the facility on [DATE]. Resident 21 had diagnoses of malnutrition (lack of sufficient nutrients in the body) and gastrostomy status (surgical intervention for a feeding tube that goes through the abdomen into the stomach). Review of the Annual Minimum Data Set Assessment, dated 08/26/2024, showed Resident 21 was dependent on staff for cares and experienced constant pain. Review of the MRR binder showed that Resident 21 had a recommendation on 08/28/2024 that said Carafate (forms a coating over ulcers to protect from stomach acid) had the potential to alter the absorption of other medications, should be given on an empty stomach, and should be given two hours before or after other medications. Review of the medication administration record for August and September 2024 showed Resident 21 had oxycodone (opioid pain medication) and Carafate scheduled at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. During an interview on 11/13/2024 at 1:44 PM, Staff C, Resident Care Manager, reviewed the EHR and said they were unable to find documentation of Resident 21's MRR recommendations on 08/28/2024 being implemented, or any documentation saying Carafate and oxycodone were reviewed or could be given together. During an interview on 11/14/2024 at 11:42 AM, Staff B, Director of Nursing Services, said their expectation for Resident 21's MRR recommendations on 08/28/2024 was that the doctor would have confirmed there was a conversation about the medication. Staff B said they were unable to provide documentation the provider was aware of the recommendation, if Carafate was being given with oxycodone was reviewed, or if the two medications were approved to be given together. Reference WAC 388-97-1300 (4)(c) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on on interview and record review, the facility failed to ensure quality of care for 2 of 5 residents (Resident 72 & 56) reviewed for unnecessary medications related to providing ordered medication. This failure placed residents at risk for medical complications and a decreased quality of life. 1) Review of the Electronic Health Record (EHR) showed Resident 10 was admitted to the facility on [DATE]. Resident 10 had a diagnosis of ESRD, required renal dialysis, and had a port (implanted venous access device). Review of the Quarterly Medicare MDS, dated [DATE], showed Resident 10 was cognitively intact. Resident 10 had an order for removing the dressing on Resident 10's port two hours after dialysis on Tuesday, Thursday, and Saturday. Review of the November 2024 administration record showed the dressing was not being removed. Review of the November 2024 progress notes showed staff were not removing the dressing to prevent infection. During an interview on 11/12/2024 at 9:14 AM, Staff C, RCM, said the dressing order was not written correctly for Resident 10's port, and this needed to be fixed. Staff C said their expectation of staff was to report problems with orders to the provider or RCM, and this did not meet expectations. During an interview on 11/14/2024 at 8:34 AM, Staff B, DNS, said their expectation for staff caring for Resident 10 was to clarify the order with the provider. 2) Review of the EHR showed Resident 56 was admitted to the facility on [DATE] and was hospitalized from [DATE] to 10/31/2024. Resident 56 had diagnosis of type two diabetes (trouble regulating sugar in the body). The Medicare 5-day MDS, dated [DATE], showed Resident 56 had a moderately impaired mental status. Resident 56 returned from the hospital on [DATE] and had an ordered dose for dulaglutide (medication for diabetes) for 11/01/2024, ordered for once a week. Review of a 11/01/2024 progress note showed Resident 56's dulaglutide dose was missed due to the medication not being available from pharmacy. The note said pharmacy was advised of the need to send the medication. Review of Resident 56's progress notes for November 2024 did not include documentation of notifying the provider of the missing dose. No additional orders were found. The next administration of the medication was given on 11/08/2024, the week following the missing dose. During an interview on 11/08/2024 at 8:39 AM, Staff C, RCM, reviewed Resident 56's EHR and said they did not see a makeup dose for the missing dulaglutide dose on 11/01/2024. Staff C said it did not meet expectations that they could not find a progress note saying a conversation happened between staff and the provider, and the provider should have rewritten the dose when it became available from pharmacy. During an interview on 11/12/2024 at 4:14 PM, Staff B, DNS, said it did not meet expectations when Resident 56 returned from the hospital that the dulaglutide dose was not available and there was not a makeup dose. Reference WAC 388-97-1060 (1) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of the EHR showed Resident 21 was admitted to the facility on [DATE]. Resident 21 had diagnoses of anxiety (abnormal amounts of stress) and depression. Review of the Annual MDS, dated [DATE], showed Resident 21 was dependent on staff for cares. Review of a psychiatry note, dated 09/24/2024, showed Resident 21 was evaluated for a GDR for their medication. The provider recommended decreasing Resident 21's antianxiety medication dose, to decrease the sedation (decreased level of alertness) effects of the medication and to more accurately determine a diagnosis. The note ended with, repeat labs and exclude component of delirium. Review of the EHR showed that Resident 21 had their antianxiety medication reduced on 09/27/2024. Review of the EHR showed Resident 21's next laboratory blood tests were not done until 11/07/2024, in a response to a change of condition of the resident. During an interview on 11/13/2024 at 1:44 PM, Staff C, Resident Care Manager, said they could not find any evidence of the recommendation from the 09/24/2024 psychiatry note being followed for Resident 21, and if the provider did not give direct orders, that the interdisciplinary team would hopefully review the progress notes and follow up on recommendations. During an interview on 11/14/2024 at 1:33 PM, Staff B, DNS, said they were now following up to find out what laboratory tests the provider wanted, and they should have followed up on the laboratory tests for the 09/24/2024 psychiatry visit. Reference WAC 388-97-1060 (3)(k)(i) Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecting the mind) medications by ensuring Gradual Dose Reductions (GDR) were attempted for 1 of 5 residents (Resident 27) reviewed for unnecessary medications and that GDR recommendations that included laboratory tests were followed up on for 1 of 5 residents (Resident 21) reviewed for unnecessary medications. This failure placed residents at risk for medical complications, receiving unnecessary medications and a diminished quality of life. Findings included . 1) Resident 27 was readmitted to the facility on [DATE] with diagnoses of Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). The Annual Minimum Data Set, (MDS, an assessment tool) dated 06/25/2024, documented Resident 27 was moderately cognitively impaired. A physician's order, dated 04/22/2022, documented Resident 27 was prescribed duloxetine (an antidepressant used to treat depression). This order was discontinued for Resident 27 and reordered for the same dose and frequency on 08/30/2024. Review of the Medication Regimen Review book showed no evidence any GDRs had been attempted from January 2024 through October 2024. Review of the 02/22/2024, 06/06/2024 and 09/12/2024 behavior/psychoactive medications interdisciplinary team reviews for Resident 27, documented no GDRs were attempted. On 11/13/2024 at 1:11 PM, Staff B, Director of Nursing Services (DNS), when made aware of no documentation of attempted GDRs said her expectation would be that this documentation would be in the Electronic Health Record (EHR), and she would attempt to reach the physician to provide the documentation. No further documentation was provided.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and interview, the facility failed to ensure residents received COVID-19 vaccines that were consented for, for 2 of 7 residents (Residents 10, 21) reviewed for vaccinations. This failure placed residents at risk for a decreased immune response to COVID-19, related complications if infected, and a diminished quality of life. Findings included . 1) Review of the Electronic Health Record (EHR) showed Resident 10 was admitted to the facility on [DATE] and consented to receive the COVID-19 vaccination on 05/13/2024 and 10/29/2024. During an interview on 11/13/2024 at 8:51 AM, Staff C, Resident Care Manager (RCM), said the COVID-19 vaccinations were not previously ordered from the supplier, and now the infection control nurse was aware and would be ordering. During an interview on 11/14/2024 at 8:34 AM, Staff B, Director of Nursing (DNS), said it did not meet expectations that Resident 10 signed consent and the COVID-19 vaccine was not ordered from the supplier. 2) Review of the EHR showed Resident 21 was admitted to the facility on [DATE] and consented to receive the COVID-19 vaccination on 06/03/2024. During an interview on 11/13/2024 at 8:53 AM, Staff C, RCM, said Resident 21's COVID-19 vaccine was not ordered with the supplier, and this did not meet expectations. During an interview on 11/14/2024 at 1:43 PM, Staff B, DNS, said their expectation was that if Resident 21 consented to COVID-19 vaccination, then it would have been completed. No Associated WAC. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Resident 43 was admitted to the facility on [DATE]. The admission MDS, dated [DATE] documented Resident 43 was moderately cognitively impaired. No AD or AD receipt was found in the EHR. On 11/08/2024 at 12:18 PM, Staff I, Patient Advocacy Resource, said that an AD or AD receipt should have been done upon admission. When asked if it was done for Resident 43, Staff I said he would follow up on it. On 11/12/2024 at 9:00 AM, Staff I said he was unable to locate an AD or AD receipt for Resident 43, and that it should have been done by this time. 4) Resident 60 was admitted to the facility on [DATE]. The admission MDS dated [DATE] documented Resident 60 was cognitively intact. No AD or AD receipt was found in the EHR. On 11/08/2024 at 12:18 PM, Staff I, Patient Advocacy Resource, said that an AD or AD receipt should have been done upon admission. On 11/12/2024 at 9:01 AM, when asked if he was able to locate an AD or AD receipt for Resident 60, he said he was unable to locate them. When asked if it should have been done by now, Staff I said yes. Reference WAC 388-97-0280 (3)(c)(i-ii) Based on interview and record review the facility failed to provide an Advanced Directive (AD, a written instruction of health care directions) for 4 of 5 sampled residents (Residents 59, 28, 43 & 60 ) reviewed for ADs. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . 1) Resident 59 was admitted to the facility on [DATE]. The Quarterly Minimal Data Set (MDS, an assessment tool), dated 10/10/2024, documented Resident 59 was cognitively intact. Resident 59's Electronic Health Record (EHR), documented an AD receipt was signed by Resident 59 on 10/15/2024, indicating Resident 59 had chosen not to formulate an AD at this time. Review of Resident 59's EHR documented, prior to 10/15/2024, no other attempts to offer or assist Resident 59 with formulating an AD. On 11/06/2024 at 2:43 PM, Staff I, Patient Advocacy Resource, said he was unable to locate any other AD's for Resident 59. At 2:54 PM, Staff B, Director of Nursing Services (DNS), said AD's had not been completed, this had been identified as an issue and a Performance Improvement Plan (PIP) had been completed to correct the issue. 2) Resident 28 admitted to the facility on [DATE]. Review of their EHR showed no AD or AD receipt was present. On 11/06/2024 at 2:43 PM, Staff I, Patient Advocacy Resource, said they were unable to locate documentation to show the facility had asked Resident 28 if they had an AD and/or informed them of their right to formulate one. Staff I acknowledged that this should have occured as part of the admission process.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Medicare Hallways> Medicare A and Medicare B Nurses station and hallways On 11/04/2024 at 1:00PM, two dinner plate sized ...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Medicare Hallways> Medicare A and Medicare B Nurses station and hallways On 11/04/2024 at 1:00PM, two dinner plate sized dark brown stains were seen on the carpet by the Medicare hall nurse's station. A large, approximately three-feet by three-feet, dark brown stain was seen outside of room [ROOM NUMBER] and another slighly smaller stain was seen outside of room [ROOM NUMBER]. Several squares of carpet up and down the hallways were coming up at the seams. The squares under the fire doors outside of the nurse's station had blue, black, and tan peices of tape holding the seams together. The transition was missing between the hallway carpet and the hard surface flooring for room [ROOM NUMBER]. On 11/05/2024 at 1:23 PM, Staff M, Maintenance Supervisor, was asked about the condition of the carpets. He said that he knew they were in bad shape, and that he was trying to replace them. He stated, There has just been too much red tape. Reference WAC 388-97 -0880 Based on observation and interview the facility failed to maintain a safe, clean and comfortable environment through maintenance of the hallway and dining room carpets for 3 of 3 halls (Olympic, Mountainview and Medicare) observed. This failure has the potential to place residents at risk for not having a homelike environment and a diminished quality of life. Findings included . On 11/05/2024 at 11:41 AM, in the hallway with room [ROOM NUMBER], near the double doors there were worn areas and stains observed on the carpet and blue tape on the carpet appeared to prevent the carpet from peeling up. On 11/12/2024 at 4:19 PM Staff A, Administrator, said the carpets needed to be replaced and she has a contractor that should be starting the work within the next 30 days.<Olympic Hallway> On 11/13/2024 at 11:02 AM, observation of the carpet in the activity room in the Olympic Hallway showed the carpet was worn and heavily soiled. There was a three by four-foot circular stain just inside and to the right of the entrance. Five additional one by one-foot dark brown circular stains with distinct edges were noted on the carpet throughout the room. The stains appeared to be the result of spilled liquids that had dried prior to being cleaned up. On 11/05/2024 at 1:12 PM, Staff C, Resident Care Manager, said the activity room had been previously used as the assist dining room. <Mountainview Hallway> On 11/13/2024 at 11:04 AM, observation of the carpet in front of the first kiosk in the Mountainview hallway showed the carpet had been cut in multiple places and replaced with non-matching carpet (different color and pattern). An approximately eight-foot by four-foot section of carpet had been replaced with darker brown carpet with a different pattern and an approximately 18 foot by three-foot section had been replaced with light brown carpet of a different pattern. The seams (between the carpet patches and the original carpet) had been secured with black duct tape.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident Council> During an interview with members from the Resident Council on 11/06/2024 at 1:00 PM, concerns were brou...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident Council> During an interview with members from the Resident Council on 11/06/2024 at 1:00 PM, concerns were brought forward about the grievance process. When asked if the facility considers their views and acts promptly to resolve grievances and implement recommendations, the Resident Council members said not normally. One member said they had filed five grievances and only heard back from the facility twice. Another member said they felt like they did not have anyone to go to with a grievance. During a review of recent Resident Council meeting minutes, multiple dates had concerns brought up without grievances filed. During the 05/21/2024 meeting, a concern was brought up about sufficient staffing and no grievance was filed. During the 08/20/2024 meeting, a concern was brought up about appointment notifications and no grievance was filed. During the 09/17/2024 meeting, concerns were brought up about blood glucose meters, when more staffing would happen, and about pharmacy services, without these concerns filed as grievances. During the 09/17/2024, a grievance was filed on the behalf of the Resident Council, related to wanting to know ahead of time about appointments. The grievance form did not include any notification to the Resident Council on the resolution. During an interview on 11/13/2024 at 11:10 AM, Staff S, Activities Director, confirmed that 05/21/2024, 08/20/2024, and 09/17/2024 meetings had concerns that should have been filed as grievances and were not listed on the grievance log. For the 09/17/2024 grievance that was filed related to appointment notification, Staff S said it did not meet expectations that there were no listed resident council members for notification of the resolution. During an interview on 11/14/2024 at 1:50 PM, Staff B, DNS, stated the 05/21/2024, 08/20/2024, and 09/17/2024 meetings did not meet expectations for filing grievances, and that the 09/17/2024 grievance should have documented who it notified. Reference WAC 388-97-0460 Based on interview and record review, the facility failed to ensure grievances were initiated, logged, investigated, and/or promptly resolved/responded to for 1 of 1 residents (Resident 40) and the Resident Council reviewed for grievances. This failure placed residents at risk for feelings of frustration, powerlessness, and a decreased quality of life. Findings included . Review of the facility's policy titled Grievances, revised 02/01/2017, showed that general concerns could be voiced at Resident Council (a group of residents that meet regularly to discuss living at the facility) meetings, and that the concern would be evaluated and investigated. A response would occur within three working days to the individual with the concern, to acknowledge the steps taken for resolution. <Resident Greivance> Resident 40 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessement tool), dated 10/17/2024, documented Resident 40 was cognitively intact. On 10/22/2024, Resident 40 filed 2 grievances: 1) Resident 40 documented residents were not receiving restorative services due to restorative aides being pulled from assigned job, due to staff shortages. 2) Resident 40 documented residents were not getting showers due to shower aides being pulled from assigned job, due to staff shortages. Neither grievance was documented on the Grievance log. Grievances were not addressed until 11/05/2024 (14 days later). On 11/12/2024 at 12:45 PM, Staff B, Director of Nursing Services, said the process for grievances included completing the grievance form, and turning it into Social Services (SS) who would review it and speak with the resident. Once all questions were answered, SS would review it with the DNS and Administrator, who would sign off on the grievances. Then the form would be uploaded into the EHR. Staff B said all grievances concerns were discussed in stand-up meeting. When shown the missing grievances not filed on the Grievance log, Staff B said the grievances should have been documented on the Grievance log.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Resident 16 admitted to the facility 07/17/2019. The Annual MDS dated [DATE], documented that Resident 16 was cognitively intact. Resident 16 was hospitalized from [DATE] until their return on 03/20/2024. The EHR showed no documentation of a transfer notice. 4) Resident 60 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented that Resident 60 was cognitively intact. Resident 60 was hospitalized from [DATE] until their return on 09/19/2024. The EHR showed no documentation of a transfer notice. On 11/08/24 12:37 PM, Staff B, DNS, said she had no transfer notices for Resident 16 and Resident 60, and that the notices should have been completed. Reference WAC 388-97-0120 (2)(a-d) 2) Resident 40 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 40 was cognitively intact. Resident 40's EHR showed Resident 40 was transferred to the hospital on [DATE] and discharged from the hospital and returned to the facility on [DATE]. Resident 40's EHR did not show documentation that Resident 40 was offered and/or provided a transfer/discharge notice. On 11/12/2024 at 10:05 AM, Staff E, RCM/RN, said when completing a resident transfer to the hospital, a assessment in the EHR should be completed. Staff E said the resident should be sent to the hospital with a transfer form, most recent orders, progress notes, history and profile, labs results and vitals. Staff E said the transfer notice was not completed for Resident 40, but should have been. At 12:45 PM, Staff B, DNS, said the transfer notification was not completed for Resident 40 and should have been. Based on interview and record review, the facility failed to provide a written transfer/discharge notice to the resident and/or their representative for 4 of 4 sampled residents (Residents 18, 40, 16 & 60), reviewed for hospitalization. This failure placed the resident and/or their representative at risk for not having an opportunity to make informed decisions about transfers/discharges. Findings included . Review of the facility's policy section, Admission/Discharge/Transfer, revised in 11/2016, said Information shall be provided to the resident and/or his/her representative in a language they can understand at the time of .transfer to the general acute hospital. 1) Resident 18 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 08/05/2024, documented the resident was cognitively intact. A review of Resident 18's progress notes in the electronic health record (EHR) showed Resident 18 transferred to the hospital on [DATE] and discharged from the hospital and returned to the facility on [DATE]. A review of the EHR did not show documentation that Resident 18 was offered and/or provided a transfer/discharge notice. On 11/12/2024 at 12:47 PM Staff K, Resident Care Manager (RCM)/Registered Nurse (RN) said she did not see a transfer notice in Resident 18's chart. At 1:29 PM Staff B, Director of Nursing Services (DNS), said she did not have a transfer notice, and her expectation was that there would be one.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 16 admitted to the facility 07/17/2019. The Annual MDS, dated [DATE], documented that Resident 16 was cognitively intact. Resident 16 was hospitalized from [DATE] until their return on 03/20/2024. The EHR showed no documentation of a bed-hold notice for the transfer. 3) Resident 60 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented that Resident 60 was cognitively intact. Resident 60 was hospitalized from [DATE] until their return on 09/19/2024. The EHR showed no documentation of a bed-hold notice for transfer. On 11/08/24 at 12:37 PM, Staff B, DNS said she had no bed-hold notices for Resident 16 and Resident 60's transfer, and the notices should have been completed. Reference WAC 388-97-0120 (4) Based on interview and record review, the facility failed to provide a bed hold notice to the resident and/or their representative for 3 of 4 sampled residents (Residents 40, 16 &60), reviewed for hospitalization. This failure placed the resident and/or their representative at risk for not having an opportunity to make informed decisions about bed hold and a diminished quality of life. Findings included . 1) Resident 40 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, (MDS, an assessment tool), dated 10/17/2024, documented Resident 40 was cognitively intact. Resident 40's Electronic Health Record (EHR) showed Resident 40 was transferred to the hospital on [DATE] and discharged from the hospital and returned to the facility on [DATE]. Resident 40's EHR did not show documentation that Resident 40 was offered and/or provided a bed hold notice. On 11/12/2024 at 10:05 AM, Staff E, Resident Care Manager/Registered Nurse, said Social Services completed bed hold notifications, but could not locate a bed hold notice in the EHR. At 12:45 PM, Staff B, Director of Nursing Services, said the bed hold notification was not completed for Resident 40 and should have been.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of the EHR showed Resident 10 was admitted to the facility on [DATE]. Resident 10 had diagnoses of heart failure, muscle weakness, and end stage renal disease (kidneys no longer work at a level to keep you alive without medical interventions). Review of the Quarterly MDS, dated [DATE], showed Resident 10 had no identified weight loss. Review of Resident 10's Nutrition and Hydration Risk Evaluation, dated 11/01/2024, showed Resident 10's weight status had either a greater than 5% weight loss in last one month or a greater than 10% weight loss in last six months. During an interview on 11/12/2024 at 11:36 AM, Staff D, MDS Assistant, said that Resident 10 did have weight loss and it should have been coded on the MDS assessment. During an interview on 11/12/2024 at 4:25 PM, Staff B, DNS, said that it did not meet expectations that Resident 10's weight loss was not recognized on the MDS assessment. 3) Review of the EHR showed Resident 21 was admitted to the facility on [DATE]. Resident 21 had a suprapubic catheter (urinary tube that is placed into the bladder through a small hold in the abdomen, the tube carries urine outside of the body and is connected to a drainage bag that collects urine). Review of the Annual MDS, dated [DATE], showed Resident 21 had an indwelling catheter (thin, flexible tube), which included suprapubic catheters. The MDS also had selected ostomy (an artificial opening in an organ of the body creating a stoma, which is a protruding red and round area on the surface of the abdomen). During an interview on 11/08/2024 at 9:06 AM, Staff D, MDS Nurse, said that a suprapubic catheter was not an ostomy. During an interview on 11/12/2024 at 4:29 PM, Staff B, DNS, stated that Resident 21 did not have an ostomy, this was an error, and it did not meet expectations that an ostomy was coded on the 08/26/2024 MDS. 4) Review of the EHR showed Resident 56 was admitted to the facility on [DATE]. Resident 56 had no active diagnosis of depression. Review of Resident 56's 09/19/2024 Medicare 5-Day MDS, showed a diagnosis of depression was selected. During an interview on 11/08/2024 at 8:39 AM, Staff C, RCM, said that Resident 56 did not have a diagnosis of depression on the diagnosis list. Staff C reviewed the MDS for 09/19/2024 and said that they would need to update the MDS due to the miscode. During an interview on 11/12/2024 at 4:14 PM, Staff B, DNS, stated that their expectation for the 09/19/2024 MDS was that it would not say a diagnosis of depression. Based on interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS, an assessment tool) accurately reflected the status for 6 of 25 sampled residents (Residents 53, 10, 21, 56, 176 & 23) reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . 1) Resident 53 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 53 was moderately cognitively impaired, had a weight loss of 5% or more and was on a prescribed weight loss program. On 11/12/2024 at 12:45 PM, Staff B, Diretor of Nursing Services (DNS), said when a Resident was on a prescribed weight loss program the facility should be monitoring weights weekly with the interdisciplinary team, the Registered Dietitian should be completing weekly reviews, and there must a Physician order for the diet plan. Staff B said the Resident must be involved in the weigh loss program too. When asked about Resident 53's weight loss program, Staff B said Resident 53 was not on a weight loss program, the resident was expected to lose weight due to diuretic use. When shown the MDS coding, Staff B, said the MDS was incorrect. 5) Resident 176 admitted to the facility on [DATE]. The admission MDS, dated 10/24//2024, showed the resident's pneumococcal vaccination was not up to date and had not been offered. A Resident Consent For Influenza, Pneumococcal, and COVID-19 Vaccination form, dated 10/18/2024, showed Resident 176 was offered and consented to the pneumococcal vaccination. On 11/12/2024 at 3:38 PM, Staff D, MDS Assistant, stated, Yes, [the pneumococcal vaccination] was offered and acknowledged the MDS was incorrectly coded. 6) Resident 23 admitted to the facility on [DATE]. A 08/30/2024 order was obtained to start the resident on Risperdal (an antipsychotic medication) for dementia with psychotic disturbance and severe anxiety. A Level II Preadmission Screening and Resident Review (PASRR) evaluation, dated 06/30/2024, showed the evaluator determined the resident had indicators of serious mental illness including major neurocognitive disorder with underlying psychosis, anxiety and mood disorders. Review of the Quarterly MDS, dated [DATE], showed the resident received antipsychotic medication but did not have active diagnoses of psychosis, anxiety or depressive disorders. On 11/14/2024 at 12:03 PM, Staff D, MDS Assistant, said they should have coded psychotic, anxiety and depressive disorder on Resident 23's MDS, but failed to do so. Reference WAC 388-97-1000 (1)(b) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7) Review of the EHR showed Resident 21 was admitted to the facility on [DATE]. Resident 21 had diagnoses of malnutrition (lack of sufficient nutrients in the body), muscle weakness, and gastrostomy status (surgical intervention for a feeding tube that goes through the abdomen into the stomach). Review of the Annual MDS, dated [DATE], showed Resident 21 was dependent on staff for cares. <Activities of Daily Living> Resident 21 had a care plan for decreased ability in activities of daily living (ADL's) self-care performance, with goals of will attain most independent level of ADL's and mobility as his PT/OT/ST [physical therapy, occupational therapy, speech therapy] progresses until next review date and will safely perform Bed, Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene through the review date. The same care plan had an intervention to encourage and assist Resident 21 to get up to a chair daily. During an interview on 11/13/2024 at 10:14 AM, Staff C, RCM, said that Resident 21 was not getting up to the chair daily, was not receiving PT/OT/ST, and that to safety perform bed mobility, transfers, eating, dressing, grooming, toilet use, or personal hygiene were not Resident 21's current abilities or goals. During an interview on 11/14/2024 at 8:45 AM, Staff B, DNS, said it did not meet expectations that Resident 21's care plan was not updated. <Nutritional Status> Review of Resident 21's orders showed an active order, started 07/19/2024, for giving 180 milliliters (ml) of water every six hours. Resident 21 had a care plan on nutritional status with an intervention listed for giving 100 ml of water every six hours. During an interview on 11/13/2024 at 10:22 AM, Staff C, RCM, said Resident 21's care plan had not been updated when the water order was changed. During an interview on 11/14/2024 at 8:53 AM, Staff B, DNS, said Resident 21's care plan for nutritional status was not updated and this did not meet expectations. Reference WAC 388-97-1020(2)(c)(d) Based on interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 7of 35 residents (Residents 62, 176, 376, 67, 23, 28, and 21) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life. Findings included . 1) Resident 62 admitted to the facility on [DATE]. An Activities of Daily Living (ADL) self-performance CP, revised 04/26/2024, directed staff to provide one person assistance with bathing per the resident's chosen schedule. The care plan did not identify what the resident's chosen bathing schedule was. 2) Resident 176 admitted to the facility on [DATE]. On 11/04/2024 at 3:38 PM, Resident 176 said they wanted a shower at least every three days but was scheduled for only one. An ADL CP, revised 10/30/2024, showed the resident required substantial assistance with bathing. The care plan did not identify the resident's desired type (shower, bath, bed bath, etc.) or frequency of bathing. 3) Resident 376 admitted to the facility on [DATE]. On 11/04/2024 at 2:59 PM, Resident 376 reported they wanted to be showered at least three times a week but was scheduled for only one. An ADL care plan, initiated 10/30/2024, showed the resident required substantial assistance with bathing. The care plan did not identify the resident's desired type (shower, bath, bed bath, etc.) or frequency of bathing. 4) Resident 67 admitted to the facility on [DATE]. An ADL care plan, revised 08/14/2024, showed Resident 67 required one person moderate to maximum assistance with bathing. The CP did not identify the resident's desired type (shower, bath, bed bath, etc.) or frequency of bathing. On 11/12/2024 at 1:18 PM, Staff C, RCM, said initially all residents were assigned one shower a week upon admission, but the frequency could be changed at resident request or during the initial care conference to their desired frequency. When asked where a resident's preferred bathing type and frequency would be documented once obtained, Staff C stated, On the care plan. On 11/13/2024 at 12:41 PM, Staff B, Director of Nursing Services, said residents should be asked their desired method and frequency of bathing. When asked if it should be on the CP Staff B said no, they just care plan bathing per resident's preference, but was unable to indicate how one would know what the resident's preferred bathing type and frequency was. 5) Resident 23 admitted to the facility on [DATE]. A psychotropic drug use CP, revised 10/15/2024, directed staff to document episodes of visual hallucinations and delusions of grandeur. The care plan did not identify what hallucinations or delusions the resident had previously experienced, the nature or effect of them (were they disturbing or pleasant e.g. seeing an angel in the corner of the room) or what action staff should take, if any, staff should take (other than documenting them). On 11/14/2024 at 12:10 PM, when if Resident 23's CP should identify what their hallucinations and delusions were and the effect they had on the resident, Staff B, DNS, said yes and acknowledged it was not on the CP. 6) Resident 28 admitted to the facility on [DATE]. A Dehydration Fluid Maintenance CP, revised 07/22/2024, directed staff to monitor and document intake & output (I&O, measured amout of fluid consumed and urine output usually compared over a 24 hour period) as per facility policy. Review of the electronic health record (EHR) showed the resident did not have an order for I&O and facility staff were not monitoring the Resident 28's I&O. Similar findings were noted for Resident 176 whose At Risk for Altered Fluid Maintenance CP, initiated 11/1/2024, directed staff to monitor and document intake and output (I&O) as per facility policy Review of the EHR showed the resident did not have an order for I&O and facility staff were not monitoring the Resident 176's I&O. On 11/08/2024 at 11:53 AM, Staff GG, Resident Care Manager (RCM) said if a resident doesn't have an order for I&O and the facility is not monitoring it, it should not be on the CP. Staff GG indicated the CP needed to be revised.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to ensure dependent residents were provided scheduled bathing/showering opportunities for 6 of 8 residents (Residents 43, 19, 64, 176, 67 and 62) reviewed for activities of daily living (ADL's). This failure placed residents at risk of not having their ADL care needs met and a diminished quality of life. Findings included . 1) Resident 43 was admitted to the facility on [DATE]. The admission Minimum Data Set, (MDS, an assessment tool) dated 10/22/2024, documented Resident 43 was moderately cognitively impaired and required substantial/maximal assistance with showering/bathing. The Shower Schedule dated 10/6/2024, documented Resident 43's shower day was to occur on Tuesdays during day shift. Resident 43's shower record, dated 10/15/2024 through 11/7/2024, documented no bathing activity was documented from 10/15/2024 until 10/29/2024, for 14 days. There were no refusals documented. On 11/08/24 at 9:59 AM, Staff Q, Certified Nursing Assistant, when informed Resident 43 had not received a shower from 10/15/2024 to 10/29/2024, two weeks, Staff Q said that a resident going two weeks without a shower was not acceptable. 11/08/24 at 12:33 PM. Staff B, Director of Nursing Services, said Resident 43 admitted to the facility on Tuesday 10/15/2024, and the next scheduled shower day should have been Tuesday, 10/22/2024 and a shower should have been done and documented on 10/22/2024 and it wasn't. 2) Resident 19 was admitted to the facility on [DATE]. The Quarterly, MDS, dated [DATE], documented Resident 19 was moderately cognitively impaired. Resident 19 required extensive/total assist with all ADLs. On 11/04/2024 at 2:12 PM, Resident 19 said they wanted to be shaved, but the facility does not shave them. Resident 19 said they have to beg staff for a shave, but staff does not have time. Resident 19 said their family brought in an electric razor to use. Resident 19 was observed with a full beard, long in length. Resident 19's shave schedule in the Electronic Health Record (EHR) documented no entries under the ADL tab. Resident 19's ADL Care Plan documented no information regarding offering or completing the shaving activity. 3) Resident 64 was admitted to the facility on [DATE]. The Significant Change MDS, dated [DATE], documented Resident 64 was moderately cognitively impaired. Resident 64 required extensive/total assistance with all ADL's. On 11/04/2024 at 2:51 PM, when asked about shaving and a haircut, Resident 64 said staff don't do that. Resident 64 said they have asked staff before for a shave and a haircut, but they are slow to cut my hair or shave me. Resident 64 said they have asked staff multiple times for a haircut and a shave, but it never gets done. Resident 64 said they have a family member shave and cut his hair when they visit. Resident 64 was observed with yellow, thick, long, over ¼ inch fingernails. Resident 64 toenails were observed to be thick and crusty yellow. Resident 64's had long shaggy unkept facial hair and long, over 2 inches, wiry hair sticking straight up on his head. A Physician's order dated 08/29/2024, documented to check that Resident 64 has been offered a shave every Monday, Wednesday and Friday, to include documentation if the resident refused. Resident 64's ADL Care Plan documented Resident 64 was to be offered a shave every Monday, Wednesday and Friday. Resident 64's Shaving record showed Resident was offered a shave on 10/09/2024- accepted, 10/23/2024 -refused and 10/30/2024 accepted. The EHR showed no documentation that Resident 64 had been offered a shave any other days. On 11/12/2024 at 10:05 AM, Staff E, Resident Care Manager/Registered nurse, said all tasks for CNA's are documented in the EHR, CNA's are able to document when the task was completed. When asked about specific tasks, Staff E, said the system does not break down the specific tasks, instead just documents personal hygiene. When asked about shaving task, Staff E said there is no specific selection in the EHR for shaving. When asked how often staff should be offering shaving, Staff E said some men like long beards, but staff should be asking routinely about cleaning, washing and shaving. When provided information that staff were not offering shaving, Staff E said that is not ok, residents should be getting shaved. When asked about hair cut, Staff E said the facility just hired a new barber yesterday. Staff E said residents should be getting haircuts when asked for. Staff E said if the resident gives the facility permission, staff can cut the resident's hair. At 12:45 PM, Staff B, DNS, said it is the normal standard of care that the facility honors resident preferences for ADL's and staff should be asking about ADL's every shift. Staff B said the facility just hired a person for haircuts, but the facility can also transport residents outside the facility for haircuts too. When provided information regarding lack of resident shaving and haircuts, Staff B said the residents should have been offered shaves and haircuts. 4) Resident 176 admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively intact, required physical assistance with bathing, and choices related to bathing were identified as Very Important. On 11/04/2024 at 3:38 PM, Resident 176 said they were not asked about the type or frequency of bathing they preferred. The resident reported staff just informed them that they would be showered one day per week. Resident 176 said they preferred daily showers but while at the facility, they wanted one at least every three days. An ADL care plan, revised 10/30/2024, showed Resident 176 required substantial assistance with bathing. The care plan did not identify the resident's desired frequency of bathing. Review of Resident 176's bathing records from 10/18/2024 - 11/08/2024 (21 days), showed the resident was offered/provided bathing once, on 10/29/2024. On 11/14/2024 at 7:43 AM, Staff B, DNS, confirmed Resident 176's bathing documentation showed for the 21-day period between 10/18/2024 - 11/08/2024, the resident was offered /provided bathing once, on 10/29/2024. 5) Resident 67 admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed the resident was cognitively intact, required substantial assistance with bathing, and choices related to bathing were identified as Very Important. On 11/07/2024 at 11:52 AM, Resident 67 said due to staffing, the shower aid did not always show up on their scheduled shower day(s). An ADL care plan, revised 08/14/2024, showed Resident 67 required one person moderate to maximum assistance with bathing. Review of the Resident 67's bathing record showed the resident went the following periods without being offered/provided bathing: a) 08/01/2024- 08/14/2024 (14 days) b) 08/16/2024- 09/09/2024 (25 days) c) 09/25/2024- 10/07/2024 (13 days) On 11/14/2024 at 7:43 AM, Staff B, DNS, confirmed Resident 67's bathing documentation showed they went the above referenced periods without being offered or provided bathing. 6) Resident 62 admitted to the facility on [DATE]. The Quarterly MDS, dated 10/092024, showed the resident was cognitively intact, required substantial assistance with bathing, and choices related to bathing were identified as Very Important. On 11/05/2024 at 10:50 AM, Resident 62 said they were happy with one shower a week, if the shower aide was always available to provide it, but indicated they were sometimes unavailable due to staffing. An ADL self-performance care plan, revised 04/26/2024, directed staff to provide one person assistance with bathing per the resident's chosen schedule. The care plan did not identify what the resident's chosen bathing schedule was. Review of the Resident 62's bathing record showed the resident went the following periods without being offered/provided bathing: a) 09/13/2024- 10/25/2024 (42 days) b) 09/01/2024- 09/12/2024 (12 days) On 11/14/2024 at 7:43 AM, Staff B, DNS, confirmed Resident 62's bathing documentation showed Resident 62 went the above referenced periods without being offered or provided bathing. Reference WAC 388-97-1060 (2)(c) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6) Resident 61 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 61 was cognitively intact. On 11/04/2024 at 3:29 PM, Resident 61 said the facility is having staffing issues, especially in Physical Therapy (PT). Resident 61 said they were supposed to have PT fivedays a week, but right now they are only getting it 2-3 times a week, because the restorative aides continue to get pulled to work the floor. A Physical Therapy (PT) Evaluation & Plan of Treatment dated 12/01/2023, documented Resident 61 was to have PT 5 times a week, for 4 weeks. Documentation showed Resident 61 attended Rehabilitative services and was discharged [DATE] due to highest practical level achieved. Discharge recommendations included restorative program up to 5 times a week as tolerated. A Progress note, dated 09/26/2024, from Social Services, documented Resident 61 would like more than two days of restorative therapy. Resident was not receiving restorative services due to restorative aides being pulled from assigned job to work the floor tp provide patient care. Reference WAC 388-97-1060 (3)(d), (j)(ix) Based on interview and record review, the facility failed to provide restorative services at the frequency residents were assessed to require for 6 of 7 residents (Residents 48, 22, 55, 46, 25 and 61) reviewed with restorative nursing programs (RNPs). The failure to provide RNPs at the frequency residents were assessed to require, placed residents at risk for decrease in Range of Motion (ROM), development and/or progression of contractures, increased dependance on staff for care needs and a diminished quality of life. Findings included . 1) Resident 48 admitted to the facility on [DATE]. Review of the Annual MDS, dated [DATE], showed the resident was cognitively intact, and did not receive restorative nursing services during the assessment period. A restorative nursing care plan, initiated 08/15/2024, showed the resident would be provided active ROM restorative program to bilateral (both) upper extremities (UE) and lower extremities (LE) five times a week (5x/wk.), to maintain ROM and prevent contracture formation. Review of restorative documents showed the resident had an Active ROM program to bilateral UE/LEs using the Omni cycle or NuStep (modified and recumbent exercise bike that works UE and LEs) 4-6x/wk., and an ambulation program, with a goal of walking 100 feet using a front wheeled walker 4-6x/wk. On 11/13/2024 at 2:55 PM, when asked for restorative programs written as 4-6x/wk, who decided if the program would be provided four, five or six times in a given week, Staff B, Director of Nursing Services (DNS), stated, the resident and so if the resident shows six times a week, then the program would have to be offered six days a week, and if they declined, a refusal would be documented. Review of the September 2024 restorative records showed staff offered/provided Resident 48's ROM program on 10 of 25 days (Note: 10 is the number of times the program was offered/provided in September and 25 is the number of times at 6x/wk., the program should have been offered) and the ambulation program on 20 of 25 days. Review of the October 2024 restorative records showed Resident 48's ROM and ambulation programs were offered and provided on 7 of 26 days. 2) Resident 22 admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident was cognitively intact, and received restorative nursing services on 3 of 7 days during the assessment period A Restorative program care plan, revised 08/20/2024, showed the resident was to participate in an active ROM program to bilateral UE and LEs using the omni cycle on level two 5x/wk. Review of the October 2024 restorative record showed the active ROM program was offered/provided on 14 of 21 days. 3) Resident 55 admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident was cognitively intact, and did not receive restorative nursing services. A Restorative Program care plan, revised 08/20/2024, showed the resident would participate in a restorative ambulation program with four wheeled walker and with a goal of ambulating 200 feet 3x/wk. Review of the October 2024 restorative record showed Resident 55 was offered/provided their ambulation program 4 of 13 days. 4) Resident 46 admitted to the facility on [DATE]. Review of the quarterly MDS, dated [DATE], showed the resident was cognitively intact, and did not receive restorative nursing services. Review of Resident 46's restorative documents showed the resident was to participate in a active ROM restorative program four to six times per week utilizing the omni cycle. An ADL care plan, revised 11/12/2024, showed as of 10/31/2024, Resident 46 was to participate in a restorative ambulation program with a two wheeled walker 5x/wk. and active ROM/strengthening program using the omni cycle 5x/wk. Review of the November 2024 restorative records through 11/14/2024 showed the resident was offered/provided their ROM program on 5 of 10 days, and their ambulation program on 4 of 10 days. 5) Resident 25 admitted to the facility on [DATE]. Review of the Annual MDS, dated [DATE], showed the resident was moderately cognitively impaired, had impaired functional ROM to one lower extremity (LE), and received restorative nursing services on 2 of 7 days during the assessment period. Resident 25's restorative documents showed they were to receive an active ROM program using the omni cycle four to six times a week. Review of the September 2024 restorative documents showed the resident was offered/provided the program 13 of 24 days. On 11/13/2024 at 10:27 AM, when asked if there was anything preventing them from offering/providing resident restorative programs at the frequency they were assessed to require Staff FF, Restorative Aide, said, staffing. Staff FF explained they were the only Restorative Aide and were frequently pulled from restorative to work the floor. On the days they were pulled to the floor Staff FF indicated most of the restorative programs did not get done, although therapy staff would help as able. Staff FF said they did not currently have a Restorative Nurse. Staff FF said they had spoken with Staff A, Administrator, who had acknowledged that more Restorative staff were needed. For the period from 10/16/2024 - 11/01/2024 (16 days), Staff FF worked 13 shifts. Of the 13 shifts worked, Staff FF was pulled from restorative to work the floor seven times. On 11/13/2024 at 12:03 PM, Staff A, Administrator, said they were aware that restorative needed more assistance and acknowledged that staffing had detracted from the provision of restorative services at the frequency residents were assessed to require.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Review of the Electronic Health Record (EHR) showed Resident 21 was admitted to the facility on [DATE]. Resident 21 had diagnoses inlcuding malnutrition (lack of sufficient nutrients in the body), hyponatremia (low sodium levels) and gastrostomy status (surgical intervention for a feeding tube that goes through the abdomen into the stomach). Review of the Annual MDS, dated [DATE], showed Resident 21 was dependent on staff for cares. <Formula> Review of the EHR showed Resident 21 was ordered to receive 1400 milliliters (ml) of formula (liquid nutrition). Review of Resident 21's October administration record for formula showed: 406 ml on 10/15/2024 and 938 ml on 10/26/2024. Review of Resident 21's progress notes showed no documentation of why volumes were low on these dates. During an interview on 11/13/2024 at 10:22 AM, Staff C, RCM, after looking through the EHR said their expectation regarding the formula being recorded as 406 ml on 10/15/2024 was that there should have been a progress note. During an interview on 11/14/2024 at 8:53 AM, Staff B, DNS, said their expectation was for staff to have notified the provider when a resident did not get the correct formula volume, and should have documented a reason or what the plan was. <Weights> Review of Resident 21's weights record showed none since 08/10/2024. Review of Resident 21's nutrition progress notes on 09/18/2024 and 10/16/2024 recommended staff obtain an updated weight. Review of Resident 21's progress notes from August to November 2024 showed no mention of any refusals or reason to not obtain a weight. During an interview on 11/13/2024 at 9:16 AM, Staff K, Registered Nurse (RN), said long term residents should receive monthly weights. During an interview on 11/13/2024 at 10:22 AM, Staff C, RCM, said their expectation for Resident 21's weights was to have seen something documented in the progress notes if the resident had refused any. During an interview on 11/14/2024 at 11:36 AM, Staff B, DNS, said after looking at the EHR they were unable to find an updated weight for Resident 21 and a weight should have been done monthly. <Water Flushes> Review of Resident 21's laboratory results showed Resident 21 had a sodium level of 128 (results show normal value is 134-144), on 04/22/2024. Resident 21 was seen at an outside hospital, and review of hospital records showed Resident 21 had sodium levels of 136 on 05/31/2024 and 138 on 06/01/2024. Review of Resident 21's orders showed Resident 21 had an updated order on 07/19/2024 that increased every six-hour water flushes (dose) of the gastrostomy tube, from 100 ml to 180 ml. No laboratory results were found after the updated water flush order on 07/19/2024, until 11/07/2024 when Resident 21's sodium level was 111, a critically low value. During an interview on 11/13/2024 at 9:16 AM, Staff K, RN, said residents with low sodium levels should have less water. During an interview on 11/13/2024 at 12:51 PM, Staff L, Registered Dietician, said for Resident 21 the water flushes were increased to meet hydration needs. Staff L said for residents with low sodium, water flushes should be reduced. When asked to provide documentation that the sodium levels were reviewed in making the decision to increase the water flush, Staff L was unable to provide documentation. During an interview on 11/14/2024 at 8:53 AM, Staff B, DNS, said, regarding Resident 21's increase in water flushes, that the registered dietician recommended the flushes, this change should be discussed and reflected with labs, and this should have been presented to the provider to follow up on what they wanted ordered. 4) Review of the EHR showed Resident 10 was admitted to the facility on [DATE]. Resident 10 had diagnoses of heart failure and ESRD. Resident 10 was requiring dialysis (intervention to filter the blood to remove waste). Review of Resident 10's orders showed they were on a fluid restriction of 1000 ml per day. Review of Resident 10's fluid intake record of the past 30 days showed: 240 ml on 10/15/2024, 240 ml on 10/16/2024 and 150 ml on 10/17/2024. The nursing administration records were reviewed, and no additional documentation was present for fluid intake on 10/15/2024, 10/16/2024, or 10/17/2024. During an interview on 11/12/2024 at 8:53 AM, Staff C, RCM, said the fluid intake record would be recorded by the nursing aids and would be missing values done by nursing. Staff C reviewed the nursing administration records for Resident 10, said the fluid given by nursing staff was not recorded on the administration record, and this did not meet expectations. During an interview on 11/12/2024 at 4:25 PM, Staff B, DNS, said a resident on a fluid restriction should have documentation on how many fluids they are receiving, and this documentation of fluid intake for Resident 10 did not meet expectations. Reference WAC 388-97-1060 (3)(h)(i) 2) Resident 64 was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS, an assessment tool), dated 09/12/2024, documented Resident 64 was moderately cognitively impaired. Resident 64 is an extensive/total assist with all activities of daily living (ADL's). Resident 64 admitted to the facility weighing 237.6 pounds (lbs). A Licensed Nurse (LN) Nutrition/Hydration Risk Evaluation, dated 04/15/2024, documented Resident 64 was able to self-feed, had a stable weight, no dental issues, consumed 50%-75% of meals with more than 2000 cubic centimeters (cc) of fluid intake. Overall score 4.0 (low risk). A Nutrition-admission Evaluation, dated 04/17/2024, documented Resident 64 was on a restricted concentrated sweets and Renal (kidney) diet. Resident 64 was reported to have a good appetite, no swallowing disorders or gastroenterology issues. Documented target weight was 266 pounds (lbs). A LN Nutrition Interdisciplinary Team review, dated 04/24/2024, documented Resident 64 had end-stage renal disease (ESRD, a permanent condition where the kidneys are no longer able to function and require dialysis or a kidney transplant), weight loss was related to fluids and diuretic (a drug that increases the amount of urine produced by the kidneys, which helps the body get rid of excess water and salt) use. Resident was averaging 63% of meal consumption. Recommendation was to obtain dialysis weights. Weights as followed: 04/17/2024 14:30 244.4 Lbs 04/20/2024 21:08 244.6 Lbs 05/31/2024 09:35 239.8 Lbs 06/18/2024 14:22 226.82 Lbs 06/27/2024 14:21 224.18 Lbs 07/09/2024 14:13 208.12 Lbs 07/11/2024 14:10 211.64 Lbs On 04/15/2024, the resident weighed 237.6 lbs. On 07/11/2024, the resident weighed 211.6 pounds which was a -10.94 % Loss. A Licensed Nurse (LN) Nutrition/Hydration Risk Evaluation, dated 07/15/2024, documented Resident 64 was able to self-feed, had a stable weight, no dental issues, consumed 50%-75% of meals and more than 2000 cc of fluids. Overall score 4.0 (low risk). A Nutrition Quarterly Evaluation, dated 07/17/2024, documented Resident 64 was taking Nepro (supplement) twice a day and Prosource (supplement) twice a day. Documented target weight was 222 lbs. Per dialysis weight, Resident 64 had a significant weight loss of 6.5% in 1 month and 9.1% decrease in 3 months. At 11:02 AM, Staff B, Director of Nursing (DNS), when asked about Resident 64's nutritional status, said Resident 64 was being seen by the Registered Dietitian, Resident 64 was reviewed 04/17/2024, 07/17/2024 and 09/12/2024 and 10/09/2024. Staff B said the Interdisciplinary Nutrition team reviewed Resident 64's nutrition on 04/24/2024, 08/14/2024, 08/29/2024 and 09/05/2024. When asked about the significant weight loss (more than 7.5% in 3 months) between Resident 64's admission and the quarterly review, Staff B said there was no other reviews and Resident 64's significant weight loss should have been caught before the quarterly review Based on interview, and record review, the facility failed to ensure residents receiving enteral feedings, were administered enteral formula at the physician ordered rate and volume for 1 of 1 resident (Resident 21) reviewed for enteral feeding. The facility also failed to ensure routine resident weights were obtained, reviewed, weight loss trends identified, and nutritional nutritional interventions were timely identified and implemented for 2 of 2 residents (Resident 64 and 21) reviewed for weight loss. Additionally, the facility failed to have a system in place that ensured fluid intake was accurately monitored, documented, and 24-hour intake totals were calculated and evaluated, and labs were monitored for fluid and electrolyte imbalances for 2 of 2 residents (Resident 58 and 10) reviewed with a fluid restrictions. These failures placed residents at risk for continued weight loss, inadequate nutrition, fluid volume overload, fluid and electrolyte imbalances and other medical complications. Findings included . <Fluid Restriction> Resident 58 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had diagnoses of kidney disease and heart failure, and required diuretic (medication to draw extra fluid from the body through urine) therapy. A nutrition care plan, revised 10/25/2024, showed Resident 58 was on a 1500 milliliter per day (ml/day) fluid restriction, with nursing providing 180 ml per shift and 118 ml health shake for a total of 658 ml/day, and dietary providing 360 ml at breakfast, and 240 ml with lunch and dinner for a total 840 ml/day. A fluid restriction care plan, revised 10/25/2024, showed the resident received diuretic therapy and directed staff to implement fluid restriction per physician orders. Review of Resident 58's EHR showed their fluid intake with meals was recorded on the meal monitor in point of care (computer program), and fluids provided by nursing were recorded on the Medication Administration Record (MAR). Review of the November 2024 MAR showed nurses were recording the amount of fluid they provided each shift, but there was no direction or spot provided for nursing to reconcile the fluid intake recorded on the meal monitor with the fluid intake recorded on the MAR to calculate the resident's 24-hour fluid intake total. On 11/08/2024 at 11:53 AM, Staff GG, Resident Care Manager (RCM), explained the purpose of the fluid restriction was to manage the resident's fluid volume status due to chronic kidney disease. Staff were to record the resident's fluid intake and then assess whether the resident was adherent or non-adherent with the restriction. If the resident was non-adherent, nursing would educate the resident to the risks and benefits and notify the physician. On 11/08/2024 at 11:53 AM, when asked if there was any documentation to support staff had calculated the resident's 24 hour fluid intake to evaluate if the resident was adherent with the fluid restriction Staff GG, RCM, said no, and acknowledged the fluid restriction had not been effectively implemented or monitored and needed to be corrected.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on observation, interviews and record review, the facility failed to have sufficient staff to provide and supervise care as evidenced by information provided by 7 resident interviews (Resident 18, 19, 59, 64, 376, 40 & 58), Resident Council interviews (Residents 40 & 59) and Staff interviews (Staff E, BB, CC, DD, EE & H) and as evidenced by failed practices in many identified quality of life and quality of care areas. The facility had insufficient staff to ensure residents received assistance with Activities of Daily Living (ADL) including grooming and showers, assessments, care planning, care plan revision, restorative services, hospice services and infection control in accordance with established clinical standards, and resident needs and preferences. These failures placed residents at risk for unmet care needs, negative outcomes and a diminished quality of life. Findings included . <Resident Interviews> On 11/04/2024 at 11:03 AM, Resident 18, said staff would come in and tell them they were busy and would have to wait. At 11:18 AM, Resident 19 said staff took a long time to respond, it depended who was on duty on how long we they would have to wait for staff to respond. At 12:15 PM, Resident 59 said my call light was on a least an hour last night, I waited for staff to come and remove the urine tub. Resident 59 said it was upsetting when staff would tell them they would be back and then would not return for hours. Resident 59 said it took staff an hour and half to return to help them last night. At 2:46 PM, Resident 64 said they would have to wait a long time, sometimes up to 30 minutes for staff to respond. Resident 64 said they used the clock on their cell phone to keep time. Resident 64 said sometimes it could be up to an hour for staff to respond and it was across all shifts. At 3:12 PM, Resident 376 said the facility did not have enough staff and stated, I hold it [bathroom use] long enough to where I cannot hold it much longer. On 11/05/2024 at 8:30 AM, Resident 40 said they had concerns that staff were being pulled (restorative and shower aids) to help on the floor, they were not getting restorative services and only one shower a week. At 9:17 AM, Resident 58 stated, I can wait for hours for them to get me out of bed and clean me, I need a hoyer [mechanical] lift, I have sat in my pee until they get me up with the hoyer. <Grievances> On 10/06/2024 a grievance was filed by Resident 59, documenting they had not received a shower in almost two weeks due to shower aides not being available to provide showers. On 10/22/2024, Resident 40 filed two grievances: 1) Resident 40 documented residents were not receiving restorative services due to restorative aides being pulled from assigned job, due to staff shortages. 2) Resident 40 documented residents were not getting showers due to shower aides being pulled from assigned job, due to staff shortages. <Resident Council Minutes> Resident Council minutes for May 2024 documented, once again we must bring up informing the residents of appointments ahead of time and a day or two in advance would be better than a few minutes before pickup. Residents who need assistance transferring are still having to wait a half-hour, an hour or more to use the bathroom or go to bed. This seem to be an ongoing problem with lack of sufficient staffing to provide coverage. Resident Council minutes for June 2024 documented, Still concerns about getting light answered timely. Resident Council minutes for August 2024 documented, How can we get notified of appointments? Resident find out the day of the appointment and not told ahead of time. Resident Council minutes for September 2024 documented, a grievance was filed on the behalf of the Resident Council, related to wanting to know ahead of time about appointments. Concerns regarding when more staffing would happen was also brought up. On 11/06/2024 at 1:00 PM, Resident Countil member interviews showed: Resident 17 said sometimes thier needs were not being met until after a long wait time. Resident 17 said shower aides were being pulled and they weren't getting showers. Resident 17 said there had not been a Social Services person. Resident 40 said they felt like residents did not have anyone to go to to get their problems addressed. <Staff Interviews> On 11/12/2024 at 10:05 AM, Staff E, Resident Care Manager, said everything was in transition and the facility was trying to get the new Social Services (SS) team set up and it had been a struggle. Staff E said the facility lost the previous Social Services person and it staffing had been a struggle. On 11/13/2024 at 1:20 PM, when asked if staff had time to answer staffing questions, Staff BB, Certified Nursing Assistant, stated, you have to walk with me, I can't stop. When asked if she felt she had enough time to complete her daily tasks, Staff BB said not really, see how fast I am walking, you have to hurry and go. Staff BB said she had been asked to work overtime a lot lately. At 1:33 PM, Staff CC, Licensed Practical Nurse (LPN), said when she was working eight hours a day, she was not able to get her daily assignments completed, but since switching to 12 hour days, she has been able to complete her daily assignments. Staff CC said it was worse on weekends because the Administrative staff were not there to help with processing orders, treatments, phones, etc. Staff CC said wound care was hard because the contracted wound services they used would only come in on Wednesdays, and the rest of the time wound care was on the nursing staff. Staff CC said it would be more helpful if there were more nursing assistants helping to answer call lights, pass meal trays and provide care, so the nurses could focus on medication administration and treatment orders. Staff CC said the restorative and shower aides were often pulled from their assignments because people would call out. At 1:52 PM, Staff DD, CNA, said it would depend on how the day was going, if he was able to get all his daily assignments completed. When the facility was busy, he would not be able to complete all his assignments. Staff DD said it was usually pericare and showers that were not completed. Staff DD said the shower aides and restorative aides were often pulled to provide patient care, this would happen 3-4 times a week. Staff DD said he stayed late twice last week. At 2:02 PM, Staff EE, LPN, said it would take her all morning to do medication administration and the only other thing she had time to complete was wound care. <Restorative Services> On 11/13/2024 at 10:27 AM, when asked if there was anything preventing them from offering/providing resident restorative programs at the frequency they were assessed to require Staff FF, Restorative Aide, said, staffing. Staff FF explained they were the only Restorative Aide and were frequently pulled from restorative to work the floor. On the days they were pulled most of the restorative programs did not get done, although therapy staff would help as able. Staff FF said they did not currently have a Restorative Nurse. Staff FF said they had spoken with Staff A, Administrator, who had acknowledged that more Restorative staff were needed. For the period from 10/16/2024 - 11/01/2024 (16 days), Staff FF worked 13 shifts. Of the 13 shifts worked, Staff FF was pulled from restorative to work the floor seven times. <Bathing Services> On 11/07/2024 at 1:51 PM, when asked if there was anything that prevented them from providing resident bathing/showers as scheduled Staff II, Shower Aide, stated, Yes, the only thing is getting pulled [from showers to provide direct care, due to staffing issues]. At 2:35 PM, Staff H, CNA/Shower Aide, said most of the time she could complete her daily tasks, but was pulled 1-2 times a week to help provide patient care. When asked about making up showers for the residents that missed their shower day, due to staffing, Staff H said she would try to make them up the next day. On 11/13/2024 at 12:19 PM, Staff B, Director of Nursing Services, when asked if staffing had affected the ability for staff to provide bathing and restorative services at the frequency residents were assessed to require, Staff B said that staffing may have inadvertently affected the provision of both. At 2:54 PM, Staff A, Administrator, said there had been staffing issues, and they had been trying to address them. Staff A said yes, when asked if the staffing issues had affected resident care. Refer to F578, F623, F625, F676, F684, F688, F804, F849 & F880 .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on observation and interview, the facility failed to ensure expired medications and supplies were removed/discarded in 1 of 2 medication storage rooms (Medicare A and Medicare B medication room) reviewed for medication storage and labeling. This failure placed residents at risk of receiving compromised and/or ineffective medications and medical supplies. Finding included . On 11/04/2024 at 2:50 PM, the following outdated medications and supplies were observed: - Package of blood glucose lancets, label read, facility should use or discard by 06/30/2024 - 3 bottles of blood glucose strips, expired 08/22/2024. - Ibuprofen 200 milligram (mg), opened, expired 09/2024. - Vitamin B-6 100 mg opened, expired 10/2024. - Daily Vitamin formula plus iron, opened, expired 08/2024. - Arexvy (a vaccine to protect against lower respiratory tract disease) 120 micrograms (mcg)/0.5mg vial in fridge, expired, label read, use or discard by 09/25/2024. - Tuberculin Purified Protein Derivative vial in fridge, date accessed 09/13/2024, expired 10/13/2024. - Bottle of Urine Reagent Strips (used to test for specific parameters in urine) read, do not use after 90 days of breaking foil seal, bottle was opened but not dated. On 11/04/2024 at 3:05 PM, Staff C, Resident Care Manager, said nursing staff were responsible for going through medications and supplies to remove and dispose of expired medications and supplies. On 11/12/2024 at 3:48 PM, Staff B, Director of Nursing, said her expectation would be that those expired medications be destroyed or removed at the expiration date. Reference WAC 388-97 -1300 (1)(b)(ii), (c)(ii-iv) .

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on observation, interview and record review, the facility failed to prepare food in a manner that ensured meals were appetizing, palatable and served at appropriate temperatures for 9 of 15 sampled residents (56, 43, 58, 19, 18, 59, 64, 13 and 126) reviewed for dining. This placed residents at risk for a decreased nutritional intake and dissatisfaction with meals. Findings included . <Resident Interviews> On 11/04/2024 at 2:02 PM, Resident 56 said, the food here stinks, the food texture is pasty, it feels like you are eating glue, like they glued it all together. The soups seem to be leftover stuff from other meals. At 12:14 PM, Resident 43 said the food did not always taste good and was often that the hot was not hot and the cold was not cold. On 11/05/2024 at 9:27 AM, Resident 58 stated, The food is terrible. It is not good. On 11/04/2024 at 11:00 AM, Resident 19 said he wanted a hot meal, the meals were consistently cold, and the bacon always had the taste of oil. Resident 19 said they had sent meals back because it was cold. At 11:05 AM, Resident 18 said the food was cold and it could it happen at any meal. At 12:17 PM, Resident 59 said the food was bland and it had a freezer burnt taste. Resident 59 said they gave them menus and they would check off what you would want and not want, but they wouldn't always give them what they wanted. Resident 59 said it was the same stuff every two weeks and gave the example that they receive Salisbury steak at least twice a week and breakfast was always eggs. At 2:35 PM, Resident 64 said the food was terrible, it doesn't taste good and the temperature was medium, but not hot. At 2:59 PM, Resident 13 said some meals were, mystery meat. Resident 13 said they had spoken to the kitchen, but nothing had changed. Resident 13 said they had a refrigerator in their room where they kept beef soup, if they did not like what was being served. On 11/05/2024 at 8:45 AM, Residents 126 ate less than 25 percent of breakfast, only a few bites of eggs. Resident 126 said they did not like the texture of eggs. Resident 126 said lunch and dinner depended on what was being served. Resident 126 said they would prefer cereal for breakfast. On 11/06/2024 at 8:36 AM, Resident 59 (who had eaten breakfast in the dining room) said the breakfast was not hot, the pancakes were cold and didn't taste the best. Resident 59 said they covered the pancakes in syrup to help. On 11/07/2024 at 1:52 PM, Resident 59 said lunch was Chicken Almondine and that it tasted good but was cold. <Observations of Meal Delivery> On 11/06/2024 at 8:27 AM, a meal cart was observed sitting in the [NAME] Mountain Hall next to the nurses' cart. No meals delivered at this time. At 8:44 AM, a staff member brought a breakfast meal tray to Resident 61 (17 minutes after arrival of the meal cart to the floor). At 8:45 AM, a staff member brought a breakfast meal tray to Resident 64 (18 minutes later). <Meal Preparation> Observation of meal preparation and tray line on 11/12/2024 from 10:47 AM - 12:23 PM showed dietary had removed all resident beverages (juices and milks) from the refrigerator and placed them on trays in the tray carts by 11:20 AM. At 12:21 PM, after preparing the Garden Room and Medicare A Hall meal cart(s) for delivery staff had not checked the temperature of any of the beverages, which had been sitting out on the carts since 11:20 AM (61 minutes.) Upon request, Staff MM, Dietary Aide, checked the temperature of a cup of cranberry juice which was 57.1 degrees. Staff MM then placed the juice back on the cart for delivery. <Test Tray> On 11/12/2024, a test tray was delivered at 12:54 PM. The temperature of the juice was 58.9 degrees, the milk was 56.3 degrees, and the chocolate pudding was 57.4 degrees. On 11/12/2024 at 3:27 PM, when asked if they always prepared and placed resident beverages on the meal carts 40 minutes to an hour prior to meal service, Staff LL, Dietary Manager, indicated they had to prepare them ahead of time and place them on the trays so tray line would go smoother. No explanation was provided as to why the beverages could not be placed on ice and added to resident trays by the dietary aide while the cook was plating the food. Reference WAC: 388-97-1100 (3) .

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on observation, interview and record review, the facility failed to ensure residents' received therapeutic diets as prescribed by the physician, and/or assessed by the interdisciplinary team for 5 of 23 residents whose meals were observed (Residents 46, 24, 10, 50 and 42), and to provide the correct portion size for 6 of 6 residents (Residents 42, 71, 24, 43 64 and 127) observed with orders for small or large portions. Failure to ensure residents' received physician ordered therapeutic diets and/or portion sizes placed residents at risk for medical complications and/or unmet nutritional needs. Findings included . <Therapeutic Diets> On 11/12/2024 at 11:20 AM, dietary staff had already placed beverages and condiments on all resident trays and placed them into the tray carts. Observation of the trays at that time, showed each tray had been provided a container of tartar sauce. Review of the therapeutic menu for the lunch meal, which consisted of cakes, rice pilaf with mushrooms, seasoned green peas with chocolate cream pie, showed the following diet types were not to receive tartar sauce: No added salt (NAS); low fat/low cholesterol; two grams sodium (2 GM Na); renal (low sodium/potassium). During tray line on 11/12/2024 from 11:39 AM - 12:23 PM, the following residents' trays were observed being prepared and sent out for delivery: 1) Resident 46 who was on a renal diet. 2) Resident 24 who was on a NAS diet. 3) Resident 10 who was on a NAS diet. 4) Resident 50 who was on a 2 GM Na diet. 5) Resident 42 who was on a controlled carbohydrate diet with Additional Directions of NAS. Each of the above residents were provided tartar sauce on their meal tray despite the therapeutic menu directing staff not to provide it. On 11/12/2024 at 12:23 PM, Staff LL, Dietary Manager, confirmed all residents, including the above referenced residents, had been provided tartar sauce on their trays and should not have been. After confirming it, Staff LL failed to direct staff to remove the tartar sauce from other residents' trays who were on NAS, low fat/low cholesterol, 2 GM NA or renal diets. <Portion Sizes> Observation of tray line on 11/12/2024 from 11:39 AM - 12:23 PM, showed staff had green handled spoodles (4 oz or 1/2 cup) placed in the rice pilaf and seasoned green peas, as the recipe called for. During tray line on 11/12/2024 from 11:39 AM - 12:23 PM, Staff JJ, Cook, was observed plating meals for the following residents: 1) Resident 42 whose diet under Additional Directions, directed staff to provide small portions, but the resident was provided a full serving of seasoned peas, rice pilaf and crab cake. 2) Resident 71's diet ticket directed staff to provide small desert portions, but the residents was provided a full portion of desert. 3) Resident 24's diet ticket directed staff to provide small portions, but the resident was provided full serving of seasoned peas, rice pilaf and crab cake. 4) Resident 43's diet ticket directed staff to provide small desert portions, but the resident was provided a full potion of desert. 5) Resident 64's diet ticket directed staff to provide large protein portions, but the resident was only provided one crab cake. 6) Resident 127's diet ticket directed staff to provide large portions, but the resident was provided one crab cake and 1/2 cup of seasoned peas and rice pilaf. On 11/12/2024 at 12:15 PM, Staff JJ, Cook, and Staff MM, Dietary Aide, both confirmed that the same 1/2 cup spoodle for each of the above referenced residents and agreed each resident received one scoop, despite the ordered portion size. Staff JJ indicated they had visually adjusted the amount they had in the scoop (e.g. filled it halfway for small portions etc.) On 11/12/2024 at 12:23 PM, Staff LL, Dietary Manager, explained that staff usually did use just one spoodle and visually adjust the amount they scooped, rather than using a 1/4 cup scoop for small portions or providing a 1/2 cup and a 1/4 cup scoop for large portions. When asked if small portions of desert meant the resident should get 1/2 desert Staff LL stated, Yes. On 11/12/2024 at 12:58 PM, when asked if dietary staffs' practice of visually adjusting the scoop size of a 1/2 cup spoodle to provide a 3/4 cup serving for large portions and 1/4 cup for serving small portions was acceptable Staff A, Administrator, said no, they should use the appropriate size spoodle. Reference WAC 388-97-1200(1) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on interview and record review, the facility failed to seek/ obtain approval from the Resident Council, and to ensure residents were provided a nourishing snack at bedtime, when the time between the dinner and breakfast meals was increased from 14 hours to 15 hours. These failures precluded residents from having input about extending the time between meals beyond 14 hours and placed them at risk for feelings of hunger and inadequate nutrition. Findings included . a) The Garden Room and Medicare A hall were served dinner at 5:00 PM and breakfast at 8:00 AM, for a total of 15 hours in between meals. b) Medicare B was served dinner at 5:10 PM and breakfast at 8:10 AM, for a total of 15 hours in between meals c) [NAME] Mountain and Mountain View Halls were served dinner at 5:15 - 5:20 PM and breakfast at 8:15 - 8:20 AM, for a total of 15 hours in between meals. On 11/14/2024 at 7:45 AM, Staff B, Director of Nursing Services, said they were unable to find documentation to show they sought approval from the Resident Council prior to extending the time between Dinner and Breakfast meals beyond 14 hours. When asked if the facility was serving residents a nourishing snack at bedtime, Staff B said only diabetic residents were served snacks at bedtime, but indicated snacks were available to other residents if requested. Reference WAC 388-97-1200(1) .

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to have a system in place that ensured effective communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 2 of 2 residents (Resident 64 & 28) reviewed for hospice services. The facility failed to obtain and/or maintain a copy of a resident's current hospice coordinated plan of care, to have documentation in residents' Electronic Health Records (EHR) that showed what hospice disciplines (e.g. registered nurse, chaplain, certified nursing assistant, massage therapist) had visited, when they visited, and what care was provided. These failures detracted from staffs' ability to effectively collaborate, communicate and coordinate care with the hospice provider and placed residents at risk for not receiving necessary care and services and/or unmet care needs. Findings included . Review of the facility's Hospice Service Agreement, effective date [DATE], showed the facility and hospice would each designate a Registered Nurse responsible for coordinating the implementation of the plan of care for each hospice patient. Additionally, hospice and the facility agreed to develop a plan of communication for each hospice patient and further agreed, as required by state or federal regulations, to enter all necessary information into each Hospice patient's medical chart. 1) Resident 64 was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS, an assessment tool), dated [DATE], documented Resident 64 was moderately cognitively impaired. Resident 64 was placed on hospice on [DATE]. Resident 64's Hospice Care Plan, dated [DATE], documented hospice would only provide a bed bath once a week and Activities of Daily Living (ADL's) once a week. The facility was responsible for providing all other ADL assistance, except when hospice staff was present, including wound care. Review of facility/hospice services binder, located at the Long Term Nurses station, only provided information that Resident 64 was no longer receiving the 12 microgram Fentanyl patch. No other information was located in this hospice binder. The facility/hospice service binder at the Medicare A and B Nurses station, provided no documentation for Resident 64's hospice care. The last progress note from hospice was on [DATE], no further documentation was in the EHR. Progress notes on [DATE] and [DATE] showed the facility contacted hospice regarding medications. No other progress notes showed communication with hospice. On [DATE] at 10:05 AM, Staff E, Resident Care Manager, said the facility currently did not have a designated person for communication with hospice and the nurse who communicated with hospice should document all communication. When asked about the hospice binder, Staff E said every resident on hospice should have a tab in the binder for communication between the facility and hospice. Staff E said Resident 64 should have had a section specific to them. Staff E said any hospice communication documentation should have been given to the nurse, who would process the order and then give the record to medical records to upload into the EHR. At 12:45 PM, when reported there was no documentation from hospice since [DATE], Staff B, Director of Nursing Services (DNS), said there should have been documentation in the hospice binder for Resident 64 and all residents on hospice. 2) Resident 28 admitted to the facility on [DATE]. Review of the [DATE] Quarterly MDS showed the resident had a terminal diagnosis and received hospice services. A Certificate of Terminal Illness showed Resident 28 started on hospice services on [DATE]. Review of the most recent hospice plan of care in Resident 28's record showed it had expired on [DATE]. A recertification visit, dated [DATE], was present in the record but not a copy of the resident's current coordinated plan of care. On [DATE] at 12:03 PM, when asked who the facility designated as the liaison to coordinate and implement hospice residents' plans of care, Staff B, DNS, said that any nurse could communicate and coordinate hospice care and said there was not a specific staff member identified. Staff B then indicted that for further hospice questions Staff X, Registered Nurse, was the best person to speak with. A Hospice care plan, revised [DATE], showed the resident was to receive weekly hospice nurse visits as well as weekly aide visits to provide shower/sponge baths. Review of Resident 28's EHR showed no documentation was present to show what hospice disciplines had visited, when, or what they did. Additionally, it was unclear if the hospice care plan remained accurate as the facility did not have a copy of the resident's current coordinated hospice plan of care. On [DATE] at 12:30 PM, when asked if they could tell what hospice disciplines had visited the resident in the past two weeks, when, and what they did during the visit (e.g. provide bed bath etc.), Staff X said No. Staff X explained that they had identified issues with the communication between hospice and the facility and recently initiated a hospice binder to improve communication but indicated it was in process. Staff X said they had requested hospice aide documentation and hospice nurse after visit summaries. When asked if they could find a current coordinated hospice plan of care for Resident 28, Staff X said no, but indicated they would request it. No Associated WAC .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <PPE Carts> Observation on 11/04/2024 at 10:27 AM, showed a resident's half eaten meal tray on the PPE cart across the hal...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <PPE Carts> Observation on 11/04/2024 at 10:27 AM, showed a resident's half eaten meal tray on the PPE cart across the hall from their room, next to Resident 21's room. At 10:41 AM, the tray was no longer on the PPE cart and staff were observed to place items (brief, absorbent pads) onto the PPE cart as they applied PPE and then entered Resident 21's room. Observation on 11/06/2024 at 8:31 AM, showed a PPE cart next to room [ROOM NUMBER] had a half empty mug filled with a dark liquid substance in it on the cart. At 8:44 AM, the PPE cart was observed to have the same mug, with a nursing aid putting new items next to it (milk, orange juice, water, and straws) on the PPE cart. The new items were observed to be brought into the room, the half-filled mug remained on the PPE cart. During an interview on 11/13/2024 at 9:58 AM, Staff C, RCM, said their expectation for PPE carts was staff not put anything on the PPE cart, and if they do then they clean it before putting something else on it. <Food Carts> Observation on 11/07/2024 at 9:29 AM, showed that a food cart labeled Med Cart B contained coffee on the bottom of the cart, and staff were putting used trays (taken from resident rooms) and putting the trays above the coffee that continued being served. A nursing aid was asked about the process and confirmed coffee was stored on one side and cups were stored on the other side of the cart, and that used trays were kept above. On 11/07/2024 at 12:17 PM, the Mountain View: food cart was delivered to the hall. Observation of the food cart at 12:21 PM showed staff were serving coffee/ tea from carafes stored on the bottom of the food cart underneath the residents' trays. Observation on 11/08/2024 at 12:21 PM showed the food cart labeled Med Cart B still had coffee being kept at the bottom of the cart. During an interview on 11/14/2024 at 1:43 PM, Staff B, DNS, said their expectation was for coffee to not be kept on the bottom of the food cart with staff still using the coffee. <Standard Precautions> Observation on 11/08/2024 at 12:34 PM showed Staff T, CNA, put a tray into the food cart labeled Med Cart B, went into an EBP room and took a tray from a resident, left the room, touched the food cart to put tray back into cart. Staff T went into another room and touched the door, left the room, then entered another residents room and was observed to help the resident clean up their chest using a tissue. Staff T then left the room with a bag of linen, went into the soiled linen room for a few seconds, left the room, and then went into a another room where they touched a wheelchair and the resident. No hand sanitizer was used at any point during this observation. During an interview on 11/08/2024 at 12:38 PM, Staff T said they forgot to hand sanitize, and they should have used hand sanitizer when entering a room. At 1:04 PM, Staff C, RCM, said for standard precautions (precautions used for all patient care) you should use hand sanitizer when you enter and leave rooms. During an interview on 11/13/2024 at 9:58 AM, Staff C, RCM, said the observation did not meet expectations, and they would have expected hand hygiene to have been completed several times. During an interview on 11/14/2024 at 1:43 PM, Staff B, DNS, said the observation did not meet expectations. <Urinary Catheter> Review of the Center for Disease Control and Prevention (CDC) document Guidelines for Prevention of Catheter (thin tube that collects urine)-Associated Urinary Tract Infections dated 2009, recommended staff maintained unobstructed urine flow by keeping the catheter and collection tube free from kinking (bend or twist obstructing flow of urine), the bag should not rest on the floor, and standard precautions should be used during any manipulation of the catheter's collecting system. Resident 21 Review of the Electronic Health Record (EHR) showed Resident 21 was admitted to the facility on [DATE]. Resident 21 had a suprapubic catheter (urinary tube that is placed into the bladder through a small hole in the abdomen, the tube carries urine outside of the body and is connected to a drainage bag that collects urine). Observation of Resident 21's catheter tubing on: 11/04/2024 at 10:25 AM, 11/05/2024 at 8:28 AM & 9:59 AM, 11/06/2024 at 10:34 AM, 12:22 PM & 3:26 PM, 11/07/2024 at 9:09 AM & 10:27 AM, and 11/08/2024 at 8:11 AM showed urine in the dependent part of the catheter tubing that loops down, then the tubing loops up creating a section where the urine has to move against gravity to move up in the tubing, before it loops back down into the urine bag. Observation on 11/06/2024 at 10:38 AM showed Staff Z, CNA, after assisting Resident 21 with cares, went into the bathroom and grabbed a urinal, came out and emptied the urine bag attached to the catheter. Staff Z did not change gloves or perform hand hygiene before emptying the urine bag, and did not empty the urine tubing into the urine bag before emptying it. Observation on 11/06/2024 at 10:34 AM showed Resident 21's catheter tubing and bag were touching the floor. During an interview on 11/13/2024 at 2:29 PM, Staff C, RCM, said their expectation was for staff to use hand hygiene before emptying the urine bag into the urinal, and this did not meet expectations that the urine bag and tubing had touched the ground. During an interview on 11/14/2024 at 9:13 AM, Staff B, DNS, said their expectation was the catheter tubing would be drained into the urine bag before emptying, staff would follow hand washing techniques when they emptied the urine bag, and the catheter tubing would not touch the ground. <Negative Pressure Wound Treatment> Resident 56 Review of the EHR showed Resident 56 was admitted to the facility on [DATE]. Resident 56 had a diagnoses of surgical amputation (removal of a limb) and muscle weakness. The Medicare 5-day MDS, dated [DATE], showed Resident 56's mental status was moderately impaired. Observations on 11/06/2024 at 12:33 PM and 11/12/2024 at 9:33 AM showed the tubing from the negative pressure wound treatment (a technique that uses suction to promote wound healing) was on the floor. During an interview on 11/12/2024 at 9:44 AM, Staff C, RCM, confirmed the tubing was on the floor and said their expectation was the tubing would not be on the floor and be lifted off the floor when it happened. At 4:08 PM, Staff B, DNS, said it did not meet expectations that the negative pressure wound treatment tubing was on the ground. Reference WAC 388-97-1320 (1)(c), -1320 (2)(b), -1320 (1)(a) Based on observation, interview, and record review, the facility failed to perform hand hygiene, follow Personal Protective Equipment (PPE, equipment worn to minimize exposure to a variety of hazards requirements for a resident on Enhanced Barrier Precautions (EBP, an infection control method that involves wearing gowns and gloves during high-contact interactions with residents in nursing homes) orders, failed to prevent cross-contamination for food and PPE carts, and failed to prevent medical equipment from touching the floor for 3 of 25 sampled residents (Resident 7, 21 & 56) and 1 of 3 halls (Med Cart B Hall) reviewed for infection control practices. These failures placed residents at risk of developing and transmitting infections and a decreased quality of life. Findings included . <EBP> 1) Resident 7 was admitted to the facility on [DATE] and had diagnoses including dysphagia (difficulty swallowing) and aphasia (a language disorder that affects a person's ability to understand and express written and spoken language) following a cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, resulting in brain tissue death). The Quarterly Minimum Data Set (MDS, an assessment tool), dated 10/03/2024, documented the resident had a gastric feeding tube (it can be used for long-term nutritional support and is often used for people who have difficulty swallowing or can't get enough food by mouth). Resident 7 had an order, dated 10/03/2024, for Enhanced Barrier Precautions. PPE required for high resident contact care activities. Indications: Gastric tube. On 11/08/2024 at 7:27 AM, Staff W, Licensed Practical Nurse (LPN) gave Resident 7 their medications and Staff W said, I should have gowned up when I gave Resident 7 their medications but I forgot this time. At 8:54 AM, Staff X, Infection Preventionist (IP)/Registered Nurse (RN) said when giving medication through a gastric tube the nurse should put on PPE according to the EBP order. At 12:16 PM, Staff B, Director of Nursing (DNS) said her expectation would be for the nurse to follow the order for EBP.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of the EHR showed Resident 10 was admitted to the facility on [DATE] and consented to receive the pneumococcal vaccination on 10/29/2024. During an interview on 11/13/2024 at 8:51 AM, Staff C, Resident Care Manager (RCM), stated the pneumococcal vaccinations were not previously ordered from the supplier, and now the infection control nurse was made aware and would be ordering. During an interview on 11/14/2024 at 8:34 AM, Staff B, Director of Nursing Services (DNS), stated it did not meet expectations that Resident 10 signed consent and the pneumococcal vaccine was not ordered. 3) Review of the EHR showed Resident 21 was admitted to the facility on [DATE] and consented to receive the pneumococcal vaccination on 06/03/2024. During an interview on 11/13/2024 at 8:53 AM, Staff C, RCM, stated that Resident 21's pneumococcal vaccine was not ordered with the supplier, and this did not meet expectations. During an interview on 11/14/2024 at 1:43 PM, Staff B, DNS, stated their expectation since Resident 21 consented to the pneumococcal vaccination, was that it would be completed. Reference WAC 388-97-1340(1),(2),(3) Based on interview and record review, the facility failed to provide pneumococcal vaccines for 3 of 6 residents (Residents 176, 10 and 21) reviewed for vaccinations. This failure placed the residents at a higher risk for contracting pneumococcal infections, related complications, and a decreased quality of life. Findings included . 1) Resident 176 admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated 10/24//2024, showed the resident's pneumococcal vaccinations were not up to date and documented the pneumococcal vaccination had not been offered. A Resident Consent For Influenza, Pneumococcal, and COVID-19 Vaccination form, dated 10/18/2024, showed Resident 176 consented to the vaccination and checked the box on the form that stated, Yes, I wish to receive the pneumococcal vaccine according to the CDC's recommended schedule. Review of the Electronic Health Record (EHR) showed the resident was not provided the pneumococcal vaccination despite giving written consent to receive it. Resident 176 subsequently discharged home on [DATE] without receiving the requested vaccination. On 11/12/2024 at 11:08 AM, Staff X, Infection Preventionist, indicated they were not notified that Resident 176 had consented to the pneumococcal vaccination and acknowledged that the resident did not receive it. When asked if they would have expected the vaccination to be administered given the resident was in the facility for 25 days after providing consent, Staff X stated, Yes.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and interview the facility failed to maintain the emergency fire doors in 1 of 3 main halls (outside room [ROOM NUMBER]) reviewed for maintenance were in working order. This failure placed residents and staff at risk for falls, avoidable injury, and a diminished quality of life. Findings included . During an observation on 11/04/2024 at 1:00PM, a square metal piece in the floor of Medicare A and Medicare B hallway was loose and sticking up. Facing north, the right fire door was closed to test whether or not the metal piece would hold the door and then allow the door to be opened. The exit bar had to be pushed upward and with a moderate amount of force in order to open the door. Staff P, Licensed Practical Nurse, walked by as the door was being tested and stated, oh good, that's back again, pointing to the metal piece. On 11/05/2024 at 9:31 AM, the fire door was observed to be closed. Staff O, Certified Nursing Assistant (CNA) attempted to open the door, pushing against the exit bar with one hand and could not open the door. It took several attempts and the use of both hands to successfully open the door. At 9:52 AM, a resident was observed ambulating with a walker towards the closed fire door. The resident attempted to push against the exit bar but was unable to open the door. At 11:41 AM, the double doors in the hallway near room [ROOM NUMBER] required two hands and significant force to be opened. At 3:45 PM, Staff M, Maintenance Supervisor, said he tried to glue the metal piece the day before but the glue had not cured. He said he would try to drill some type of screw through the bottom that would go into the pavement. On 11/12/2024 at 4:19 PM Staff A, Administrator, said it was their understanding that the little square, in the floor, that catches the door, had come loose and they repaired it, so it was no longer a tripping hazard. Reference WAC 388-97- 2100 .

Oct 2024 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0553 (Tag F0553)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure care plan conferences were held with the resident for 1 of 3 sampled residents (Resident 2) reviewed for participation in care planning. This failure placed residents at risk of not being fully involved and informed of decisions about care and services and a diminished quality of life. Findings included . Resident 2 was admitted to the facility on [DATE] with diagnoses including heart failure and chronic kidney disease. The quarterly Minimum Data Set (MDS), an assessment tool, dated 8/13/2024, documented Resident 2 was cognitively intact and required substantial assistance from staff with activities of daily living. The care plan, revised on 04/10/2024, documented Resident 1 wished to return to their apartment. Interventions included that the facility would evaluate/record abilities and strengths and determine gaps which effected discharge with an interdisciplinary team. Review of Resident 2's electronic health record from 05/01/2024 to 10/31/2024 showed no care conference had been conducted or offered. On 10/14/2024 at 3:25 PM, Resident 2 said they want to discharge home, but the staff has not discussed discharged plans. When asked about care conferences, Resident 2 said they do not know what a care conference is, and they did not recall ever having one. On 10/31/2024 at 3:33 PM, Staff C, Social Services, said they were new to the role. Staff C said she understood the facility was behind with care conferences and did not see a recent care conference for the resident. Staff A, Administrator, said the facility had not consistently performed care conferences. At 3:41 PM, Staff B, Registered Nurse and Director of Nursing, said the facility has not been completing care conferences consistently. Reference WAC 388-97-1020 (2)(e)(f) .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0660 (Tag F0660)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to accurately assess and determine appropriate treatments for a chronic skin condition for 1 of 3 sampled residents (Resident 1) reviewed for skin conditions, non-pressure. This failure placed all residents at risk for unmet needs, pain and discomfort, declining health, and decreased quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, peripheral vascular disease (the vessels of the heart become narrowed or blocks affecting the legs and feet), and peripheral angiopathy (a buildup of fat in the arteries of the legs and arms). The quarterly Minimum Data Set (MDS), an assessment tool, dated 8/27/2024, documented Resident 2 has moderate cognitive impairment and was dependent on staff for assistance with activities of daily living. The care plan, revised 09/01/2024, documented Resident 1 had diabetes mellitus and was at risk for skin breakdown. The resident would have good fluid intake to keep skin hydrated. The resident's skin would be checked for any breakdown and staff would apply treatment as ordered by the medical provider. The Wound Clinic notes, dated 08/28/2024, documented Resident 1 had hemosiderin staining (discoloration on the legs and/or ankles yellow, brown, black, or rusty in appearance due to the breakdown in red blood cells) to their legs. The resident was noted as having chronic skin issues. Staff should apply house emollient as needed for skin hydration. The skin evaluation, dated 09/15/2024, made no note of skin on Resident 1's legs. The skin evaluation, dated 09/22/2024, made no note of skin on Resident 1's legs. The skin evaluation, dated 09/24/2024, noted Resident 1's shins were very dry. No notation of treatment was noted. The Interdisciplinary Team Skin Review, dated 09/27/2024, made no note of skin on Resident 1's legs. The skin evaluation, dated 10/01/2024, made no note of skin on Resident 1's legs. The Interdisciplinary Team Skin Review, dated 10/03/2024, made no note of skin on Resident 1's legs. The skin evaluation, dated 10/06/2024, showed the resident refused an assessment of their skin. The Interdisciplinary Team Skin Review, dated 10/09/2024, made no note of skin on Resident 1's legs. The skin evaluation, dated 10/13/2024, noted brownish discoloration to Resident 1's lower legs. The skin evaluation, dated 10/20/2024, noted brownish discoloration to Resident 1's lower legs. The skin evaluation, dated 10/27/2024, noted dry, flaky skin below the resident's knees. No notation of treatment noted. On 10/14/2024 at 1:20 PM, Resident 1 was observed in lying in bed. Resident 1's legs were exposed. Both lower legs were observed to be ruddy (reddish tone with a blotchy appearance) with dried, flaky skin. Both lower legs had scattered scabs and evidence of healed skin impairment. The resident said there are ongoing issues with skin breakdown on their legs. On 10/31/2024 at 1:45 PM, Resident 1 was observed lying in bed. The resident's left lower leg was ruddy with signs of healed skin impairment. Resident 1's right lower leg was covered in a large area of moist, flaky skin. The sheet underneath the resident's right lower leg was observed to be wet and discolored. Resident 1 did not know why their sheets were wet. Resident 1 said she continued to have scabbing and flaky skin on her shins. Resident 1 said she was not aware if she received a treatment to manage her skin impairment. At 1:50 PM, Staff E, Nursing Assistant, said Resident 1's skin was impaired on her lower legs. Staff E said the dry, flaky skin was moist. Staff E said Resident 1 refused personal care often, so it made it difficult to keep her skin intact. Staff E said Resident 1's sheets were wet. Staff E said this could be because the resident refused incontinence care. At 3:09 PM, Staff F, licensed practical nurse (LPN), said Resident 1's skin on the lower legs would heal and then flare up again. Staff F said it was a chronic condition and she did not know the cause of the skin breakdown. Staff F said they had tried many different treatments, but the impairment returned. She had tried may over the counter treatments as well. The resident was sensitive to feeling of creams/lotions on her legs. Staff F said there was a treatment with aluminum as an ingredient, but they did not have an order for this anymore. Staff F said there were no orders for the resident's lower legs at the time. Staff F said she was not sure if there was an assessment or documentation of the skin condition and treatment attempts available for staff to reference. At 3:41 PM, Staff B, Registered Nurse and Director of Nursing, said Resident 1's skin impairment was chronic but she was unsure of the cause of the skin impairment. The resident's skin would heal then become dry and flaky. Staff B said there was no current treatment of the skin impairment. Staff B said they monitor the skin weekly. Staff B said she would do a further review of the record. No further information was provided. Reference WAC 388-97-1060(1) .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0687 (Tag F0687)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to provide necessary diabetic nail care and treatment in accordance with professional standards for 1 of 3 sampled residents (Residents 1) reviewed for foot care. This failure placed residents at risk for developing further medical complications, discomfort and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, peripheral vascular disease (the vessels of the heart become narrowed or blocks affecting the legs and feet), and peripheral angiopathy (a buildup of fat in the arteries of the legs and arms). The quarterly Minimum Data Set (MDS), an assessment tool, dated 8/27/2024, documented Resident 2 had moderate cognitive impairment and was dependent on staff for assistance with activities of daily living. The care plan, revised 09/01/2024, documented Resident 1 has diabetes mellitus. The resident required daily inspection of feet for sores, blisters, and redness. The Treatment Administration Record (TAR), dated September and October 2024, documented staff provided diabetic nail care for the resident weekly. A review of the medical record showed no discussion regarding podiatry services with the resident. On 10/14/2024 at 1:20 PM, Resident 1 was observed in lying in bed. Resident 1's feet were exposed and the resident's toenails were observed to be long, thick and jagged. The resident said her toenails were long and would like someone to cut them for her. On 10/31/2024 at 1:45 PM, Resident 1 was observed lying in bed. Resident 1's feet were exposed. The resident's toenails were observed to be long, thick and jagged. Resident 1 said the long toenails were uncomfortable and just wanted someone to cut them. The resident could not recall the last time their nails were cut. Resident 1 said they were willing to see podiatry to get their nails cut. At 1:50 PM, Staff E, Nursing Assistant, said Resident 1's toenails were long and jagged. The resident did not always let staff cut their nails. Staff E could not recall the last time the resident had their nails cut. At 3:09 PM, Staff F, licensed practical nurse (LPN), said she was going to try and tackle the resident's toenails that day. Staff F said the resident would refuse to let staff cut their toenails. Staff F said Resident 1's toenails did bother them due to the length. Staff F said sometimes, she would just try and clip the rough parts of the nail. Staff F said she did not know if podiatry comes to the facility and did not think the resident has seen a podiatrist. Staff F said she does sign off weekly nail care even if the resident refuses their toenails cut because she will often cut the resident's fingernails at that time. Staff F said she has not reported the refusal of nail care to her supervisor. At 3:25 PM, Staff A, Administrator, said the facility would follow up on Resident 2's need for podiatry services. At 3:41 PM, Staff B, Registered Nurse and Director of Nursing, said the facility has mobile podiatry services and would follow up with the resident. During a discussion regarding the TARs signed off for nail care that was not provided, Staff B said she was not aware staff were signing it off without performing nail care. Staff B said she would do further review of the record and provide evidence of nail care, if found. No further information was provided. Reference WAC 388-97 -1060 (3)(j)(viii) .

Jan 2024 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure activities of daily living (ADLs) were provided for dependent residents including toileting for one of three residents (Resident 3) reviewed for ADL care. This failure placed residents at risk of not receiving the care and services needed for which they were unable to perform themselves and a diminished quality of life. Findings included . Resident 3 was admitted to the facility on [DATE]. The quarterly Minimum Date Set, (MDS) an assessment tool, dated 12/09/2023, documented Resident 3 was cognitively intact and required maximum assistance from staff for toileting. The care plan intervention, initiated on 07/31/2023, documented the resident was to be toileted in the morning when waking, after meals, and at night. Review of the ADL task record for toileting showed Resident 3 was toileted 27 times in the previous 30 days, less than once per day. Review of a facility investigation report, dated 12/08/2023, documented Resident 3 had reported she was not receiving the care that she needed due to her call light not being answered in a timely manner. Residents were interviewed and reported call light wait time occurrences from 30 minutes to two hours. On 01/05/2023 at 9:59 AM, Resident 3 said she frequently would wait a long time for the call light to be answered, It could be 15-20 minutes, or it could be over an hour. Resident 3 said she preferred to be toileted some time after breakfast. At 10:09 AM, Resident 3 was observed pressing her call light. At 10:12 AM, a staff member was observed answering Resident 3's call light and told Resident 3 they would be back with another staff member. At 10:16 AM, two staff members were observed entering Resident 3's room and began to assist resident and then left the room two minutes later, at 10:18 AM, to get supplies. At 10:26 AM, Staff I, LPN, was observed entering Resident 3's room to assess the resident for pain. At 10:30 AM, Resident 3 stated, There is no hope, I am almost 99 and this isn't the life, I just lay here and look up at the ceiling. Resident 3 said this was frequently her experience -- that staff would answer the call light but she was not actually taken to the toilet. A 10:34 AM, Staff I administered pain medication to Resident 3 and asked if she still wanted to get up. Resident 3 said she wanted to get up and go to the toilet, Staff I replied to her that staff had said they just changed her. Staff I told Resident 3 to let them know when she wanted to get up. After Complaint Investigator intervention to clarify with Resident 3 what her needs were, Resident 3 stated emphatically, I want to get up and get out of the bed and go to the toilet! Staff I replied that she only had three aides on the hall, and one was giving a shower, and Staff I was not able to assist with the transfer. When asked what she would do if a resident had a need to be toileted but staff were not available to assist, Staff I replied that she would go find someone. At 10:41 AM, Resident 3 reported she was having abdominal cramping and voiced frustration because she knew when she had to have a bowel movement and could report to staff when she needed assistance. At 10:43 AM, Staff J, Nursing Assistant (NA) and an unidentified NA arrived to assist Resident 3 with toileting, 34 minutes after she initially pressed her call light. At 1:24 PM, Staff J said that call lights were expected to be answered within 15 minutes and she usually toileted Resident 3 between 9:00-11:00 AM, after she turned on her call light. Staff J said she felt there was enough staff to meet resident needs. At 2:17 PM, Staff B, Registered Nurse (RN), Resident Care Manager (RCM), said there were enough staff to meet resident needs and if a resident required assistance of two staff and one was assisting other residents, he would expect the licensed nurse (LN) to find other staff to assist. At 2:45 PM, Staff A, RN, Director of Nursing, said there were enough staff to meet resident needs, and residents should be assisted as soon as possible with toileting needs and if staff were assisting other residents and a resident required two staff to assist - the LN could assist or find the RCM. Staff A would not expect a resident to wait 30 minutes to be assisted to the toilet. Reference WAC 388-97-1060 (2)(c) .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to offer the influenza and pneumococcal vaccine to 2 of 8 sampled residents (Resident 1 and 2). This failure placed residents at risk for developing influenza and pneumonia and medical complications. Findings included . Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 11/14/2023, documented the resident was moderately cognitively impaired. Resident 1's medical record did not show documentation of the resident's influenza or pneumococcal vaccine status. The medical record did not document if the resident was offered or received an influenza or pneumococcal vaccine. Resident 2 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented the resident was moderately cognitively impaired, and the influenza and pneumococcal vaccine was not offered. Resident 2's medical record did not show documentation of the resident's influenza or pneumococcal vaccine status. The medical record did not document if the resident was offered or received an influenza or pneumococcal vaccine. On 01/05/2024 at 2:27 PM, Staff B, Registered Nurse (RN), Resident Care Manager, said influenza and pneumococcal vaccines were offered to residents upon admission and then annually. Staff B was not sure what the process was to ensure that happened but the infection preventionist (IP) would oversee that. At 2:45 PM, Staff A RN, Director of Nursing, said the facility's previous IP would offer influenza and pneumonia vaccines weekly, but they were no longer working at the facility and Staff B believed vaccines were last offered the week of December 11th. Staff A said they were working with the new IP to ensure this happened. Staff A was not able to provide documentation that Resident 1 and 2 were offered and educated regarding the influenza and pneumococcal vaccines. Reference WAC 388-97-1340 (1)(2)(3) .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure residents and/or resident representatives were provided education on the risks and benefits including potential side effects of the COVID-19 (a highly infectious respiratory illness caused by a virus) vaccine and ensure documentation of the acceptance or refusal to receive the vaccine was in the medical record for 3 of 8 sampled residents (Residents 1, 2 & 8) reviewed for COVID-19 immunizations. This failure placed residents and resident representatives at risk of not having the opportunity to make an informed decision about the COVID-19 vaccine and the adverse health effects of this communicable disease. Findings included . 1) Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's immunization record on 01/04/2024, showed no documentation of an updated COVID-19 vaccination or documentation the facility provided education of the risks and benefits of the COVID-19 vaccine or that the resident was offered and declined the COVID-19 vaccine. 2) Resident 2 was admitted to the facility on [DATE]. A review of Resident 2's immunization record on 01/04/2024, showed no documentation of an updated COVID-19 vaccination or documentation the facility provided education of the risks and benefits of the COVID-19 vaccine or that the resident was offered and declined the COVID-19 vaccine. 3) Resident 3 was admitted to the facility on [DATE]. A review of Resident 2's immunization record on 01/04/2024, showed no documentation of an updated COVID-19 vaccination or documentation the facility provided education of the risks and benefits of the COVID-19 vaccine or that the resident was offered and declined the COVID-19 vaccine. On 01/05/2024 at 2:27 PM, Staff B, Registered Nurse (RN), Resident Care Manager said COVID-19 vaccines were offered to residents upon admission and then annually. Staff B said they were not sure what the process was to ensure that happened but the infection preventionist (IP) would oversee that. At 2:45 PM, Staff A, RN, Director of Nursing, said the facility's previous IP would offer COVID-19 vaccines but they were no longer working at the facility and believed they were last offered the week of December 11th. Staff A said they were working with the new IP to ensure this happened. Reference WAC 388-97-1780 (2)(c) .

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control (IPC) guidelines and standards of practice for 4 of 4 units (Mountain View, [NAME] Mountain, Medicare A and Medicare B) reviewed for IPC procedures when the facility failed to ensure staff followed standards of practice related to donning (placing on) recommended Personal Protective Equipment (PPE) prior to entering a room with resident(s) who were positive for COVID-19 (a highly transmissible respiratory virus) and following recommendations to keep doors closed to rooms with residents on aerosol precautions due to COVID-19, and source control masking. This failure placed all residents, staff and visitors at risk for contracting and potentially spreading COVID-19. On 01/02/2024 at 9:25 AM, the facility lobby was observed with a sign indicating there were COVID-19 positive residents in the facility and all staff were to wear N95s for source control. Staff A, Director of Nursing, Registered Nurse, said staff were wearing surgical masks for source control. At 10:04 AM, Staff C, Licensed Practical Nurse (LPN), was observed donning PPE prior to entering room [ROOM NUMBER] (on the Mountain View Unit). room [ROOM NUMBER] had a sign indicating the resident(s) in the room were on aerosol precautions and staff were to donn (put on) a gown, mask, goggles (eye protection or shield) and gloves. Staff C did not wear appropriate eye protection upon entering the room. At 10:18 AM, Staff C, LPN said staff were not using a face shield because they were not required to use eye protection unless the residents had symptoms such as a productive cough or secretions. At 10:25 AM, Staff D, Nursing Assistant (NA), was observed entering room [ROOM NUMBER] (on Mountain View unit). room [ROOM NUMBER] had a sign indicating the resident(s) in the room were on aerosol precautions and staff were to donn a gown, mask, eye protection, and gloves. Staff D did not wear appropriate eye protection upon entering the room. At 10:37 AM, Staff D, NA said wearing the face shield had been up in the air so she usually asked the nurse. Staff D said if the resident was coughing, they would wear eye protection. At 11:16 AM, the lobby sign was still posted and directed all staff to wear N95s for source control. At 2:06 PM, three staff were observed at the nurses' station not wearing masks. Staff identified as E, F, and G by Staff B, Resident Care Manager and Registered Nurse. At 2:32 PM, Staff E, F, and G were observed wearing N95 masks. At 2:32 PM, Staff F, LPN, said staff were to wear masks all the time and there were no common areas where they did not need to wear them. At 4:18 PM, room [ROOM NUMBER] and 45 still had aerosol precautions signs on the doors. On 01/05/2023 at 9:34 AM, room [ROOM NUMBER] (Crystal Mountain) was observed with an aerosol precaution sign on door, the sign indicated the door should remain closed. The door was observed open. At 9:53 AM, Staff H, LPN, said he believed the resident had opened the door and the COVID-19 positive resident was near the window, but said the door should have been closed. Staff H closed the door. At 1:22 PM, Collateral Contact 1, local health jurisdiction staff, confirmed they expected staff to donn gloves, gown, mask, and eye protection prior to entering all COVID-19 positive rooms, as well as participate in source control masking. At 2:27 PM, Staff B said that all staff were to wear source control mask and on 01/02/2024 that would have required them to wear an N95 mask. Staff B said staff were expected to wear PPE including eye protection when entering COVID-19 positive resident rooms. At 2:45 PM, Staff A, Director of Nursing and Registered Nurse said she knew staff had not followed aerosol precautions, but staff were expected to follow the guidance on the sign posted on the door and should wear eye protection when entering a COVID-19 positive room. Reference WAC 388-97-1320 (2)(b) .

Oct 2023 14 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**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 in a dignified manner which maintained and enhanced quality of life for 2 of 2 sampled residents (Resident 51 & 55) reviewed for dignity. This failure placed residents at risk for feelings of embarrassment, disrespect, decreased self-worth and a diminished quality of life. Findings included . 1) Resident 51 admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS, an assessment tool), dated 09/16/2023, documented Resident 51 was cognitively intact. On 10/09/2023 at 2:18 PM, Resident 51 said she requested assistance from staff to use the bathroom prior to breakfast. Resident 51 said they were told staff could not assist residents until after staff had finished delivering breakfast trays to all residents. Resident 51 said this resulted in them urinating in their night gown and on their recliner chair. Resident 51 stated, I'm tired of this. Resident 51 said staff did not come in to change her until 10 AM that day. 2) Resident 55 admitted to the facility on [DATE]. The Significant Change MDS, dated [DATE], documented Resident 55 was severely cognitively impaired. On 10/12/2023 at 10:12 AM, Resident 55 was observed sitting in her recliner chair with a blanket pulled over her body. When asked how she was doing, Resident 55 said she was not good. When asked what had happened, Resident 55 stated, I'm sitting in crap. Resident 55 said she had been incontinent for a while and could not reach her call light to call for help. Resident 55's call light was observed positioned between her and the back of the recliner and out of reach. The odor of feces could be smelled when approaching Resident 55. At 10:13 AM, Staff M, Licensed Practical Nurse, was informed of Resident 55's need for assistance. Staff M responded to Resident 55's room and assessed Resident 55. Staff M left the room and informed Staff N, Certified Nursing Assistant (CNA) and Staff O, CNA, of Resident 55's need for assistance. At 10:24 AM, Staff N assisted Resident 55 with toileting care. Resident 55's progress note, dated 10/12/2023 at 5:15 PM, documented Resident 55 had stated she waited for almost two hours for peri-care because she couldn't reach her call light that was behind her in her recliner. On 10/12/2023 at 2:33 PM, Staff B, Director of Nursing Services, said he expected staff to use their judgement when providing care to residents in need, including emergencies and call light priorities. Staff B said he expected staff to address safety concerns first and then all other concerns as soon as possible. Staff B said it was not acceptable for a resident to have to wait on staff to the point they eliminate in their clothing. At 3:04 PM, Staff A, Administrator, said he expected staff to prioritize care needs using the 4 P's - potty, positioning, possessions, and pain and toileting care was a first priority. Staff A said it was unacceptable for residents to have to wait on staff to the point they urinated or defecated in their clothing. Reference WAC 388-97-0180 (2) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0638 (Tag F0638)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on interview and record review, the facility failed to ensure resident quarterly Minimum Data Sets (MDS, an assessment tool) were completed within 14 days of the assessment reference date (ARD) as required for 1 of 20 (Resident 58) sample residents reviewed for timely assessments. Failure to timely complete resident quarterly assessments, 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 quarterly assessments must be completed no later than the ARD +14 calendar days. Resident 58's electronic health record showed a quarterly MDS had an ARD of 09/26/2023. Review of the quarterly MDS completion date showed it was not completed until 10/13/2023, 17 days after the ARD. On 10/13/2023 at 9:21 AM, Staff D, MDS Assistant, said Resident 58's 09/26/2023 quarterly MDS assessment was completed late. Reference WAC 388-97-1000(5)(d) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review the facility failed to ensure assessments were accurate and reflected the residents' health status for 1 of 20 sampled residents (Resident 33) reviewed for assessments. This failure placed residents at risk for receiving unnecessary medications and/or unmet care needs. Findings included . Resident 33 admitted to the facility on [DATE]. Resident 33's Level I Pre-admission Screening and Resident Review (screening tool for intellectual disabilities or mental illness), dated 03/31/2023, showed the resident had indicators of serious mental illness related to diagnoses of depression and anxiety disorders. Resident 33's admission orders, dated 04/02/2023, showed the resident had orders for an antianxiety medication for a diagnosis of anxiety, and an antidepressant medication for a diagnosis of depression. The admission Minimum Data Set (MDS, an assessment tool), dated 04/06/2023, documented Resident 33 received antidepressant medication on five of five days during the assessment period and did not receive antianxiety medication. Diagnoses for anxiety or depression were not documented. Resident 33's April 2023 Medication Administration Record (MAR) showed the resident was administered antianxiety medication for a diagnosis of anxiety and antidepressant medication for a diagnosis of depression daily from 04/02/2023 - 04/06/2023 (5 days) during the assessment period. Resident 33's Quarterly MDS, dated [DATE], showed the resident received antianxiety and antidepressant medication on seven of seven days during the assessment period, and did not have active diagnoses of anxiety and depressive disorders. Resident 33's July 2023 physician's orders showed the resident had an order for antianxiety medication to treat anxiety and an order for an antidepressant to treat depression. On 10/16/2023 at 11:05 AM, Staff C, MDS Coordinator, said Resident 33's admission MDS was inaccurately coded and should have reflected the administration of antianxiety medication on five of five days and included the active diagnoses of anxiety and depression. Staff C said the Quarterly MDS was inaccurate, and anxiety and depression should have been included on the active diagnoses list. Reference WAC 388-97-1000 (1)(b) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 3 of 20 sampled residents (Residents 49, 57 and 58) of 20 reviewed. The failure to follow and/or clarify incomplete physician's orders when indicated, and to only sign for those tasks completed, placed residents at risk for medication errors and unmet care needs. Findings included . 1) A physician order for Resident 58, dated 06/21/2023, documented to provide Foley catheter care (a flexible tube used to empty the bladder and collect urine in a drainage bag) and check function every shift. Resident 58's electronic health record (EHR) showed a 08/30/2023 nurses note which documented Resident 58's urinary catheter was discontinued. Resident 58's August and September 2023 Treatment Administration Record (TAR) showed facility nurses signed they provided catheter care and validated the catheter was functional on 08/31/2023 day, evening, and night shift; and 09/01/2023 day and night shift, after the catheter had been discontinued. On 10/12/2023 at 1:47 PM, Staff B, Director of Nursing, said it was the expectation that nurses only sign for tasks they completed or validated as complete. Staff B acknowledged that facility nurses erroneously signed that they provided catheter care and verified function of Resident 58's urinary catheter after it had been discontinued. A physician order for Resident 58, dated 07/23/2023, documented to change Resident 58's foley catheter and drainage bag every month. Resident 58's August 2023 TAR showed facility nurses signed that they completed the resident's catheter and drainage bag change daily from 8/16/2023 - 08/31/2023 (with exception of 08/21/2023). On 10/12/2023 at 1:47 PM, Staff B said facility nurses erroneously signed daily that they had completed the resident catheter and drainage bag change and indicated the order was input into the EHR incorrectly causing it to show up daily. Staff B said facility nurses should have identified the order was inputted incorrectly and clarified the order. A physician order for Resident 58, dated 06/21/2023, documented to administer oxygen to keep oxygen saturation greater than 90%. The order did not indicate the rate or method of oxygen delivery (e.g., nasal cannula, simple mask, non-rebreather mask etc.) Resident 58's September 2023 Medication Administration Record (MAR) showed facility nurses signed three times a day that they carried out the order. On 10/12/2023 at 1:26 PM, Staff B said facility nurses should have identified Resident 58's oxygen order was incomplete and clarified the order. 2) A physician order for Resident 57, dated 08/27/2023, documented for nurses to validate the residents bilevel positive airway pressure machine (BIPAP, a form of non-invasive ventilation therapy used to facilitate breathing) was set Per previous settings and apply it at bedtime. The order did not identify what the previous settings were. Review of Resident 57's EHR showed no documentation or indication what Resident 57's previous BIPAP settings were. Resident 57's September 2023 MAR showed facility nurses signed daily that they validated Resident 57's BIPAP settings and applied the BIPAP at bedtime as ordered. On 10/13/2023 at 10:01 AM, Staff B acknowledged facility nurses could not have validated Resident 57's BIPAP settings as the resident's previous BIPAP settings were not identified. Staff B said that facility nurses should not have signed for a task they did not complete, should have identified the order was incomplete and clarified it. 3) A physician order for Resident 49, dated 09/15/2023, documented for nurses to validate the resident's continuous positive airway pressure machine (CPAP, a form of non-invasive ventilation therapy used to facilitate breathing) was set per home settings and apply it at bedtime. The order did not identify what the home settings were. Review of Resident 49's EHR showed no documentation was present that identified what Resident 49's CPAP home settings were. Resident 49's September 2023 MAR showed facility nurses signed daily that they validated Resident 49's CPAP settings and applied the BIPAP at bedtime as ordered. On 10/13/2023 at 10:01 AM, Staff B acknowledged facility nurses could not have validated Resident 57's BIPAP settings as the resident's previous BIPAP settings were not identified. Staff B said that facility nurses should not have signed for a task they did not complete, should have identified the order was incomplete and clarified it. Reference WAC 388-97-1620(2)(b)(i)(ii), (6)(b)(i) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

. Based on observation, interview and record review, the facility failed to consistently assist with the application of a hearing aid for 1 of 2 residents sampled residents (Resident 36) reviewed for communication. This failure placed residents at risk for communication difficulties, frustration, and diminished quality of life. Findings included . Resident 36's physician orders, dated 08/22/2022, showed the facility staff were to assist the resident in application of the left hearing aid every morning and the hearing aid was kept in the medication room at night. On 10/09/2023 at 3:33 PM, Resident 36 said they had trouble obtaining their hearing aid from staff in the morning. The resident said they wanted to wear the hearing aid. At 3:33 PM, Resident 36 was observed with no hearing aid in the left ear. On 10/10/2023 at 11:42 AM, Resident 36 was observed with no hearing aid in the left ear. On 10/11/2023 at 11:13 AM, Resident 36 was observed with no hearing aid in the left ear. At 2:37 PM, Resident 36 was observed with no hearing aide in the left ear. Resident 36 said they wanted the hearing aid but had not received it from the nurse. At 2:38 PM, Staff Q, Licensed Practical Nurse, said they did not apply Resident 36's hearing aid if the resident napped during the day. Staff Q said the resident was awake for lunch, but they waited until the resident asked. On 10/13/2023 at 9:30 AM, Staff B, Director of Nursing, said Resident 36 should have their hearing aid applied every morning as outlined in the physician order. Reference WAC: 388-97-1060 (3)(a) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to provide services to prevent decline in range of motion for 1 of 3 sampled residents (Resident 9) reviewed for mobility. This failure placed residents at risk for loss of functional mobility, further decline in range of motion and discomfort. Findings included . Resident 9 admitted to the facility on [DATE]. The Minimum Data Set (an assessment), dated 07/11/2023, showed the resident had functional limitation in range of motion in their upper and lower extremities. Resident 9's medical provider progress note, dated 09/13/2023, showed Resident 9 had contractures (fixed tightening of joints) of both knees. Resident 9's electronic health record on 10/12/2023 at 2:57 PM, showed no documentation of a nursing restorative program. On 10/12/2023 at 3:00 PM, Staff V, Therapy Program Manager, said Resident 9 was seen in July of 2023 for therapy. Staff V said the therapist established a nursing restorative program for the resident when the resident was discharged from therapy. Staff V said they did not have access to the therapy records because the facility switched therapy companies. On 10/13/2023 at 9:50 AM, Staff B, Director of Nursing, said there was no record a nursing restorative program was initiated for Resident 9. Staff B said the resident should have been on a restorative program and if they located records that showed why a program was not initiated, they would provide them. No further documentation was provided. Reference WAC: 388-97-1060 (3)(d) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to provide nutrition and hydration between meals for 1 of 4 sampled residents (Resident 69) reviewed for nutrition. This failure placed the resident at risk for thirst, hunger, and discomfort. Findings included . Resident 69 was admitted to the facility on [DATE] with a diagnosis of dementia and malnutrition. The Minimum Data Set, an assessment tool, dated 07/21/2023, showed the resident had impaired cognition and required extensive assistance for eating and transfers. Resident 69's Registered Dietician nutrition note, dated 10/08/2023, showed the resident was underweight and staff were to provide support and encouragement for the resident to consume as many foods and beverages as possible. Resident 69's care plan, dated 07/31/2023, showed staff were to offer and encourage snacks/fluids between meals, encourage to drink fluids of choice at least 1000 cubic centimeter [milliliters]/day, and offer drinks during one-to-one visits. Resident 69's snack documentation, from 09/13/2023 -10/11/2023, showed no snack was ordered on 13 out of 30 opportunities after dinner. An observation on 10/10/2023 at 3:01 PM, showed Resident 69 in bed, with a fall mat next to the bed and a water pitcher on the bedside table across the room. On 10/11/2023 at 8:13 AM, Resident 69 was observed sitting up in bed and yelling. Staff were observed walking by the resident's room and no staff stopped to offer food and/or fluid. No fluids were visible in the room. At 8:31 AM, staff were observed stopping in the doorway of Resident 69's room and no fluids and/or food was offered. No fluids were observed in the room. At 9:17 AM, a staff member was observed going into Resident 69's room and no fluids and/or food offered. Observations on 10/11/2023 at 10:28 AM and 11:51 AM, showed no fluids were present in Resident 69's room. A continuous observation on 10/11/2023 from 12:03 PM to 12:10 PM showed Resident 69 yelling Yo continually, staff were observed walking by the doorway, no fluids and/or food were offered. No fluids were observed present in the resident's room. At 1:36 PM, Staff S, Certified Nursing Assistant, said Resident 69 received hydration at meals and staff would offer it to the resident between meals. Staff S said they had not offered the resident any water between breakfast and lunch and the resident had not had to urinate since they started their shift prior to breakfast. At 1:50 PM, Staff S was observed offering to assist Resident 69 out of bed and adjusted their bed linens, no food and/or fluid offered. No fluids were observed in the room. On 10/13/2023 at 8:35 AM, Staff B, Director of Nursing, said the staff should be offering Resident 69 snacks and hydration between meals and they did not meet their expectations. Reference WAC: 388-97-1060 (h) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0744 (Tag F0744)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to provide individualized non-pharmacological care approaches and/or meaningful activities for 1 of 2 sampled residents (Resident 69) reviewed for dementia. This failure placed residents at risk for unnecessary medications, unrelieved distress, and a diminished quality of life. Findings included . Resident 69 was admitted to the facility on [DATE] with a diagnosis of dementia. Resident 69's Medical Provider Progress Note, dated 09/26/2023, showed the resident had a diagnosis of dementia and was seen for persistent anxiety, agitation, and constant yelling, screaming. Review of Resident 69's care plan, dated 07/31/2023, showed no documentation related to Resident 69's constant yelling and screaming. Resident 69's Behavior/Psychoactive Medication interdisciplinary team (IDT) review, dated 09/28/2023, showed the resident had a target behavior of agitation and calling out repeatedly. The review showed the behaviors had worsened since the previous quarter and the interventions had not been effective. The documentation showed no recommendations for care approaches or non-pharmacological interventions. On 10/11/2023 at 8:13 AM, Resident 69 was observed in a dark room, lying in bed, yelling non-distinguishable sounds which were audible from the hallway. At 8:31 AM, the resident had continued yelling and a staff member stopped at the doorway, turned on the light but did not enter the room. At 9:16 AM, Resident 69 was observed/could be heard yelling from the hallway. A staff member went into the room but did not speak to the resident and left the room. A continuous observation on 10/11/2023 from 12:03 to 12:10 PM showed Resident 69 yelling Yo continually, staff were observed walking by the doorway, but did not enter the room. At 1:36 PM, Staff S, Certified Nursing Assistant, said Resident 69 was usually in bed all day. Staff S said they tried to get the resident up and dressed but if the resident said no, they went and got the licensed nurse. Staff S said they did not know of any specific care approaches to utilize for the resident. Staff S said they mainly tried to talk with the resident and kept trying different things. At 2:08 PM, Staff T, Licensed Practical Nurse, said they had no idea why Resident 69 yelled but said the resident had dementia. Staff T said they did not have any specific interventions they used when the resident was yelling, they just tried to ask the resident questions and talked to them. Staff T said they were not sure what type of activities the resident liked, they just tried different things, nothing specific. At 3:58 PM, Staff G, Activity Supervisor, said they did not have an activity program for their dementia residents. Staff G said in the past they had programming for dementia residents, but the program had stopped and was not restarted. On 10/13/2023 at 8:35 AM, Staff B, Director of Nursing, said Resident 69 called out continuously due to restlessness and perceived mental anguish. Staff B said sometimes staff felt the resident was calling out because they had a need and other times it was mental anguish. When asked if there were any behavior interventions in place to help the resident, Staff B said staff tried distraction and offered food/fluid, but they could not point to anything specific they had in place. Staff B said they did not have any specific care plan interventions in place to aid staff in caring for Resident 69 when the resident was yelling and/or calling out. Staff B said facility staff had not evaluated the effectiveness or recommended changes to the behavior interventions for Resident 69 to ease their restlessness and mental anguish. Staff B said the facility did not have dementia programs in place for Resident 69. Reference WAC: 388-97-1040 (1)(a-c) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on interview and record review, the facility failed to consider and act promptly to address concerns raised by residents for 4 of 4 sampled months (June 2023, July 2023, August 2023 & September 2023) reviewed for Resident Council. This failure to ensure resident concerns were considered, acted upon, or a rationale provided when action could not be taken, left residents at risk for unresolved concerns, frustration, a less than homelike environment, and a diminished quality of life. Findings included . A facility policy titled, Resident and Family Grievances including Missing Items Policy, dated 08/19/2022, documented grievances may be voiced verbally during resident or family council meetings and the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. Review of the facility's resident council meeting minutes showed residents voiced concerns about the following: <June 2023 > 1) The Garden Room doors needed to be fixed so residents could get in and out without getting hit. 2) Residents would like to have the servers come when the food comes, so they don't have to eat cold food. 3) A resident council member requested new bed controls as some of the wires were showing and was told if she touched the wires, she would not get much of a shock. 4) Residents complained that call lights were not answered in a timely manner. 5) Beds were not being made and were left for the evening shift. 6) Aides would answer call lights and say they will tell your aide, and no aides returns. 7) Residents would like a snack cart in the evening. <July 2023> 1) Call lights still not answered in a timely fashion. 2) Residents had a hard time finding aides and nurses. 3) Beds still not being made in a timely fashion. 4) Residents wondered about a snack cart again. 5) Residents would like to know what is going on when there are no activities. 6) Residents would like aides in the dining room when trays arrive, so food doesn't get cold. <August 2023> 1) Call lights still not answered timely. <September 2023> 1) Resident concerns regarding trouble with the Wi-Fi. 2) Call lights still were a problem. Review of the grievance logs, dated June 2023, July 2023, August 2023, and September 2023, showed no grievances were initiated or logged related to resident concerns voiced during resident council meetings. On 10/12/2023 at 8:17 AM Staff G, Activities Supervisor, said she kept a copy of the resident council minutes and gave a copy to Staff A, Administrator, and Staff BB, Assistant Director of Nursing. Staff G said Staff A and Staff BB would follow up with concerns and write a response to the residents. At 2:00 PM, when asked if the facility considered their views from the resident group or acted upon grievances and recommendations, multiple resident council members said the facility did not respond to their concerns and there was no one to talk to stating, We would just like an answer. On 10/13/2023 at 8:50 AM, Staff A said the resident council secretary brought a copy of meeting minutes to him. Staff A said the responsibility for following up on grievances from the resident council meetings had recently changed to social services. Staff A said it was his expectation that concerns voiced in the resident council meetings were put on the Grievance Log and followed up with. Staff A said he would be sure social services received a copy of the resident council meeting minutes. Reference WAC 388-97-0920(4)(5) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6) Resident 36 was admitted to the facility on [DATE] with a diagnosis of hearing loss. Review of Resident 36's physician orders, dated 08/22/2022, showed the resident had a left hearing aid. Resident 36's care plan, dated 08/02/2023, showed the resident had a communication problem related to a hearing deficit. Further review of the care plan showed no documentation of a hearing aid. On 10/09/2023 at 3:33 PM, Resident 36 said that they had trouble getting their hearing aid from staff. On 10/11/2023 at 12:26 PM, Staff P, Certified Nursing Assistant, said Resident 36 did not wear a hearing aid. On 10/12/2023 at 9:10 AM, Staff D, MDS Assistant, said Resident 36's hearing aid should have been documented on the care plan and they would add it. Reference WAC: 388-97-1020 (5)(b) Based on observation, interview and record review, the facility failed to ensure residents' care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 6 of 22 sample residents (Residents 58, 33, 64, 49, 57, and 36) whose CPs were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life. Findings included . 1) Resident 58's electronic health record (EHR) showed the resident had a provider order, dated 06/21/2023, to titrate oxygen to maintain oxygen saturation greater than 90 %. The order did not include what diagnosis or condition the oxygen was intended to treat. Review of Resident 58's comprehensive CP showed no oxygen or respiratory CP had been developed or implemented. On 10/12/2023 at 1:47 PM, Staff B, Director of Nursing (DON), stated that Resident 58's comprehensive CP needed to be revised to include the resident's use of supplemental oxygen. Resident 58's urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) CP, initiated 07/31/2023, showed the resident had an indwelling urinary catheter secondary to urinary retention. A nursing note, dated 08/30/2023, documented Resident 58's urinary catheter was discontinued on 08/30/2023. On 10/12/2023 at 1:47 PM, Staff B, DON, said Resident 58's urinary catheter CP needed to be discontinued. 2) Resident 33's Quarterly Minimum Data Set (MDS, an assessment tool), dated 07/07/2023, showed the resident required extensive staff assistance with activities of daily living (ADLs) and had a diagnosis. Resident 33's comprehensive CP showed direction was not provided to staff to assist the resident with nail care, nor did it identify who would perform nail care and at what frequency. On 10/13/2023 at 1:13 PM, Staff B, DON, said Resident 33's CP needed to be updated/revised to reflect who was responsible for the resident's nail care. 3) Resident 64 admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed the resident required extensive assistance with most ADLs. On 10/10/2023 at 11:17 AM, Resident 64 said they had not received nail care since they admitted to the facility. Resident 64's ADL care plan, revised 09/11/2023, showed there was no direction to staff to assist the resident with nail care or identification of who would provide nail care and at what frequency. On 10/13/2023 at 1:13 PM, Staff B, said Resident 64's CP needed to be updated/revised to reflect who was responsible to provide nail care and at what frequency. 4) Resident 49's MDS, dated [DATE], showed the resident required the use of a continuous positive airway pressure machine (CPAP, a machine that uses mild air pressure to keep breathing airways open while you sleep) during the assessment period and that it was very important to go outside to get fresh air when the weather was good. Resident 49's physician's orders, dated 08/27/2023, showed an order directing nurses to ensure the residents CPAP machine was on at bedtime. Resident 49's altered respiratory status CP, revised 07/31/2023, showed the following interventions: Assist with CPAP application (Specify: bedtime, continuous); and CPAP settings: (Specify). However, the CP did not Specify what the CPAP settings were or whether it was to be worn continuously or at bedtime. On 10/13/2023 at 10:29 AM, Staff B, DON, said the CP needed to be updated/revised to reflect Resident 49's current CPAP settings and that it was to be used at bedtime. Review of the Preferences for Customary Routine and Activities assessment, dated 07/27/2023, showed in the Interview for Activity Preferences Resident 49 identified one activity as Very important and that was going outside for fresh air when the weather was nice. Resident 49's comprehensive CP, revised 07/31/2023, showed no care plan or interventions had been developed or implemented related to Resident 49's preferred activity of going outside for fresh air when the weather was nice. On 10/13/2023 at 9:19 AM, Staff G, Activity Supervisor, said Resident 49's activity CP needed to be updated to reflect the importance to the resident to go outside. Resident 49's impaired visual function CP, revised 07/31/2023, showed staff were directed to ensure the appropriate visual aids (Specify) were available to support the resident's participation in activities. The care plan did not identify what the visual aides were that needed to be available. On 10/13/2023 at 10:29 AM, Staff B, DON, said the CP needed to be updated to reflect what visual aids Resident 49 required. 5) Resident 57's Quarterly MDS, dated [DATE], showed the resident required the use of a bilevel positive airway pressure machine (BIPAP, a form of non-invasive ventilation therapy used to facilitate breathing). A provider order, date 09/15/2023, documented for staff to place the resident's BIPAP daily at bedtime. Resident 57's altered respiratory status CP, revised 08/01/2023, showed the following: a) Staff were directed to clean the resident's BIPAP per manufacturers recommendations. The care plan did not identify what the manufacturer's recommendations were or where they could be found. b) Staff were directed to document what the oxygen flow rate was for the BIPAP, but no flow rate was listed. c) Staff were directed to Specify Resident 57's BIPAP settings, but the BIPAP settings were not identified. On 10/13/2023 at 10:29 AM, Staff B, DON, said Resident 57's CP needed to be updated/revised to reflect what the resident's BIPAP settings, oxygen flow rate, and manufacturer's cleaning guidelines were.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for 4 of 8 sampled residents (Residents 64, 33, 83 and 58) reviewed for ADLs and choices. Failure to provide assistance with nail care and/or bathing to residents depend on staff for care, placed the residents at risk for unmet needs, poor hygiene, diminished self-image, and decreased quality of life. Findings included . 1) Resident 64 admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated 09/04/2023, showed the resident required extensive assistance with bed mobility, dressing and bathing. On 10/10/2023 at 11:17 AM, Resident 64 said that their toenails had not been cut since they admitted to the facility and stated, They need it. Resident 64's toenails were observed and were long, thick, untrimmed, and starting to curve around the end of the toes. Resident 64's ADL care plan (CP), revised 09/11/2023, showed there was no direction to staff to assist the resident with nail care. On 10/13/2023 at 1:13 PM, Staff B, Director of Nursing (DON), indicated Resident 64's toenails were long, thick, and untrimmed, and curling around the end of the toes and stated, I would say they need to be cut. 2) Resident 33 admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], showed the resident was cognitively intact and required extensive assistance with ADLs. On 10/10/2023 at 12:39 PM, Resident 33 said their toenails needed to be trimmed. The resident would not allow their toenails to be viewed because they were embarrassed of them. Resident 33's ADL care plan, revised 10/09/2023, showed there was no direction to staff to assist the resident with nail care. On 10/13/2023 at 1:13 PM, Staff B, DON, indicated Resident 33's toenails were long, thick, and untrimmed, and said nail care needed to be provided. 3) Resident 83 admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed the resident was cognitively intact and required extensive assistance with ADLs. On 10/09/2023 at 2:27 PM, Resident 83 said their fingernails and toenails had not been cut since they admitted to the facility and needed to be trimmed. Observation of Resident 83's fingernails and toenails showed they were long, untrimmed with jagged edges where the nails had chipped. Resident 83 indicated their toenails often got caught on their bedding. Resident 83's ADL care plan, revised 09/01/2023, showed staff were directed to trim and clean the resident's nails on bath day. The care plan did not identify what Resident 83's bath day was. During an observation and interview on 10/13/2023 at 1:13 PM, Staff B, DON, indicated Resident 83's fingernails and toenails were long and untrimmed and stated that it appeared nail care had not been provided. 4) Resident 58 admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], showed the resident required extensive assistance with ADLs and was not bathed during the seven-day assessment period. On 10/10/2023 at 9:29 AM, Resident 58 said they were not being bathed frequently enough. Resident 58's ADL care plan, revised 07/31/2023, showed the resident required one-to-two-person assistance with bathing. The CP did not identify the frequency at which bathing should be provided. On 10/13/2023 at 9:58 AM, Staff B, DON, stated that all residents are bathed once a week unless they request bathing more frequently. Resident 58's bathing record for a 30-day look-back period (09/12/2023 - 10/12/2023) showed the resident was offered bathing one time, on 09/23/2023. On 10/13/2023 at 10:18 AM, Staff B, DON, stated that Resident 58 should have been offered/provided bathing a minimum of weekly, but acknowledged that did not occur. Reference WAC 388-97-1060(2)(c) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview, observation and record review, the facility failed to provide an ongoing program of activities to meet the individual residents' interests and needs for 3 of 5 sampled residents (Residents 9, 69 and 49) reviewed for activities. This failure placed the residents at risk for boredom, isolation, and a diminished quality of life. Findings included . 1) Resident 9 was admitted to the facility on [DATE]. Review of the Minimum Data Set assessment (MDS), dated [DATE], showed the resident was cognitively impaired and it was very important for the resident to do things with groups of people. Resident 9's Activity Quarterly Evaluation, dated 10/10/2023, showed the resident liked group activities that included bingo, music events and birthday/holiday socials. Resident 9's care plan, dated 08/05/2023, showed the following interventions: engage in simple, structured activities that avoid overly demanding tasks, provide a program of activities that accommodates abilities, introduce residents with similar interests/disabilities, communicate activity interests to health care team and invite, encourage activities with a low stimulation environment. During observations on 10/10/2023 at 1:00 PM, 2:58 PM, 3:03 PM, 3:20 PM and 3:30 PM, Resident 9 was observed sitting in their wheelchair against the wall in the hallway outside of their room. The resident was not observed participating in any group activities and/or independent activities. An observation on 10/10/2023 at 3:33 PM, showed an arts and craft activity in the dining room. Resident 9 was not in attendance. Review of the facility's activity calendar on 10/11/2023, showed a read-aloud activity at 10:30 AM. On 10/11/2023 at 10:24 AM, Resident 9 was observed in bed and the resident did not attend the read-aloud activity. On 10/11/2023 at 10:18 AM, Staff R, Certified Nursing Assistant (CNA), said they did not know what activities Resident 9 enjoyed except hanging out by the nursing station. Staff R said it was not their responsibility to assist residents to an activity unless the resident asked them. At 3:58 PM, Staff G, Activity Supervisor, said Resident 9 enjoyed group activities and should have been brought down to the arts and craft activity and the aides should know to bring the resident down to activities. Staff G said they only had programs for people that can actively participate. Staff G said Resident 9 did not have an activity program specific to their needs. 2) Resident 69 was admitted to the facility on [DATE] with a diagnosis of dementia. Resident 69's care plan, dated 07/31/2023, showed the following interventions: engage in simple/structured activities that avoid overly demanding tasks, such as music time, current events or bingo, activities to maintain engagement and provide a calming atmosphere, listen to soul and Motown music, watch/listen to western movies in their room. Observations on 10/11/2023 at 08:13 AM, 8:30 AM, 9:16 AM, 10:28 AM, 11:51 AM, 12:03 PM, 12:08 PM, 12:41 PM and 1:50 PM, showed Resident 69 in their room with their curtain closed, the TV on with no sound, no music playing, and no other activities observed. On 10/11/2023 at 1:36 PM, Staff S, CNA, said Resident 69 spent their days mainly in bed. Staff S said if the resident's family member came, they would leave the TV on. Staff S said they did not know what the resident enjoyed and/or if they liked music. At 2:08 PM, Staff T, Licensed Practical Nurse (LPN), said they are not sure what type of activities Resident 69 liked. Staff T said they just tried different things but did not know anything specific. At 3:58 PM, Staff G, Activity Supervisor, said the activity staff mostly had group activities during the day and Resident 69 did not attend. Staff G said they provided 1:1 visits up to twice per week but did not have time to visit all residents. Staff G said they did talk with Resident 69 and played their music but did not have specific programs and/or activities for Resident 69 and/or other residents with dementia.3) Resident 49 admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented the resident had severe cognitive impairment, diagnoses including dementia The MDS documented it was very important for Resident 49 to go outside for fresh air when the weather was nice, and important to do things with group, but the resident was unable to or had no choice. On 10/10/2023 at 12:20 PM, Resident 49 was observed lying in bed with no television or radio on. Resident 49 indicated they were bored and had nothing to do. Resident 49's activity care plan, revised 08/09/2023, showed the resident had little to no involvement with activities related to their physical limitations. The established goal was for the resident to express satisfaction with the type of activity and their level of involvement in the activity when asked. Staff were directed to encourage family members to attend activities with Resident 49 and to invite the resident to music programs, church services and special events. The care plan did not identify that it was very important for the resident to go outside for fresh air or that it was important for them to do things in a group. The care plan did not indicate why the resident was unable or had no choice related to doing things in a group activity as assessed on the 7/27/2023 quarterly MDS. On 10/13/2023 at 9:19 AM, Staff G, Activity Supervisor, said they were unsure why Resident 49 was assessed as unable to attend group activities, but believed it might have been related to the resident's poor vision and cognition. When asked if they had specific activities scheduled for residents with dementia Staff G stated, No. Additionally, Staff G said Resident 49's desire to go outside for fresh air when the weather was nice, should have been incorporated into the resident's activity plan of care, but acknowledged it was not. Reference WAC: 388-97-0940 (1) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure respiratory care and services were provided in accordance with Physician's orders and accepted professional standards of practice for 3 of 4 sampled residents (Residents 57, 49 and 58) reviewed for respiratory care when the facility failed to identify and implement maintenance and monitoring orders for resident continuous positive airway pressure/bilevel positive airway pressure machines (CPAP/BIPAP, a form of non-invasive ventilation therapy used to facilitate breathing) and to document the administration of oxygen on resident(s) Medication Administration Records(MAR). This placed residents at risk for unidentified and/or unnecessary oxygen use, respiratory compromise, and other negative health care outcomes. Findings included . 1) Resident 57's Quarterly Minimum Data Set (MDS, an assessment tool), dated 08/15/2023, showed the resident required the use of a BIPAP and supplemental oxygen during the assessment period. Resident 57's physician's orders showed the following oxygen and BIPAP orders: An order, dated 09/15/2023, for nurses to apply Resident 57's BIPAP daily at bedtime and verify the BIPAP was set Per previous settings An order, dated 09/15/2023, to clean and disinfect Resident 57's BIPAP every morning; An order, dated 09/19/2023, for oxygen via nasal canula (NC) at 3-4 liters per minute (3-4L/min) to maintain oxygen saturation greater than 92%. The orders did not identify what Resident 57's BIPAP settings were supposed to be, what solution, if any, was to be used to sanitize the resident's BIPAP mask daily or provide instruction about filling the resident's BIPAP humidifier bottle or what solution to fill it with. Resident 57's altered respiratory status care plan (CP), revised 08/01/2023, showed staff were directed to clean the resident's BIPAP per manufacturers recommendations. No information was provided related to what the manufacturer's cleaning/sanitizing recommendations were and/or where they could be found. Staff were also directed to specify what Resident 57's BIPAP settings were, but the BIPAP settings were not identified. Review of Resident 57's electronic health record (EHR) showed no documentation of what Resident 57's BIPAP settings were supposed to be or what the manufacturer's cleaning and sanitizations recommendations were. On 10/13/2023 at 9:04 AM, Staff F, Registered Nurse (RN), said they cleaned and sanitized Resident 57's BIPAP and refilled the humidifier bottle with distilled water. When asked what they used to clean and sanitize the BIPAP, Staff F explained they generally used something soft like face tissue and water for a fast cleaning, but if the BIPAP was visibly soiled, they might use dish soap and a soft toothbrush. Staff F, RN, said she was unsure if her cleaning method was consistent with the manufacturer's instructions for cleaning and sanitizing and confirmed the manufacturer recommended cleaning instructions were not included in the resident's order. At 10:01 AM, Staff B, Director of Nursing (DON), said Resident 57's BIPAP settings, humidifier bottle maintenance/solution and cleaning and sanitizing instructions should be included in the physician's orders. Staff B acknowledged facility nurses could not validate Resident 57's BIPAP was set at the correct settings, given the settings were not identified. 2) Resident 49's Quarterly MDS, dated [DATE], showed the resident had a diagnosis of sleep apnea (serious sleep disorder in which breathing repeatedly stops and starts), and required the use of a CPAP machine. Resident 49s physician's orders showed the following CPAP administration, maintenance and monitoring orders: a 08/27/2023 order to ensure Resident 49's CPAP machine was set to home settings and to apply it. Review of Resident 49's EHR, showed no documentation indicating what Resident 49's ordered CPAP settings were. On 10/13/2023 at 09:29 AM, when asked how facility nurses were able to validate Resident 49's CPAP was set per their home settings if the home settings were not identified, Staff E, Registered Nurse/ Resident Care Manager (RN/RCM), stated, They couldn't. Staff E then confirmed Resident 49's CPAP home settings were not identified in the resident's EHR. At 10:01 AM, Staff B, DON, said Resident 49's CPAP settings should be included in the CPAP order, but acknowledged they were not. 3) Resident 58's Significant Change MDS, dated [DATE], showed the resident required use of supplemental oxygen during the assessment period. Resident 58's EHR showed a 06/21/2023 to titrate (adjust) oxygen to keep oxygen saturation greater than 90%. The order did not indicate the method of delivery that should be used (e.g., nasal canula, simple mask, non-rebreather mask etc.) or what flow rate restrictions, if any, existed. Resident 58's September 2023 MAR showed facility nurses signed off three times a day, that they titrated Resident 58's oxygen to maintain their oxygen saturation greater than 90%. Review of the MAR showed the resident's oxygen saturation ranged from 91-99% on room air in September 2023 and that the resident received no supplemental oxygen. On 10/12/2023 at 1:20 PM, Staff D, MDS Assistant, said they identified and coded in their assessment that Resident 58 received oxygen because Resident 58 was receiving supplemental oxygen during their assessment of Resident 58. At 1:26 PM, Staff B, DON, said if Staff D saw Resident 58 receiving oxygen during their MDS assessment, then the resident was administered oxygen. Staff B said facility nurses must have failed to document the oxygen administration on Resident 58's MAR as required. Staff B also said Resident 58's oxygen order was incomplete and needed to include the ordered oxygen flow rate and the method of delivery. Reference WAC 388-97-1060 (3)(vi) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

. Based on observation, interview, and record review, the facility failed to ensure refrigerator temperatures were maintained within acceptable ranges and/or failed to document refrigerator temperatures for 2 of 3 refrigerators reviewed for food service. These failures placed residents at risk of food-borne illness and a diminished quality of life. Findings included . <Out of Range Temperatures> Review of the July 2023, August 2023, September 2023, and October 2023 temperature logs for the Reach-In refrigerator in kitchen, showed refrigerator temperatures were recorded at over 41 degrees Fahrenheit (F) on the following dates: July 2023: 4th 44F, 7th 42F, 8th 43F, 9th 44F, 10th 42F, 16th 43F, 17th 46F, 19th 42F, 21st 43F, 22nd 44F, 23rd 46F, 26th 46F, 30th 42F, 31st 50F. August 2023: 5th 42F, 6th 45F, 7th 45F, 8th 44F, 10th 44F, 12th 42F, 13th 43, 14th 47F, 15th 49F, 17th 43F, 20th 43F, 21st 45F, 22nd 47F, 24th 42F, 27th 44F, 28th 45F, 29th 47F. September 2023: 3rd 42F, 4th 43F, 5th 44F, 7th 43F, 9th 42F, 10th 47F, 11th 48F, 12th 46F, 15th 46F, 16th 42F, 17th 43F, 18th 46F, 18th 43F, 21st 42F, 24th 42, 25th 43F, 26th 46F, 28th 43F. October 2023: 1st 43F, 2nd 46F, 6th 43F, 7th 46F, 8th 46F, 9th 46F. <Incomplete Temperature Documentation> Review of the Garden Dining room refrigerator temperature log showed no log was completed for October 2023. On 10/12/2023 at 9:45 AM, Staff H, Dietary Supervisor with Staff J, Cook, present, as well, said kitchen staff record the refrigerator temperatures when the kitchen opens at 4:00 AM. Staff H said on Tuesdays and Thursdays, freight was delivered and cold items would be placed in the refrigerator. Staff H said when staff stocked the refrigerators, the doors would often be left open, which resulted in the internal temperature of the refrigerator rising. Staff H said she would come back to recheck the refrigerator to make sure it was back within appropriate temperature range. Staff J, said while Staff H was on leave, Staff H's duties were delegated amongst the kitchen staff, and no one doubled checked the refrigerator to make sure it was within required temperature range. Staff H said the refrigerators should have been double checked. At 2:33 PM, Staff B, Director of Nursing, said it was the responsibility of kitchen staff to document the correct refrigerator temperatures for kitchen refrigerators daily and report any concerns to maintenance. Staff B said it was the responsibility of housekeeping to document daily temperatures of the dining room refrigerators. Staff B said temperatures above 41 degrees Fahrenheit, were not acceptable. At 3:04 PM, Staff A, Administrator, said kitchen staff documented refrigerator temperatures for all kitchen refrigerators and housekeeping documented all dining room refrigerator temperatures. Staff A said any refrigerator temperature over 41 degrees Fahrenheit, was not acceptable. On 10/13/2023 at 9:22 AM, Staff K, Housekeeping Supervisor, said once housekeeping completed the refrigerator temperature log, it would be thrown away. Staff K stated, I don't have them, and was unable to provide any copies documenting the Garden dining room refrigerator temperatures. At 9:26 AM, Staff L, Maintenance Supervisor, said all the dining room refrigerator temperature logs should have been kept. Reference WAC 388-97-2980 (1) .

Aug 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that nursing assistants demonstrated competency caring for residents after a fall for 1 of 3 residents (Resident 1) reviewed for falls. This failure placed the resident at risk for delayed medical attention, unnecessary pain, and potential clinical complications. Record review of the facility's undated policy titled, Incidents and Accidents, showed that in the event of an incident or accident, immediate assistance will be provided, and any injuries will be assessed by the licensed nurse and the affected individual will not be moved until safe to do so. Resident 1 was admitted to the facility on [DATE]. Review of the Minimum Data Set assessment, dated 04/28/2023, showed the resident was cognitively intact and had a prior fall with injury. On 08/23/2023 at 10:13 AM, Resident 1 stated that they had taken themselves to the bathroom on 07/18/2023 in the evening and had fallen. The resident stated that two nursing assistants put them back in bed and they had pain from the fall. On 08/25/2023 at 1:10 PM, Staff A, Licensed Practical Nurse, stated that they were assessing Resident 1 immediately after a fall on the morning of 07/19/2023. Staff A stated that Resident 1's right shoulder was swollen, and the resident was unable to raise their right arm. Staff A stated that they did not believe the swelling was due to the present fall and questioned Resident 1 if they had any prior falls in the past few days. Staff A stated that Resident 1 reported they had fallen in the evening on 07/18/2023 after walking to the bathroom. Staff A stated that there was no report or documentation of a fall on 07/18/2023. Review of the facility investigation, dated 07/21/2023, showed that Resident 1 fell on [DATE] and during the investigation of that fall, Resident 1 reported another fall on the evening of 07/18/2023. The investigation further showed that on 07/18/2023, Staff B, Certified Nursing Assistant (CNA), had found Resident 1 on the bathroom floor and assisted the resident back into bed prior to a licensed nurse's assessment. Review of the witness statement provided by Staff B, CNA, dated 07/20/2023, showed that Staff B had assisted Resident 1 back into the bed after they found the resident on the floor in the bathroom at approximately 9:45 PM on 7/18/2023. The statement further showed that Staff B was unaware if the licensed nurse had checked on Resident 1 after the fall. Record review of Facility Inservice Sign in Form, dated 06/21/2023, showed education was provided on the Incident and Accident policy and showed Staff B, CNA, was in attendance. On 08/25/2023 at 2:11 PM, Staff C, Director of Nursing, stated that Certified Nursing Assistants cannot assess a resident for injuries after a fall and Staff C expects that a licensed nurse would assess the resident for injuries prior to the resident being moved. Reference WAC 388-97-1680 (2) (a)(b)(i-ii)(c)

May 2023 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the amount of supervision 1 of 3 (Resident 1) sampled residents who was at risk for falls was care planned to require. This failure resulted in harm when Resident 1 was left unattended in the bathroom, fell, and sustained a hip fracture. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses to include stroke and left sided weakness. Review of the Minimum Data Set assessment, dated 01/03/2023, showed the resident was cognitively impaired and required extensive assistance with toileting. Resident 1's care plan, revised on 02/03/2022, showed that Resident 1 was not to be left unattended on the toilet due to impulsiveness. Resident 1's Fall Risk Assessment, dated 03/30/2023, showed the resident was a high risk for falls. On 05/03/2023 at 1:26 PM, Resident 1 stated that they had fallen, and it hurt bad. On 05/03/2023 at 1:32 PM, Staff B, Certified Nursing Assistant (CNA), stated that they had cared for Resident 1 often and knew the resident well. Staff B stated that the resident was impulsive and always tried to stand up without assistance. Staff B stated the resident was not aware of their limitations and had always been that way. Review of Resident 1's progress notes, dated 04/05/2023, showed that Resident 1 was found on the floor next to the toilet. The progress notes further showed that that the resident was complaining of left hip pain and was sent to the hospital for evaluation of a hip fracture. Review of the Hospital Records, dated 04/06/2023, showed Resident 1 had a left acetabulum (socket portion of the ball and socket hip joint) fracture. The Facility's Investigation, dated 04/07/2023, showed that Staff C, CNA, on 04/05/2023, had transferred Resident 1 onto the toilet and left the bathroom. The investigation showed that Staff C was at the nursing station when they heard the resident scream, returned to the bathroom, and found the resident on the floor. The investigation further showed that Staff C was unaware the care plan directed staff not to leave the resident unattended on the toilet. On 05/09/2023 at 12:20 PM, Staff A, Director of Nursing Services, stated staff were expected to provide care based on a resident's care plan. Staff A stated that Resident 1's care plan showed not to leave the resident unattended in the bathroom prior to the fall on 04/05/2023. Staff A stated that the expectation was for staff to have followed the resident's care plan and remained with the resident in the bathroom during toileting. Staff A stated that staff did not follow the care plan when they toileted the resident prior to the fall. Reference WAC 388-97-1060 (3)(g)

Nov 2022 30 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide information on the risks and benefits of a psychoactive medication and obtain an informed consent for 1 of 1 resident (Resident 73) reviewed for Behavioral/Emotional and 1 of 5 residents (Resident 64) reviewed for unnecessary medications. Failure to obtain an informed consent with risks and benefits prior to use of a psychoactive medication had the potential for the residents to have a lack of knowledge to make an informed decision regarding the use of the medication and a decreased quality of life. Findings included . RESIDENT 73 During an interview on 11/16/2022 at 11:07 AM, Resident 73 stated that the nurses bring an antidepressant every day, but the resident did not take it. Resident 73 stated they felt the doctors started it without talking to her first and the resident felt they were not depressed. Resident 73 stated if the staff had talked to them about the side effects or how they worked, they might have taken it. Review on 11/16/2022 at 11:45 AM of Resident 73's order for fluoxetine (an antidepressant medication) for depression and showed a start date of 04/01/2022. Review on 11/16/2022 at 11:47 AM of the Medication Administration Record (MAR) for November 2022 showed Resident 73 had refused 12 of 16 administrations during the month of November. No documentation related to notifying the provider was found. Review on 11/16/2022 at 11:49 AM of a consent form for fluoxetine dated 04/01/2022 showed no signature of the resident or their Power of Attorney. During an interview on 11/18/2022 at 1:00 PM, Staff M, Licensed Practical nurse (LPN) stated that Resident 73 was administered fluoxetine this morning. Staff M stated, if you enter the room singing, she sings with you and takes her meds. During an interview on 11/18/2022 at 8:29 AM, Staff G, Social Services (SS) stated that during the monthly psych meeting they would discuss any refusals. Staff G further stated that they were aware of Resident 73 refusing the antidepressant medications and had spoken with the family and nurses to reschedule the medication to the evening shift. During a follow up interview on 11/21/2022 at 11:12 AM, Staff G, SS stated that Resident 73 should have had the risks and benefits explained to them, that the provider should have been notified of refusals and the consent form signed by the resident or power of attorney prior to administering or had been discontinued. RESIDENT 64 Review of the annual Minimum Data Set assessment (MDS) dated [DATE] showed Resident 64 admitted to the facility on [DATE] with diagnoses that included altered mental status and schizophrenia (a mental illness that affects how a person thinks, feels, and behaves). It further showed that Resident 64 was able to make needs known and had received antipsychotic medication. Review of electronic health records (EHRs) on 11/17/2022 showed that Resident 64 was prescribed olanzapine (an antipsychotic medication) since 08/13/2021. Review of Resident 64's November 2022 MARs showed that the resident was provided/received olanzapine medication per physician orders. Review of the Psychoactive Medication Agreement/consent for the use of olanzapine showed that Resident 64 signed and dated the form on 08/18/2021; however, this form did not have documentation of the diagnosis or any benefits for the use of the antipsychotic medication. During an interview on 11/21/2022 at 10:37 AM Staff N, Resident Care Manager (RCM) stated that an informed consent should be obtained prior to providing an antipsychotic medication to a resident. Additionally, Staff N stated that Resident 64's Psychoactive Medication Agreement/consent for olanzapine should have had a diagnosis and benefits documented on the form. During an interview on 11/21/2022 at 3:26 PM Staff B, Director of Nursing Services (DNS) stated that Resident 64's Psychoactive Medication Agreement did not meet expectations for it was missing a diagnosis for indication of use and should have included benefits for use. Reference WAC 388-97-0260 .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0560 (Tag F0560)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to allow a resident the right to refuse transfer to another room that was for the purpose of transferring the resident to the long-term care unit for 1 of 5 residents (Resident 7) reviewed for choices. This failure placed the residents at risk for emotional distress and frustration. Findings included . Resident 7 was admitted to the facility on [DATE]. Review of the Minimum Data Set assessment dated [DATE], showed the resident was cognitively intact. On 11/15/2022 at 11:54 AM, Resident 7 stated that the facility moved them to a different room, they had no choice or notice, and they dreaded it. Review of Resident 7's census tab in their electronic health record, showed a room change on 11/07/2022. Further review of the record showed no other documentation of the room change. On 11/21/2022 at 4:55 PM, Staff G, Social Services/admission Coordinator, stated that the facility moved residents from their Medicare Unit (the unit that new admissions from the hospital come into), to the long-term care units when residents decided to stay long-term care. Staff G stated the facility did this because the residents that came from the hospital had higher acuity needs than the residents that stayed long-term care and they could watch the new admissions on the Medicare Unit better. On 11/22/2022 at 11:52 AM, Staff OO, admission Coordinator, stated that Resident 7 was moved to a different room because the resident was staying long term and their stay was no longer paid by Medicare. Staff OO stated Resident 7 did not have the choice to stay on the Medicare Unit. No Reference WAC .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0567 (Tag F0567)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide residents with access to their funds on the weekends for 1 of 1 resident (Resident 40) reviewed for personal funds. This failure placed the residents at risk for unmet financial needs and a diminished quality of life. Findings included . Resident 40 was admitted to the facility on [DATE]. Review of the Minimum Data Set assessment, dated 09/24/2022, showed that the resident was able to make their needs known. On 11/15/2022 at 1:25 PM, Resident 40 stated that the facility kept his money, and they were out of luck if they wanted it on the weekend. On 11/17/2022 at 12:26 PM, the list of residents that had funds held by the facility was reviewed with Staff PP, Bookkeeper. Staff PP confirmed Resident 40 had funds held by the facility. According to Staff PP a box of money used to be left at the nurse's station so residents could access their funds afterhours and on weekends. The procedure was not followed so the box of money was taken away. Staff PP stated that residents could only access their money Monday through Friday from 5:00 AM to 5:00 PM. Reference WAC 388-97-0340 (1)(2)(3) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) Level II evaluation recommendations were implemented and incorporated into the care plan (CP) for 1 of 3 residents (Resident 25) reviewed for Level II PASRRs. The failure to incorporate/implement Resident 25's treatment plan into their comprehensive CP placed the resident at risk for unmet mental health and psychosocial needs. Findings included . RESIDENT 25 According to Resident 25's 11/15/2017 level I PASRR, the resident had a significant change on 11/02/2017 and demonstrated signs of serious mental illness (SMI) including depressive and bipolar disorders. It was determined that the resident required a level II PASRR referral. Review of Resident 25's 11/17/2017 level II PASRR Initial Psychiatric Evaluation Summary showed the resident was determined to have SMI that required specialized services. Resident 25's psychiatric diagnoses were identified as depressive disorder, bipolar disorder, and anxiety disorder. Review of Resident 25's 01/03/2018 recommended treatment plan showed the following: under Mental Health Services it was recommended the resident be referred for counseling services and evaluation by a licensed Mental Health Professional (MHP) or Mental Health Agency for individual services/case management, psychiatric assessment and medication evaluation and management. Review of Resident 25's comprehensive CP showed: the resident was not identified as a level II PASRR; there was no indication the resident needed or was receiving counseling or mental health services. Review of Resident 25's electronic health record (EHR) showed no documentation or indication the resident had received counseling services in the past two years. During an interview on 11/21/2022 at 1:37 PM, Staff G, Social Services, acknowledged that the level II evaluators treatment recommendations did not get incorporated into Resident 25's plan of care. When asked about Resident 25's counseling services, Staff G stated that the resident was seeing a counselor twice a week prior to the pandemic, but the facility no longer had a contract with that provider and just recently obtained a new one. Staff G stated that Resident 25 last received counseling services in 2019. Reference WAC: 388-97-1915(4) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to obtain a physician order for the use of oxygen for 1 of 2 residents (Resident 40) reviewed for respiratory care. This failure placed the resident at risk of receiving unmonitored oxygen treatment and medical complications. Findings included . Resident 40 was admitted to the facility on [DATE] with diagnosis of lung disease. On 11/15/2022 at 1:55 PM, Resident 40 stated that they used oxygen when they were short of breath, mainly at nighttime. On 11/18/2022 at 6:56 AM, Resident 40 was observed lying in bed with oxygen on. Review of Resident 40's physician orders on 11/17/2022 at 6:56 PM, showed no order for oxygen. On 11/18/2022 at 10:28 AM, Staff X, Licensed Practical Nurse, stated that Resident 40 used their oxygen occasionally at night. Staff X reviewed Resident 40's physician orders, which showed no documentation of an oxygen order. Staff X stated oxygen requires a physician order. On 11/22/2022 at 2:25 PM, Staff B, DNS, stated that Resident 40 required an order for oxygen use. Reference WAC 388-97-1060 (3)(j)(vi) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to accurately assess 1 of 2 sampled residents (Resident 77) reviewed for pain. This failure placed the resident at a risk for inadequate pain control and a diminished quality of life. Findings Included . Review of the admission Minimal Data Set assessment (MDS) dated [DATE], showed that Resident 77 was admitted to the facility on [DATE] with diagnosis to include osteomyelitis,(inflammation of bone caused by infection) cellulitis of the right great toe (bacterial skin infection), diabetes and diabetic polyneuropathy (a disease that affects multiple peripheral sensory and motor nerves that branch out from the spine) and was not receiving medication for pain. The MDS showed that Resident 77 was in pain frequently at a 9 out of 10 on the pain scale of 0 through 10 with 10 being the highest possible pain. During an interview on 11/15/2022 at 10:20 AM, Resident 77 stated that the nurse would give her Tylenol when she asked for it. Resident 77 further stated that sometimes the Tylenol helped her pain and other times it did not help. Additionally, the resident stated that she mentioned to several staff about the pain and that the Tylenol was not always working to help relieve the pain. Review of Resident 77's electronic health records (EHR)on 11/18/2022 showed nursing staff documented Resident 77 was complaining of pain at a level between 2 and 8 consistently. Review of Resident 77's care plan dated 09/16/2022 showed a focus area for pain management with a goal that included that Resident 77 would verbalize adequate pain relief as indicated. Interventions included monitoring for effectiveness, side effects of medication and notifying medical provider of non-effectiveness. Review of the EHR on 11/19/2022 showed that Resident 77 was receiving Tylenol tablets every 6 hours as needed for pain along with a scheduled order for Tylenol three times a day for chronic right shoulder and right hip pain on a routine basis. During an interview on 11/22/2022 at 12:36 PM, Staff AA, Register Nurse/Medicare Coordinator (RN/MC) stated that she would usually contact the medical provider if the staff notified her about the resident's need for stronger pain medications. Ataff AA tated that she could not recall contacting the Medical Provider regarding Resident 77's need for stronger pain medication. Staff AA stated that she was not aware that Resident 77's pain was not adequately managed. During an interview on 11/18/2022 at 12:30 PM, Staff B, Director of Nursing Services (DNS), stated that he would contact the medical provided regarding Resident 77's pain and the need to reevaluate the resident's pain medication to better manage pain. He further stated that it was his expectation that the resident was to receive adequate pain management. Reference WAC 388-97-1060 (1) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to act on the consultant pharmacist's Medication Regimen Review (MRR) recommendations for 1 of 5 residents (Resident 53) reviewed for unnecessary medication use. Failure to act on the pharmacist's recommendations placed the resident at risk for experiencing adverse side effects, medical complications, and a decreased quality of life. Findings included . RESIDENT 53 Review of a quarterly minimum data set assessment (MDS) dated [DATE] showed that Resident 53 had readmitted to the facility on [DATE] with multiple diagnoses to include Alzheimer's Disease, chronic pain syndrome, multiple behavioral diagnoses to include bipolar (a mental illness characterized by severe highs and lows in mood), depression, anxiety, and dementia. The MDS further showed that the resident was able to make needs known and was prescribed multiple medications used for the treatment of these conditions. Review of documents titled, Consultant Pharmacist's Medication Regiment Review, dated 09/16/2022 and 10/21/2022 showed that the pharmacist had documented the following, Resident [53] has an order for electrocardiogram [EKG, a device that records the electrical signals from the heart to check for different heart conditions] every 6 months due to multiple meds and QT interval [a measurement of the total duration of heart contractions during activation and recovery]. Has one been done? I don't see one in the last six months in PCC [point click care, resident electronic health record]. The follow through in September 2022 showed that facility staff had documented, no EKG results found and renewed request. The follow through for October 2022 showed that the staff had documented, provider contacted for new orders. Review of Resident 53's electronic health records (EHR) showed that an EKG was last obtained in December 2021. No documentation was shown that an EKG was obtained six months later in the month of June 2022 as ordered or documentation that it was refused. Review of Resident 53's, Medication Administration Record (MAR) dated November 2022 showed a provider's order on 12/03/2021 for staff to obtain an EKG every six months. Additionally, the resident had been prescribed on 07/14/2022 for staff to administer, quetiapine (an antipsychotic medication). Review of a provider's progress note dated 11/18/2022 showed that the psychiatrist had documented the need for Resident 53 to have an EKG related to being administered an antipsychotic medication (quetiapine). Review of Resident 53's care plan dated 08/14/2019 showed that the resident had psychotropic drug use related to bipolar, depression, and an anxiety disorder. The goal showed that the resident would be free from adverse reaction to medication. Interventions included the staff to monitor effectiveness of the medications, as per facility policy and to assess for side effects. Review of an emailed document received on 11/17/2022 at 3:36 PM, from Staff B, Director of Nursing Services (DNS) showed documentation that he was unable to locate an EKG for June 2022, and that he would be calling the provider for further orders. During an interview on 11/18/2022 at 1:52 PM, Staff B, DNS stated that it was his expectation that the pharmacist's recommendation for Resident 53 was followed and that if the resident had refused, a progress note should have been made and the provider should have been contacted. Reference WAC 388-97-1300 (4)(c) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 40 Resident 40 was admitted to the facility on [DATE] with diagnoses to include dementia and depression. Resident 40's physician order dated 07/21/2022, showed an order for quetiapine for dementia with negative behaviors. Review of Resident 40's comprehensive MDS dated [DATE] showed no documentation of input from the resident and/or family/representative, in the care area assessment (CAA) for psychotropic drug use. Resident 40's progress note dated 07/21/2022, showed an Interdisciplinary Team (IDT) review of the resident's medications.The documentation showed the resident had their psychotropic medication increased due to angry behaviors, and no more changes recommended. Further review showed no discussion of the effectiveness of the behavioral interventions. Review of Resident 40's mood state care plan revised 08/02/2021, showed care plan interventions with last revision date of 08/02/2021. Review of Resident 40's psychosocial well-being care plan revised 08/02/2021, showed care plan interventions with last revision date of 12/03/2021. On 11/21/2022 at 3:09 PM, Staff F, MDS Coordinator/RN, stated that she did not evaluate the behavioral interventions in Resident 40's care plan. Staff F stated that she did not include the resident and/or representative when she completed the psychotropic drug use CAA. On 11/22/2022 at 2:20 PM, Staff G, Social Service, stated that the IDT meets monthly and reviews residents on psychotropic medication and residents with behavior issues. When asked if the IDT reviewed Resident 40's behavioral interventions when they met on 07/21/2022, Staff G stated that they only reviewed the medication dosage, they did not evaluate Resident 40's care planned behavioral interventions or discuss if the behavior interventions were effective. On 11/22/2022 at 2:25 PM, Staff B, DNS, stated that the IDT did not discuss and/or evaluate the behavior interventions on Resident 40's care plan. Reference WAC 388-97-1060 (3)(k)(i) RESIDENT 64 Review of the annual MDS dated [DATE] showed Resident 64 admitted to the facility on [DATE] with diagnoses that included altered mental status and schizophrenia (a mental illness that affects how a person thinks, feels, and behaves). It further showed that Resident 64 was able to make needs known and had received antipsychotic medication. Review of Resident 64's September 2022 MAR showed an order dated 08/13/2022 for, Monthly Pastorals [check changes in blood pressure while lying, sitting and standing] for Psychotropic drug monitoring every day shift starting on the 13th and ending on the 13th every month for monthly monitoring of side effects. It further showed that Resident 64 received antipsychotic medication; however, had no postural blood pressures documented for the month. During an interview on 11/18/2022 at 10:13 AM Staff L, Resident Care Manager (RCM) stated that Resident 64's September 2022 MAR showed that on 11/13/2022 it was documented/coded that the resident was away from the facility and postural blood pressures were not done. After looking at Resident 64's EHR, Staff L stated that Resident 64 should have had postural blood pressures done on another date in September of 2022, was unable to locate that documentation, and this did not meet expectations. During an interview on 11/21/2022 at 5:49 PM Staff B, Director of Nursing Services (DNS) stated that on 07/13/2022 Resident 64 was away from the facility, was unable to locate that postural blood pressures were completed for September 2022, and they should have been. Staff B stated that if postural blood pressures were not done on the scheduled date then they should have been done on another date during the month and this did not meet expectations. Based on observation, interview and record review, the facility failed to ensure monitoring of potential side effects related to the use of psychoactive medications for 3 of 5 residents (Resident's 53, 64, and 40) and evaluate behavioral interventions for 1 of 5 residents (Resident 40) reviewed for unnecessary medication use. The failure to monitor orthostatic vital signs (blood pressure [BP] and heart rate taken while lying, sitting, and standing) related to use of an antipsychotic medication and the failure to evaluate behavior interventions, placed the residents at risk for unnecessary medications, adverse side effects, medical complications, and a diminished quality of life. Findings included . Review of an email dated 11/17/2022 from Staff B, Director of Nursing Services (DNS) showed that the facility's policy directed licensed nurses (LNs) to follow the providers orders as written. The provider's orders were standardized when the psychotropic order was first written and showed that the order for monthly postural (orthostatic vital signs) for psychotropic drug monitoring was to be obtained during day shift each month. The order also directed the LNs to initiate orthostatic vital signs and monitor for side effects. Furthermore, the order was written to have a range of days each month to allow for the resident refusal or other delays. Once the orthostatic vital signs were obtained no further postural blood pressures were needed until the next month. RESIDENT 53 Review of a quarterly minimum data set (MDS) dated [DATE] showed that Resident 53 had readmitted to the facility on [DATE] with multiple diagnoses to include Alzheimer's Disease, chronic pain syndrome, multiple behavioral diagnoses to include bipolar (a mental illness characterized by severe highs and lows in mood), depression, anxiety, and dementia. The MDS further showed that the resident was able to make needs known and received multiple psychotropic medications and an antipsychotic medication. Review of Resident 53's care plan dated 08/14/2019 showed that the resident had psychotropic drug use related to bipolar, depression, and an anxiety disorder. The goal showed that the resident would be free from adverse reaction to medications. Interventions directed the staff to monitor effectiveness of the medications and to assess for side effects. Review of Resident 53's physician order dated 07/14/2022, showed an order for quetiapine (an antipsychotic medication used to treat mental conditions). An additional provider's order dated 11/25/2022 showed that orthostatic BPs were to be monitored on the 25th monthly and LNs were to notify the provider for any postural changes as ordered. Review of the November 2022 Medication Administration Record (MAR) dated 01 to 30 November 2022 showed Resident 53 was prescribed to receive quetiapine that was used in the treatment of Resident 53's behavioral and psychological symptoms to include: orthostatic hypotension. In addition, the MAR showed that LNs were to check for orthostatic hypotension/postural BP's monthly related to the use of the quetiapine every 30 days during day shift. Review of Resident 53's June 2022, MAR showed no Orthostatic Vital Signs had been documented or progress note that indicated the resident had refused; furthermore, no documentation within the resident's electronic health record (EHR) showed that the resident had been reapproached and/or offered the orthostatic BPs at another date during that month. Review of Resident 53's September 2022, MAR showed no documentation that the orthostatic vital signs were obtained. The MAR for 09/25/2022 was left blank with no indication that the resident had refused nor was reapproached later during the month. Review of Resident 53's October 2022 MAR showed that the orthostatic vital signs were obtained; however, all the three vital signs that were obtained and documented were the same 100/64 and a heart rate of 58 beats per minute for all three positions (sitting, standing, and lying). During an interview on 11/17/2022 at 1:52 PM, Staff B, Director of Nursing Services (DNS) stated that it was his expectation that licensed nurses (LNs) were to obtain monthly orthostatic blood pressures for those residents who received antipsychotic medication as directed. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to ensure a secure and safe storage for medications in one of five medication carts (Medicare hallway C medication cart) reviewed for medication storage. This failure posed a potential safety hazard for residents and visitors that had access to unsecured mediations and placed the residents at risk for loss of medications. Findings included . Review of the facility's policy titled, Medication Storage, dated 05/17/2022 showed that all drugs and biologicals would be stored in locked compartments (ie., medication carts, cabinets, drawers, refrigerators, and medication rooms). It further showed that only authorized personnel would have access to the keys to locked compartments and During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. An observation on 11/12/2022 at 12:44 PM showed a set of nine keys with one key inserted into the outside narcotic/controlled medications (double locked drawer of drugs/controlled substances that may be addictive) keyhole of the Medicare hallway C medication cart, left unattended. Additionally, one family member and two staff members walked past the medication cart. During an observation and interview on 11/22/2022 at 12:50 PM Staff KK, Licensed Practical Nurse (LPN), approached the Medicare hallway C medication cart and stated that she had forgotten the keys in the medication cart. When attempting to pull the narcotic drawer open with the keys in the narcotic drawer it would not open. Staff KK stated that it would require a different key on the key chain to open the other side of the medication cart (which was found locked) for all other medications to be open first before being able to turn the key and open the narcotic drawer. During interview on 11/22/2022 at 12:57 PM Staff B, Director of Nursing Services (DNS) approached the Medicare hallway C medication cart and Staff KK, LPN, stated, .I left the keys in the cart and went into the resident's room. During an interview on 11/22/2022 at 1:37 PM Staff B, Director of Nursing Services (DNS) stated that the expectation was that medication cart keys were not left unsecured at any time and the facility's medication storage policy be followed. Reference WAC 388-97-2340 .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to assure residents received foods in the appropriate form and/or nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's nutritional needs. Failure to ensure residents' received physician ordered therapeutic diets or portion sizes placed residents at risk for medical complications or nutritional deficits. Findings included . Observation of the lunch meal service on 11/18/2022 revealed the primary lunch meal consisted of grilled cheese sandwiches, tomato basil soup, oyster crackers, tapioca pudding and 2 % milk and the alternate meal was a chicken burger on a bun with lettuce, tomato, and breaded onion rings. According to the menu low fat, low cholesterol diets receive skim milk. Additionally, Staff J, Dietary Manager explained that residents on large protein diets get one and a half servings of the protein. Tray service for the lunch meal on 11/18/2022 started at 12:18 PM. Staff QQ, Cook, was plating the food and was assisted by Staff J, Dietary Manager. Tray line was observed on 11/18/2022 from 12:18 PM-12:43 PM and showed the following: Large Protein Diets-Staff QQ was observed preparing Resident 69's meal tray. The resident was provided a chicken burger with a single chicken patty. Review of Resident 69's tray card showed the resident was on a regular texture large protein diet and should have been provided one and a half chicken patties. Similarly, Staff QQ prepared Resident 21's lunch meal tray, the resident was provided a chicken burger with one chicken patty. Review of Resident 21s tray card showed the resident was on regular texture, consistent carbohydrate diet with large protein, and should have been provided one and a half chicken patties. During an interview on 11/18/2022 at 3:03 PM, Staff J, Dietary Manager, confirmed staff should have provided residents with large protein diets one and a half servings of the protein (in this case chicken patties), but failed to do so. Low Fat/Low Cholesterol diets- After preparing Resident 243's meal staff placed it on a tray already in the tray cart. Observation of the tray showed the resident was provided a carton off 2 % milk. Review of Resident 243's tray card showed Resident 243 was to receive a no added salt, low fat/ low cholesterol diet, and should have been provided skim milk During an interview on 11/18/2022 at 3:03 PM, Staff J confirmed the menu showed residents on low fat / low cholesterol diets were to be served skim milk but stated the facility does not order skim milk. Review of a weeks' worth of facility menus showed low fat/ low cholesterol diets were to be served with skim milk for every meal breakfast, lunch, and dinner. When asked how the facility provided a low-fat low cholesterol diet if they did not have skim milk Staff J reiterated that the facility does not order skim milk. Review of the facility's current resident diet order showed Resident 242 also had an order for a low-fat low cholesterol diet, which the facility was unable to provide. Reference WAC 388-97-1200(1) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents and/or resident representatives were educated on the risks and benefits of the influenza vaccine and pneumococcal vaccine (series), and consent or declination were obtained for the vaccine for 5 of 5 sampled residents (Residents 51, 43, 25, 81 and 66) reviewed for influenza immunization and pneumococcal vaccine series. This failure placed residents at risk of not being fully informed before making decisions regarding immunizations and receiving the vaccine. Findings included . Record review of the facility's policy titled, Influenza Vaccine, revised 09/09/2022, showed the facility's process for implementing their vaccination program between October 1st and March 31st each year: * The influenza vaccine shall be offered to residents upon availability of seasonal vaccine. * Prior to the administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative, will be provided with a copy of the CDC's (Center of Disease Control) current vaccine information statement. *Residents retain the right to refuse influenza immunization. *The resident's medical record will include documentation that the resident and/or the r esident's representative was provided education regarding the benefits and potential side effects of the immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal. Record review of the facility's policy titled, Pneumococcal Vaccine (Series), dated 10/03/2022 showed that the facility's policy for implementing the pneumococcal immunization series would be to offer the vaccine unless medically contraindicated and was to be administered in accordance with the physician's-approved standing orders. The policy stated: *Prior to offering the immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effect of the immunization. a. The individual receiving the immunization, or resident representative, will be provided with a copy of the CDC's currents vaccine information statement relative to that vaccine. b. If necessary, the vaccine information statement will be supplemented with visual presentations or oral explanations to assist vaccine receipts in understanding. *The resident/representative retains the right to refuse the immunization. A consent form shall be signed prior to the administration of the vaccine and filed in the resident's medical record. Review of Resident 51's annual Minimum Data Set (MDS) assessment, dated 09/14/2022, showed the resident admitted to the facility on [DATE] with multiple diagnoses. Review on 11/21/2022 of Resident 51's electronic health record (EHR) showed documentation that the resident refused the influenza immunization and pneumococcal vaccine series. The EHR did not show a declination letter or review of risk versus benefits of the influenza immunization and/or pneumococcal vaccine series. Review of Resident 43's quarterly MDS, dated [DATE], showed the resident was admitted to the facility on [DATE] with multiple diagnoses. Review on 11/21/2022 of Resident 43's EHR, showed documentation that the resident refused the influenza immunization and pneumococcal vaccine series. The EHR did not show a declination letter or review of risk versus benefits of the influenza immunization and/or pneumococcal vaccine series. Review of Resident 25's quarterly MDS, dated [DATE], showed the resident was admitted to the facility on [DATE] with multiple diagnoses. Review on 11/21/2022 of Resident 25's EHR, showed documentation that the resident refused the influenza immunization and pneumococcal vaccine series. The EHR did not show a declination letter or review of risk versus benefits of the influenza immunization and/or pneumococcal vaccine series. Review of Resident 81's MDS, dated [DATE], showed the resident was admitted to the facility on [DATE] with multiple diagnoses. Review on 11/21/2022 of Resident 81's EHR, showed documentation that the resident refused the influenza immunization and pneumococcal vaccine series. The EHR did not showed a declination letter or risk versus benefits of the influenza immunization and/or pneumococcal vaccine series. Review of Resident 66's admission MDS), dated [DATE], showed that the resident was admitted to the facility on [DATE] with multiple diagnoses. Review on 11/21/2022 of Resident 66's EHR, showed documentation that the resident refused the influenza immunization and pneumococcal vaccine series. The EHR did not showed a declination letter or risk versus benefits of the influenza immunization and/or pneumococcal vaccine series. During an interview on 11/21/2022 at 2:49 PM, Staff, C, Infection Control Preventionists/Registered Nurse (ICP/RN) stated that the residents (Residents 51, 43, 25, 81 and 66) who had refused the COVID vaccine had additionally refused the annual influenza and pneumococcal vaccine series. Staff C, ICP/RN further stated that she had discussed the vaccine and immunizations with the residents and had only documented the refusal in the EHR; but did not document a declination letter that indicated the risks versus the benefits of the immunizations and vaccines were reviewed. During an interview on 11/22/2022 at 3:51 PM, Staff B, Director of Nursing Services (DNS) stated that it would be his expectation that the risk versus benefit would be discussed with either the resident or the resident's representative after a refusal of the immunizations or vaccines. Reference WAC 388-07-1340 (1), (2), (3) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents and/or resident representatives were educated on the risks and benefits of the COVID-19 (a name given for a serious and sometimes potentially fatal lung infection) (SARS-CoV-2) vaccination, had failed to obtain a consent for, or a declination letter, regarding risks versus benefits for 5 of 5 sampled residents (Resident 51, 43, 25, 81 and 66) reviewed for COVID-19 vaccinations. This failure placed residents at risk of not being fully informed before making decisions regarding the vaccine. Findings included . Record review of the facility's policy titled, COVID-19 Vaccination, dated 11/01/2022 showed the facility's policy to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 by educating and offering residents the COVID-19 vaccine. Policy documented: * Prior to the administration of the vaccine, the residents will be screened and assessed for potential medical complications. *In addition, prior to offering the COVID-19 vaccine, residents or the resident's representative will be educated regarding the risks, benefits and potential side effects associated with the vaccine in a form and manner that can be accessed and understood. Review of Resident 51's annual Minimum Data Set (MDS) assessment, dated 09/14/2022, showed the resident admitted to the facility on [DATE] with multiple diagnoses and had moderate memory impairment. Review of Resident 51's electronic health record (EHR) showed documentation that the resident had refused the COVID1-9 vaccine; however, the EHR did not show any declination letter or risk versus benefits of the vaccine. Review of Resident 43's quarterly MDS, dated [DATE], showed the resident was admitted to the facility on [DATE] with multiple diagnoses and moderate memory impairment. Review of Resident 43's EHR, showed documentation that the resident refused the COVID-19 vaccine. The EHR did not show a declination letter or risk versus benefits of the vaccine. Review of Resident 25's quarterly MDS, dated [DATE], showed the resident was admitted to the facility on [DATE] with multiple diagnoses. Review of Resident 25's EHR, showed documentation that the resident had refused the COVID-19 vaccine. The EHR did not show a declination letter or risk versus benefits of the vaccine. Review of Resident 81's MDS, dated [DATE], showed the resident was admitted to the facility on [DATE] with multiple diagnoses . Review of Resident 81's EHR, showed documentation that the resident refused the COVID-19 vaccine. The EHR did not show a declination letter or risk versus benefits of the vaccine. Review of Resident 66's admission MDS, dated [DATE], showed that the resident was admitted to the facility on [DATE] with multiple diagnoses. Review of Resident 66's EHR, showed documentation that the resident refused the COVID-19 vaccine. The EHR did not show a declination letter or risk versus benefits of the vaccine. During an interview on 11/21/2022 at 2:49 PM Staff C, Infection Control Preventionists/Registered Nurse (ICP/RN) stated that the residents (Residents 51, 43, 25, 81 and 66) who refused the COVID vaccine had additionally refused the annual influenza and pneumococcal vaccine series. Staff C, ICP/RN stated that she discussed the vaccine with the residents and only documented the refusal in the electronic health record (EHR). Staff C stated she did not document a declination letter that indicated the risks versus the benefits of the COVID-19 vaccine. During an interview on 11/22/2022 at 1:58 PM with Staff A, Administrator (ADM) stated that it would be his expectation that the risk versus benefit would be discuss with either the resident or the resident's representative after a refusal of the vaccine. During an interview on 11/22/2022 at 3:51 PM, Staff B, Director of Nursing Services (DNS) stated that it would be his expectation that the risk versus benefits would be discussed with either the resident or the resident's representative after a refusal of the vaccines and documented in the residents' EHR. No Associated WAC .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 56 During an interview on 11/16/2022 at 10:14 AM, Resident 56 stated that they did not get to choose when they took a shower. Resident 56 further stated that they got one shower a week and they tell the staff almost every shower that they want three a week. Review of Resident 56's admission MDS showed the resident was able to make needs known, and choices for bathing was marked very important. Review of Resident 56's electronic health record (EHR) on 11/17/2022 at 7:48 AM showed the resident received one shower per week for the prior 30 days. During an interview on 11/17/2022 at 1:35 PM, Staff K, Certified Nursing Assistant (CNA) stated that Resident 56 does request more frequent showers during every shower, and Staff K had reported that to the nurse. During an interview on 11/18/2022 at 10:58 AM, Staff M, Licensed Practical Nurse (LPN) stated that if a resident asked for more frequent shower, they would update the tasks in the EHR to include more showers or change to their preference. Staff M further stated that they were not aware Resident 56 had requested more frequent showers. During an interview on 11/18/2022 at 10:44 AM, Staff L, Resident Care Manager (RCM) stated that staff try to accommodate any requests. Staff L further stated that the CNA would tell the nurse and the nurse can go into the EHR and update the shower schedule. Staff L also stated that they were not aware Resident 56 had requested more frequent showers. During an interview on 11/18/2022 at 9:33 AM Staff B, DNS stated that initially residents start with one shower a week, then during the care conference or if a change is requested the RCM or DNS would be notified and would update the EHR. Staff B further stated they were not aware Resident 56 had requested more frequent showers. Reference: (WAC) 388-97-0900 (1), (3) Based on interview, and record review, the facility failed to have a system in place that promoted and facilitated resident choices related to frequency and type of bathing or failed to honor residents' identified preferences related to frequency of bathing for 3 of 6 residents (Residents 6, 24 and 56) reviewed for choices. The facility's practice of assigning all new residents one shower a week rather than seeking and identifying what their bathing preferences were, detracted from residents' ability to exercise self-determination about aspects of care that were important to them. The facility's failure to identify and/or honor resident preferences related to bathing placed residents at risk for feelings of un-cleanliness, powerlessness, decreased self-worth and diminished quality of life. Finding included . RESIDENT 24 Resident 24 admitted to the facility on [DATE]. According to the 10/10/2022 admission Minimum Data Set assessment (MDS) the resident was cognitively intact, dependent on staff for bathing and that the resident's preferences related to bathing were not assessed. During an interview on 11/16/2022 at 9:13 AM, Resident 24 expressed concern about the frequency of bathing and shared that the facility only offered one shower per week. According to Resident 24 they showered daily at home but felt that was unrealistic in the current setting but indicated they needed at least two showers a week. Resident 24 stated that prior to the current conversation no one from the facility had ever asked what their desired frequency of bathing was. When asked if staff were informed, they desired more than one shower a week Resident 24 stated, No .you are lucky to get one. Review of Resident 24's October and November 2022 bathing flowsheets showed from 10/15/2022- 11/01/2022 (17 days) the facility only offered/provided the resident one shower. During an interview on 11/18/2022 at 2:37 PM, Staff B, Director of Nursing Services (DNS), explained that the facility obtained resident preferences upon admission and/or during the resident's initial care conference. Review of Resident 24's 10/06/2022 admission Assessment showed there was no questions included about resident preferences. Review of Resident 24's 10/20/2022 care conference showed the section on the form that identified Resident 24's shower days and asked, Is this satisfactory for you? this question was left blank. Additionally, the preferences section on the resident's 10/10/20/2022 admission MDS were also blank. During an interview on 11/21/2022 at 8:06 AM, Staff B acknowledged that facility staff should have assessed or identified Resident 24's bathing preferences but failed to do so. RESIDENT 6 According to Resident 6's 09/05/2022 quarterly assessment the resident was dependent on staff for bathing and the resident's preferred method of bathing was showers. Review of Resident 6's 07/27/2022 care conference showed the resident agreed to be showered one time a week. Review of Resident 6's November 2022 bathing flowsheets showed from 11/03/2022-11/15/2022 (13 days), no showers were provided. During an interview on 11/21/2022 at 8:06 AM, when asked if the facility was consistently providing Resident 6 one shower a week as identified, Staff B stated, No, not consistently. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have a system in place to identify, thoroughly investigate and timely follow up to resolve grievances for 3 of 3 residents (Residents 7, 40 and 56) reviewed for Personal Property. Failure to ensure grievances/resident concerns were thoroughly addressed and resolved timely, with supportive documentation in place, had the potential for residents to have continued concerns and affect their quality of life. Findings included . RESIDENT 56 During an interview on 11/15/2022 at 2:16 PM Resident 56 stated that they were missing a wallet and it was reported about 6 weeks ago. Resident 56 did not recall if they had filled out a grievance form. During a follow up interview on 11/17/2022 at 12:48 PM, Resident 56 stated that they reported the missing wallet to a few staff. Someone came and asked them about what it looked like and what was in it, but Resident 56 had not heard anything about it since. Review of the facility policy titled, Resident and Family Grievances Including Missing Items, dated 08/09/2022, showed the staff member receiving the grievance will record the nature and specifics of the grievance on the designated form or assist the resident/family member to complete the form and forward the form to the grievance official as soon as practicable. Review of the Grievance log showed no documented incident of Resident 56 missing a wallet. During an interview on 11/17/2022 at 1:34 PM, Staff K, Certified Nursing Assistant (CNA) stated that if a resident were to report something missing the staff member would tell nurse. Staff K further stated that they were not aware that Resident 56 had reported a missing wallet. During an interview on 11/18/2022 at 8:31 AM, Staff B, DNS, stated that when a resident reports a missing item the CNA would let the nurse know and the nurse will let DNS or Resident Care Manager know and usually social services fills out a grievance. Staff G further stated he had not been made aware of resident 56 missing a wallet. During an interview on 11/18/2022 at 8:26 AM, Staff G, Social Services, stated that nurses would let management know of any reported missing items and then they would fill out a grievance form and investigate. Staff G also stated that they had not been notified of resident 56 missing a wallet. During an interview on 11/18/2022 at 11:10 AM Staff M, Licensed Practical Nurse (LPN) stated that when a resident reports something missing, they would tell the Director of Nursing Services (DNS). Staff M also stated that they were not aware of Resident 56 missing a wallet. RESIDENT 7 Resident 7 was admitted to the facility on [DATE]. Review of the Minimum Data Set assessment dated [DATE], showed the resident was cognitively intact. On 11/15/2022 at 12:31 PM, Resident 7 stated that the facility had lost a bag that had their belongings from the hospital in it. The resident indicated she reported it to facility staff, but they were unable to locate it. Review of Resident 7's electronic medical record on 11/15/2022, showed the facility failed to complete a personal inventory list for this resident. Review of facility grievance log dated August 2022 through November 2022, showed no report of missing items for Resident 7. RESIDENT 40 On 11/15/2022 at 1:25 PM, Resident 40 stated that they had lost a ring and the facility was not able to find it. Review of Resident 40's electronic medical record on 11/17/2022, showed the facility failed to complete a personal inventory list for this resident. Review of facility grievance log dated June 2022 through November 2022, showed no report of missing items for Resident 40. On 11/17/2022 at 11:29 AM, Staff V, Certified Nursing Assistant, stated that if a resident had a missing item she would tell the charge nurse, Staff AA. On 11/17/2022 at 11:30 AM, Staff AA, Medicare Coordinator, stated she would notify the housekeeper or the admission coordinator if she was notified of a missing item, she stated that she does not write it down. On 11/22/2022 at 2:42 PM, Staff A, Administrator stated that the facility utilized the grievance procedure for missing items that included staff filling out a grievance card when they became aware of a missing item and turned it into the grievance officer. He stated that the facility had a grievance procedure and it had not been followed for missing items. Staff A stated that the system was not working, and he would correct it. Reference WAC 388-97-0460 .

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 142 Review of Resident 142's admission Minimum Data Set assessment (MDS) dated [DATE], showed that the resident admitted on [DATE] with multiple diagnoses to include kidney disease and difficulty walking. The MDS showed the resident required extensive assistance with activities of daily living (ADLs) and was able to make needs known. Review of the facility's incident investigation initiated on 11/17/2022 showed that survey personnel had reported hearing a staff member tell the resident to eat their lunch when the resident told the staff member they needed a bed change. The staff member was immediately suspended pending the outcome of the investigation. The incident investigation included four undated questionnaires about patient care from other residents on the same hall. Resident 142 was interviewed on 11/21/2022 and was to be placed on alert for potential psychosocial harm four days after the allegation. Review of Resident 142's EHR on 11/18/2022 at 1:45 PM showed no documentation that the resident was placed on alert for psychosocial needs after the incident. During an interview on 11/21/2022 at 10:27 AM Staff BB, Registered Nurse/Medicare Coordinator (RN/MC), stated that the process for incident investigation would be to make sure the resident was safe, contact the Director of Nursing, resident's family and to make a report to the state. Additionally, the nurse or charge nurse should immediately complete a risk management report and start the three-day psychosocial monitoring. Staff BB stated she was unable to locate a progress note, a completed risk management report or any current or recently discontinued monitoring in the EHR. During an interview on 11/21/2022 at 10:57 AM, Staff B, Director of Nursing Services (DNS), stated a psychosocial assessment should have been completed and the resident should have been put on comfort rounds every 15 mins for 72 hours. Staff B stated, the expectation is that the resident would have been put on alert. RESIDENT 6 FALL1 Review of Resident 6's 09/05/2022 quarterly MDS showed the resident had severe cognitive impairment, required two-person physical assistance with transfer, was unsteady moving from seated to standing position, requiring staff assistance to stabilize, and had fallen two or more times since the prior assessment. According to Resident 6's fall care plan, revised 11/23/2022, the resident was at risk for falls due to impaired gait/balance, prior stroke with left sided weakness, Parkinson's disease, and use of psychotropic medications. Interventions developed to decrease risk for falls included: keep a clear path to the bathroom; keep bed in the lowest position; Noodles (bolsters) on both sides of bed to define boundaries; remind and encourage resident to use call light to request assistance with transfers to and from the bathroom; monitor side effects of medications that may alter balance/coordination; make sure Resident 6 has proper footwear on for transfers and mobility (i.e.: non-slip socks, rubber soled shoes etc.) ; and make sure proper assistive device in place during transfers and mobility. The care plan did not identify what the proper assistive device was. Review of the facility's Incident Reporting Log (IRL) showed Resident 6 had falls on 08/31/2022 at 11:50 AM and 09/01/2022 at 7:15 PM. Review of Resident 6's EHR showed a 08/31/2022 2:46 PM nurse's note which indicated Resident 6 had an unwitnessed non-injury fall at 11:50 AM. A Certified Nursing Assistant (CNA) found the resident sitting on the floor near her wheelchair. It seems as though resident slid down her wheelchair. Resident alert per baseline, unable to verbalize why she attempted to get up. Resident denied pain. No injuries noted. Review of the facility's 08/31/2022 fall investigation showed the nurse was notified by a CNA that Resident 6 was found sitting on the floor in front of her wheelchair. The nurse assessed the resident and identified no latent injuries and the resident was subsequently assisted back to the wheelchair. Further review of the investigative documents showed under Predisposing Situation Factors staff documented Resident 6 had Improper Footwear at the time of the unwitnessed fall. Review of the nurse's Fall Scene/other occurrence investigation, dated 08/31/2022, showed for cause of the fall the nurse documented Resident unable to verbalize cause of the fall but is alert per baseline. For the question What initial interventions did you put in place to prevent further falls? The nurse documented Resident placed back into tilt wheelchair and tilted. Reminded resident of her limitations and to call for help when needed. The nurse's investigation did not identify: if Resident 6's tilt-in-space wheelchair was found upright or in the tilted position at the time of the fall; whether the resident was wet or soiled when found; what time staff last provided care or had seen the resident; and did not address that Resident 6 was found with improper footwear, despite the resident's fall care plan directing staff to ensure proper footwear was in place. Review of the Requirement of Incident Witness Statement forms completed by the CNAs showed the first question was When had you last seen/toileted/assisted the Resident? with direction to Give a specific time. Review of the two CNA statement attached to the investigation showed one CNA wrote they did not know when the resident was last toileted, and the other CNA wrote after they returned from lunch Resident 6 was still in the wheelchair. No specific times were provided, nor was there any indication when the resident had last received care and/or was toileted. According to the facility's investigative summary and conclusion Resident 6 goes through phases where she is more active and tries to stand independently but the facility is usually able to prevent falls through monitoring. The facility identified the root cause as Resident 6's positive mood swings that tend to make her more active. According to the investigative document no change to interventions was necessary but the resident would be referred to therapy for post-fall screening. The summary and conclusion did not identify or address whether the residents tilt-in-space wheelchair was tilted at the time of the incident, whether the resident was wet or soiled, when the resident had last been toileted or provided care, or that the resident was wearing improper footwear and what if anything was done about it. (e.g., appropriate footwear applied?) FALL 2 Review of the facility's 09/01/2022 fall investigation showed Resident 6 had an unwitnessed fall and was found sitting on the floor next to the bed by a CNA who notified the nurse. Resident 6 was assessed and determined to be without injury. Under the heading Predisposing Situation Factors staff checked Ambulating without assistance. According to the 09/01/2022 CNA witness statements Resident 6 was last seen at 6:30 PM, approximately 40 minutes before the fall, when a CNA removed the resident's dinner tray. At that time Resident 6 was sitting in her room in a tilt-in-space wheelchair. Review of the nurse's Fall Scene/other occurrence investigation, dated 09/01/2022, showed for cause of the fall the nurse documented attempted self-transfer. For the question What initial interventions did you put in place to prevent further falls? the nurse documented Frequent checks. The nurse's investigation did not identify if Resident 6's tilt-in-space wheelchair was tilted at the time of the fall, if the resident was wet or soiled when found, or define what frequent checks meant. According to the facility's investigative summary and conclusion Resident 6 goes through phases where she is more active and tries to stand independently but the facility is usually able to prevent falls through monitoring. The facility identified the root cause as Resident 6's positive mood swings that tend to make her more active. The facility's conclusion stated that due to multiple recent falls with no apparent cause, a urinalysis and medication review was requested from the physician. The summary and conclusion did not identify or address whether the residents tilt-in-space wheelchair was tilted at the time of the incident, whether the resident was wet or soiled when found, or the similarities/correlation with Resident 6's fall the day before on 08/31/2022. In both instances Resident 6 was left up in her tilt-in-space wheelchair next to the bed unsupervised, and later found on the floor. Additionally, there was no inidcation the facility implemented any interventions to prevent re-occurrence or that Resident 6 was ever screened by therapy as stated in the conclusion of the 08/31/2022 fall investigation conclusion. During an interview on 11/22/2022 at 1:43 PM, after discussing that the investigations failed to identify: if the resident wheelchair was tilted at the times of the falls and if so, how far; if the resident was wet or soiled when found; why the resident had inappropriate footwear on for the 08/31/2022; and to identify when the resident was last toileted. Staff B, DNS, stated that the documentation in the investigations were not as thorough as he would like. Staff B stated that the above items were identified and discussed, but the facility needed to do a better job of documenting within the investigation. During an interview on 11/22/2022 at 3:43 PM, when asked for a copy of Resident 6's post-fall therapy screen Staff B stated that it appeared it was overlooked and did not get completed. Reference WAC 388-97-0640(5) Based on interview and record review, the facility failed to complete a thorough investigation to rule out abuse or neglect for 3 of 4 residents (Resident 392, 142 and 6) reviewed for abuse, accidents and/or incidents. The facility failed to conduct a thorough investigation on an allegation of abuse for residents 392, 142 and 6. This failure to conduct a thorough investigation placed the residents at risk for unidentified abuse or neglect and continued exposure to abuse and/or neglect. Findings included . According to the Nursing Home Guidelines also known as the Purple Book, sixth edition, dated October 2015, All alleged incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated . A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It seeks to determine if abuse, neglect, abandonment, personal and/or financial exploitation or misappropriation of resident property occurred, and how to prevent further occurrences. RESIDENT 392 Review of Resident 392 admission Minimum Data Set assessment (MDS) dated [DATE], showed that the resident admitted on [DATE] with multiple diagnoses to include urinary tract infection, and difficulty walking. The MDS showed the resident required extensive assistance with activities of daily living (ADLs) and had an indwelling foley catheter (a tube inserted into the bladder to drain urine). Review of the facility's incident investigation dated 7/11/2022 showed that Resident 392 had reported that in the early morning they had asked to be helped to the restroom and that an aide had refused the request due to the resident had a catheter and did not need to use the toilet. Resident 392 further stated that instead of helping them to the toilet the aid had brought a bed pan and slammed down the resident unto the pan and made a mess all over the bed. The resident was unable to identify the staff but stated that it was a woman. The incident report showed no expanded interviews documented from the other residents on the wing. There was also no written statement obtained from other staff assigned to the wing that shift. Finally, the incident report showed that Resident 392 was not placed on alert for potential psychosocial harm after the incident nor was there documentation that the suspected aide was suspended pending the investigation. Review of the progress note dated 7/13/2022 at 10:21 AM showed that a licensed nurse had documented that Resident 392 was angry and had made accusations that staff members were rough during care on 7/13/2022; however, the incident report showed a discrepancy that the incident occurred on 7/11/2022 as documented in the Electronic Health Record (EHR). There was no written statement included in the investigation from the Licensed Nurse (LN) who documented the incident in the EHR. During an interview on 11/18/2022 at 1:40 PM, Staff H, Social Services (SS) stated that she assisted with incident investigations of resident's complaints of abuse and/or rough treatment. Staff H, SS, stated that witness statements were to be obtained, and social work staff were required to follow up with the residents to ensure psychosocial needs were met and there was no harm for 72 hours afterwards and it was supposed to be documented in the EHR. Review of Resident 392's EHR on 11/18/2022 at 1:45 PM showed no documentation by the social service department staff that the resident was placed on alert for psychosocial needs after this incident. During an interview on 11/18/2022 at 1:41 PM Staff AA, Registered Nurse/Medicare Coordinator (RN/MC), stated that the process for incident investigations would be to request witness statements of both resident and staff with any knowledge of the incident of rough treatment. The resident who had made the allegation would be placed on alert for psychosocial harm and the social services department staff would be contacted and were to follow up with the resident. During an interview on 11/22/2022 at 1:30 PM, Staff B, Director of Nursing Services (DNS), stated that he was unaware as to where the written statement from the LNs and aides who had worked that shift were located; however, indicated that it was the expectation the investigation required these statements to represent a thorough investigation of abuse. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 91 Review of resident 91's EHR on 11/18/2022 showed that resident 91 was discharged from the facility to the hospital on [DATE]. During an interview on 11/18/2022 at 1:40 PM, Staff G stated that they did not have records that the Ombudsman was notified of resident 91's discharge to the hospital. Staff G further stated that the Ombudsman was not notified of resident 91's discharge. During an interview on 11/21/2022 at 11:55 AM, Staff B, DNS, stated that the Ombudsman should have been notified of resident 91's discharge to the hospital. Staff B further stated that this did not meet his expectation. Reference WAC 388-87-0120(2)(a-d), -140(a)(b)(c)(i-iii) RESIDENT 394 Review of the discharge MDS dated [DATE] and the entry tracking record MDS dated [DATE] showed that Resident 394 was transferred from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of Resident 394's EHR on 11/22/2022 showed no documentation that a written notice of transfer/discharge was provided to Resident 394 and/or a responsible party for the transfer to the hospital on [DATE]. Additionally, no documentation was found that a notice of transfer/discharge was provided to the Ombudsman for Resident 394's transfer. During an interview on 11/22/2022 at 11:35 AM Staff B, Director of Nursing Services (DNS) stated that he was recently made aware that the facility has not been providing written notification of transfer/discharge to residents and or their representatives nor were they providing notice to the Ombudsmen for all transfers/discharges. Staff B stated, it was the expectation that this would be completed and documented going forward. Based on interview and record review, the facility failed to provide written notification of the reason for transfer/discharge to the resident or responsible party and/or to properly notify the Office of State Long-Term Care Ombudsmen (an advocacy group for residents in a nursing home) of discharges to the hospital for 3 of 3 residents (Residents 21, 91, and 394) reviewed for hospitalization. These failures denied the resident or responsible party knowledge of their rights regarding transfer/discharge from the facility, placed residents at risk for diminished protection from being inappropriately discharged , lack of access to an advocate who can inform them of their options and rights, and ensure that the Offices of the State Long-Term-Care Ombudsmen was aware of the facility practices and activities related to transfers and discharges. Findings included . RESIDENT 21 Review of the discharge Minimum Data Set assessment (MDS) dated [DATE] and the entry tracking record MDS dated [DATE] showed that Resident 21 was transferred from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of Resident 21's electronic health record (EHR) on 11/18/2022 showed no documentation that a written notice of transfer/discharge was provided to Resident 21 and/or a responsible party for the transfer to the hospital on [DATE]. In addition, the medical record showed no documentation that a notice of transfer/discharge was provided to the Ombudsman for Resident 21's transfer. During a confidential interview on 11/18/2022 at 2:36 PM Collateral Contact Y, stated that the Office of State Long-Term Care Ombudsmen had not been provided resident discharge lists since May 2019 and the facility's Social Services was made aware of this on March 18, 2022, and again on May 20, 2022. During an interview on 11/21/2022 at 9:01 AM Staff G, Social Services (SS), stated that the Ombudsman was not notified in writing of Resident 21's discharge to the hospital on [DATE] and should have been. Staff G stated they were not able to locate documentation in Resident 21's EHR that the resident or responsible party was notified in writing of the transfer to the hospital. During an interview on 11/21/2022 at 2:55 PM Staff B, Director of Nursing Services (DNS) stated that written documentation was not provided to residents or family for a transfer/discharge to the hospital. Staff B stated that the only time the ombudsman was notified was if the discharge was involuntary. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to provide bed hold notice in writing at the time of discharge for 3 of 3 sampled residents (Residents 91, 394, and 21) who were discharged from the facility. This failure placed the residents at risk for lack of knowledge regarding the right to hold their bed while they were at the hospital. Findings Included . RESIDENT 91 Review of Resident 91's electronic health record (EHR) on 11/18/2022 showed that Resident 91 was admitted to the facility on [DATE] and discharged back to the hospital on [DATE]. No documentation was found that a bed hold was offered, or a bed hold notice had been provided to the resident or the resident's representative. During an interview on 11/18/2022 at 1:40 PM, Staff G, Social Services Director stated, there is no documentation that a bed hold was offered to resident 91 at the time of their discharge. During an interview on 11/21/2022 at 11:55 AM, Staff B, Director of Nursing Services (DNS) stated that a bed hold should have been offered to resident 91 at the time of discharge from the facility. Staff B further stated that the expectation was that all residents were offered a bed hold at the time of discharge. . RESIDENT 394 Review of the discharge MDS dated [DATE] and the entry tracking record MDS dated [DATE] showed that Resident 394 was transferred from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of Resident 394's EHR on 11/22/2022 showed no documentation that a bed hold had been offered. During an interview on 11/22/2022 at 10:13 AM Staff R, Medical Records (MR), stated the resident was not offered a bed hold at the time of transfer. During an interview on 11/21/2022 at 2:55 PM Staff B, DNS, stated the expectation was that all residents that transfer to the hospital should be offered a bed hold and there should be supporting documentation in the EHR. Reference WAC 388-97-0120 (4) RESIDENT 21 Review of the discharge Minimum Data Set assessment (MDS) dated [DATE] and the entry tracking record MDS dated [DATE] showed that Resident 21 was transferred from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of Resident 21's EHR on 07/12/2022 showed no documentation that a bed hold had been offered. During an interview on 11/21/2022 at 9:01 AM Staff G, Social Services (SS), stated that Staff R, Medical Records, handled all bed holds for residents in the facility; however, was unable to locate documentation in Resident 21's EHR that a bed hold was offered for the resident's transfer/discharge to the hospital on [DATE]. During an interview on 11/21/2022 at 9:33 AM Staff R, Medical Records, stated that they were to process bed holds for residents in the facility but did not offer a bed hold to Resident 21 or to the responsible party and there should have been one offered. .

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 73 During an observation and interview on 11/16/2022 at 10:55 AM Resident 73 stated that they did not get out of bed much. Both feet were extended with toes pointing to the footboard of the bed, when asked if the resident could flex their ankles, Resident 73 was unable to fully flex her left ankle. Review of Resident 73's admission nursing assessment dated [DATE] showed the resident had a limitation in legs and/or feet but did not specify the type of limitation. During an observation on 11/18/2022 at 12:48 PM, staff P, Certified Nursing Assistant (CNA) Delivered a lunch tray to the resident, Staff P assisted Resident 73 to move up in bed, set up the lunch tray, opened items and exited the room. Resident 73 ate the meal without any further assistance. During an interview on 11/18/2022 at 12:44 PM, Staff P stated that Resident 73 did not need any assistance with meals as they ate independently, and that Resident 73 prefered to only wear house gowns and did not get dressed. During an interview on 11/18/2022 at 12:46 PM Staff K, CNA stated that the CNA's did not do restorative things with the resident. Staff let them do as much as they can on their own. There was a restorative aide who did exercises with the residents. Staff K also stated that staff set up meal trays and opened some items, but the resident ate independently. Review of Resident 73's quarterly MDS dated [DATE] showed the resident received restorative skill training and practice on six of seven days for dressing and two of seven days for eating during the lookback period of 09/28/2022 to 10/03/2022. It also showed Resident 73 required extensive assist of one person for eating and that the resident had no functional limitations in range of motion in the lower legs and/or feet. Review of the restorative log for the months of September and October 2022 showed Resident 73 received active range of motion on September 28th and no other restorative services were documented during the lookback period of 09/28/2022 to 10/3/2022. During an interview on 11/21/2022 at 11:22 PM Staff F, MDS/Registered Nurse (RN) also acting restorative supervisor, stated that CNAs were also doing some restorative activities, but the restorative aide was sometimes pulled to the floor and the programs did not get done. Staff F also stated that the restorative aide was on vacation from mid-October to mid-November and no restorative was done during that time. Staff F further stated that the MDS was coded inaccurately and should be modified. Based on observation, interview and record review, the facility failed to accurately assess 8 of 26 sampled residents (Residents 48, 11, 24, 25, 6, 12, 28 and 73) reviewed for the accuracy of Minimum Data Set assessments (MDS). Failure to accurately code Residents 48, 11, 24, 25, 6, 12, 28 and 73's restorative nursing programs (RNP), Resident 25's Pre-admission Screening and Resident Review (PASRR, a required evaluation), Resident 24's preferences and Resident 11's falls, placed the residents at risk for having inaccurate data in their medical records, unmet needs, inaccurate and/or incomplete care plans and a diminished quality of life. Findings included . According to the Resident Assessment Instrument (RAI) manual, dated October 2019, RNP in training and skill practice, are individualized to the resident's needs, planned, monitored, evaluated and documented in the resident's medical record. Review of the facility's policy titled, Restorative Nursing Programs, dated 08/22/2022, showed that residents would receive services from Restorative Aides (RA) when they were assessed to have a need for restorative nursing services. These services may include training and skill practice and the Restorative Nurse would provide oversight of the RA activities, review the documentation at least weekly and evaluate the effectiveness of the plan monthly. RESIDENT 48 Resident 48 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed the resident required extensive assistance for activities of daily living and had a RNP of training and skill practice in bed mobility and dressing and/or grooming. Resident 48's Activities of Daily Living (ADL) care plan dated 02/18/2019, showed the following interventions/tasks: personal hygiene set up at sink in bathroom or with bedside table in front of resident, dressing: cue to dress upper body and progress to lower body, cue to assist in pulling up pants, two person assist for bed mobility, cue resident to reach for transfer bar, and encourage and assist approximately every two hours. Observation of care on 10/18/2022 at 10:33 AM showed Staff V, Certified Nursing Assistant (CNA), placed Resident 48's shirt on, she did not instruct him and/or cue the resident to assist. Staff V completed personal hygiene with Resident 48 lying flat in bed. On 11/18/2022 at 1:01 PM, Staff V, CNA, stated that she had not received individualized training on how to assist Resident 48. When asked if Resident 48 had an RNP, Staff V stated that the RA completed the RNP. On 11/18/2022 at 1:54 PM, Staff W, CNA, stated that she used the [NAME] (instructions for the nursing assistants to care for the residents) to care for Resident 48. On 11/21/2022 at 8:43 AM, Staff JJ, CNA, stated that she had not received specific training for Resident 48, she stated no one trained her on the resident, she received verbal report. Staff JJ stated that she did not do exercises with the resident, they were done by therapy. On 11/21/2022 at 2:09 PM, Staff F, MDS/Registered Nurse/Restorative Supervisor, stated that the facility's restorative program had two types of programs. Staff F explained they had restorative programs that were carried out by the RA and programs that the Nursing Assistants participated in during care with the residents, during training and skill practice RNP. Staff F stated that the restorative programs completed by the RA were a collaboration between Staff F and the therapy department and the programs completed by the Nursing Assistants were initiated on admission by the admission nurses and occasionally she initiated them with care status changes. When asked if all residents have the training and skill practice programs completed by the nursing assistants, Staff F stated yes, because they were initiated on admission. Staff F stated that she reviewed the restorative programs quarterly and documented it on a Nursing Rehabilitation Quarterly Review Form. Staff F stated that for the training and skill practice programs completed by the Nursing Assistants, she reviewed them only if the tasks were completed six or seven days per week. When asked why she only reviewed the programs that were six or more days per week, Staff F stated that the programs coded on the MDS six or more days per week gave the facility a higher case-mix, the case mix determines the Medicaid rate for the facility. When asked if there was a difference between the training and skill programs and routine nursing care, Staff F stated there was no difference. Staff F stated that the training and skill practice programs completed by the Nursing Assistants should not be coded on the MDS as a restorative program because they did not meet the criteria for a restorative program. Staff F stated she did not review Resident 48's RNP. Staff F stated that Resident 48's MDS needed to be modified to show no RNP. On 11/21/2022 at 3:18 PM, Staff N, Resident Care Manager (RCM), stated that she completed the admissions, and every resident had the training and skill restorative programs that were completed by the Nursing Assistants added to their care plan at the time of admission. On 11/22/2022 at 2:48 PM, Staff B, Director of Nursing Services (DNS), stated that he was not aware of RNP that were not completed by the RA. Staff B reviewed Resident 48's care plan and the training and skill practice programs completed by the Nursing Assistants and stated that the admission nurse should not be adding RNP into the medical record without assessment and planning. Staff B stated the programs were not individualized, the Nursing Assistants were not trained in the programs, and they did not meet the definition of a restorative program. RESIDENT 11 Review of the quarterly MDS dated [DATE] showed that Resident 11 had one fall with no injury. It further showed that Resident 11 was provided Restorative Programs in training and skill practice to include four days of Bed mobility, and seven days of Dressing and/or grooming, in the seven day look back period. During an interview on 11/21/2022 at 11:00 AM Staff F, MDS Registered Nurse, stated that Resident 11'a quarterly MDS dated [DATE] had Restorative Programs coded for four days of bed mobility and seven days for dressing and grooming. Staff F stated that resident's Restorative Programs were reviewed on a quarterly bases and should be documented in the resident's medical record; however, Staff F stated that she was unable to locate quarterly reviews for Resident 11's Restorative Programs for the last three quarters and there should have been. When asked if Resident 11's Restorative program met expectations, Staff F stated, No. Review of the facility's August 2022 incident log showed documentation that Resident 11 had a fall on 08/22/2022 and another fall on 08/24/2022. During an interview on 11/22/2022 at 10:00 AM, Staff F, MDS Registered Nurse, stated that she followed the Resident Assessment Instrument (RAI) manual guidance to complete MDSs. Additionally, Staff F stated that Resident 11's quarterly MDS dated [DATE] was coded for one fall and should have been coded for two or more and this did not meet expectations. During an interview on 11/22/2022 at 2:09 PM Staff B, DNS stated that the expectation was to follow the RAI manual to complete MDSs. Staff B further stated that Resident 11's quarterly MDS dated [DATE] showed that the resident had one fall and should have been coded for two or more, falls and needed to be modified. Reference WAC 388-97-1000 (1)(b) RESIDENT 24 During an interview on 11/16/2022 at 9:13 AM, Resident 24 complained about the frequency of bathing and indicated facility staff had not inquired about her bathing preferences. Review of Resident 24's 10/10/2022 admission MDS showed facility staff failed to complete section F which identifies resident routine and activity preferences. During an interview on 11/21/2022 at 8:36 AM, Staff B, DNS, stated that Section F should have been completed for Resident 24 and he was unsure why this did not occur. RESIDENT 25 Review of Resident 25's electronic health record (EHR) showed the resident was referred for a level II PASRR assessment. A level II Initial Psychiatric Evaluation Summary with treatment plan was completed on 11/15/2017. Review of the 04/23/2020 annual MDS showed the facility coded the resident was considered by the state to be a level II PASRR due to serious mental illness. However, review of subsequent annual MDSs performed on 03/18/2021 and 03/19/2022 showed the facility coded no the resident was not determined to be a level II PASRR by the state PASRR process. During an interview on 11/21/2022 at 9:35 AM, Staff G, Social Services, stated that the 03/18/2021 and 03/19/2022 annual MDSs were inaccurate and should have been coded yes, the resident was considered by the state to be a level II PASRR due to serious mental illness. Review of Resident 25's 09/19/2022 quarterly MDSs showed facility staff coded the resident received seven days of a restorative dressing and/or grooming program. Review of Resident 25's EHR showed no documentation to support an initial restorative assessment or subsequent assessments had been performed as required to code a restorative program. RESIDENT 12 Review of Resident 12's 10/15/2022 quarterly MDS showed the resident received a dressing and/or grooming restorative program on five of seven days during the assessment period. Review of Resident 12's activities of daily living care plan, revised 03/17/2022, showed staff were to perform the following: Dressing: Have resident choose clothes, assist x1 as indicated, cue to initiate hands, arms into sleeves of top/gown. Have them progress to dressing upper body. progress to lower body, cue to initiate feet/legs into pant holes. Cue to assist in pulling up pants. Assist to complete task as needed. (i.e.: days=10 minutes, eve=10 minutes). Review of Resident 12's EHR showed no restorative initial evaluation or periodic restorative evaluations were present. RESIDENT 28 Review of Resident 28's 08/13/2022 and 11/13/2022 quarterly MDSs showed the resident received restorative programs as follows: on the 08/13/2022 MDS received a restorative bed mobility program on one of seven days, restorative transfer program on two of seven days and a restorative dressing and/or grooming on four of seven days; on the 11/13/2022 MDS- received a restorative bed mobility program on three of seven days, restorative transfer program on one of seven days and a restorative dressing and/or grooming on four of seven days. Review of Resident 28's activities of daily living care plan, revised 06/01/2022, showed staff were to perform the following: Bed mobility: Cue resident to reach for side/transfer bar to assist with repositioning in bed. encourage and assist approximately every two hours (i.e.: days-5 minutes, eves-5 minutes, nocs-5 minutes; Dressing: Have (Resident 28) choose clothes, assist x1 as indicated, cue to initiate hands, arms into sleeves of shirt/gown. Have them progress to dressing upper body. progress to lower body, cue to initiate feet/legs into pant holes. Cue to assist in pulling up pants. use assistive device for balance. Assist to complete task as needed. (i.e.: days=10 minutes, eve=10 minutes); Slide board transfer; Per Physical Therapy: demonstrates independent with transfer with use of slide board. Review of Resident 28's EHR showed there was no restorative initial evaluation or periodic evaluations present. RESIDENT 6 Review of Resident 6's 06/11/2022 and 09/05/2022 quarterly MDSs showed the resident received restorative programs as follows: on the 06/11/2022 MDS showed the resident received a restorative bed mobility program on six of seven days, restorative transfer program on five of seven days and a restorative dressing and/or grooming on six of seven days during the assessment period. Resident 6's 09/05/2022 MDS showed the resident received a restorative bed mobility program on seven of seven days, restorative transfer program on six of seven days and a restorative dressing and/or grooming on seven of seven days during the assessment period. Review of Resident 6's activities of daily living care plan, revised 11/22/2022, showed staff were to perform the following: Dressing: have resident choose clothes, assist x1 as indicated, cue to initiate hands, arms into sleeves of shirt/gown. have them progress to dressing upper body. progress to lower body, cue to initiate feet/legs into pant holes. Cue to assist in pulling up pants. Use assistive device for balance. Assist to complete task as needed. (i.e.: days=10 minutes, eve=10 minutes); Bed mobility: cue resident to reach for side/transfer bar to assist with repositioning in bed. Encourage and assist approximately every two hours (i.e.: days-5 minutes, eves-5 minutes, nocs-5 minutes; and Dressing: have resident choose clothes, assist x1 as indicated, cue to initiate hands, arms into sleeves of shirt/gown. Have them progress to dressing upper body. progress to lower body, cue to initiate feet/legs into pant holes. cue to assist in pulling up pants. Use assistive device for balance. Assist to complete task as needed. (i.e.: days=10 minutes, eve=10 minutes.) Review of Resident 6's EHR showed no restorative initial evaluation or periodic restorative evaluations were present. During an interview on 11/22/2022 at 10:43 AM, when asked to provide the initial and /or periodic restorative program evaluations for Residents 25, 12, 28 and 6, Staff F, MDS/ Restorative Nurse, stated that she could not find any and acknowledged the evaluations were required to collect restorative services on the MDS and confirmed the above referenced residents' MDSs were inaccurately coded. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were accurately completed upon or prior to admission for three of nine residents (Residents 36, 64, and 6) reviewed for PASRRs and unnecessary medications. This failure placed the residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet one's mental health care needs. Findings included . RESIDENT 36 Review of the annual Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 36 admitted on [DATE] and was able to make needs known. This MDS further showed that Resident 36 had diagnoses to include anxiety disorder, depression, and bipolar disorder (a mood disorder that causes changes in a person's mood, energy, and ability to function). Review of Resident 36's Pre-admission Screening and Resident Review (PASRR) assessment dated [DATE], completed by the hospital prior to Resident 36's admission on [DATE], showed no anxiety disorder indicated as a serious mental illness indicator documented on the form. This form further showed, No Level II evaluation indicated. Review of Resident 36's focused care plan for Psychotropic drug use, revision dated 11/07/2022 showed that psychotropic drug use was related to anxiety disorder, bipolar disorder, and depression. During an interview on 11/17/2022 at 2:46 PM Staff G, Social Services (SS), stated that Resident 36's diagnosis list showed a diagnosis of anxiety disorder dated 08/02/2017 which was the residents date of admit. Staff G further stated that Resident 36's PASRR dated 07/31/2017 should have been marked for anxiety disorder and it was not. Staff G stated that another PASRR form needed to be completed for Resident 36. During an interview on 11/18/2022 at 12:41 PM Staff B, Director of Nursing Services (DNS) stated that Resident 36's PASRR dated 07/31/2022 was not accurate and should have been marked for anxiety disorder and this did not meet expectations. RESIDENT 64 Review of the annual MDS assessment dated [DATE] showed that Resident 64 admitted on [DATE] and was able to make needs known. This MDS further showed that Resident 64 had diagnoses to include schizophrenia (a mental illness that affects how a person thinks, feels, and behaves), unspecified intellectual disabilities, and altered mental status. Review of Resident 64's PASRR assessment dated [DATE], completed by the hospital prior to Resident 64's admission on [DATE], showed no intellectual disability related conditional indicators documented on the form. Additionally, question B.6, Does the individual have a severe, chronic disability, other than mental illness, that results in impairment of general intellectual functioning or adaptive functioning? was left blank, and question B. 11, Does this individual have an intellectual disability or related condition as described in B1 - B9, do you have a reason to believe this individual has undiagnosed intellectual disability or related condition? was left blank. This form further showed, No Level II evaluation indicated. During an interview on 11/21/2022 at 9:18 AM, Staff G, SS, stated that Resident 64's PASRR dated 08/10/2021 was not correct because it should have been marked that the resident had a diagnosis of intellectual disabilities and should have been referred for a level II PASRR evaluation. During an interview on 11/21/2022 at 3:10 PM Staff B, DNS, stated that Resident 64's PASRR dated 08/10/2022 should have been marked Yes, for B.6 and B11 questions on the form. Staff B stated that they should have noticed that Resident 64's PASRR dated 08/10/2022 was inaccurate and the resident should have been referred for a PASRR level II evaluation. RESIDENT 6 Review of Resident 6's quarterly MDS dated [DATE], showed the resident was cognitively impaired, had a diagnosis of depression and received anti-depressant medication on seven of seven days during the assessment period. Review of Resident 6's current Physician's Orders showed a 06/26/2022 order for venlafaxine (an anti-depressant) daily for Depressive Disorder. Review of resident 6's 12/09/2019 level I PASRR showed the resident had no serious mental illness indicators or psychiatric diagnoses. Depressive disorder was unchecked. During an interview on 11/22/2022 at 2:37 PM, Staff G, stated that Resident 6 had a diagnosis of depressive disorder and received antidepressant medication therapy. Staff G stated that the resident's level I PASRR was inaccurate and needed to be updated. Reference WAC 388-97-1915 (1)(2)(a-c) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop comprehensive and person-centered care plans for 7 of 26 sampled residents (Residents 25, 36, 40, 44, 53, 66, and 73) whose care plans were reviewed. Failure to develop and implement care plans that were individualized, and that accurately reflected resident care needs related to oral/dental health status, activities of daily living, restorative therapy, mental health conditions, pain management, and oxygen/respiratory care placed the residents at increased risk for unmet needs, inconsistent or inadequate care and a decreased quality of life. Findings included . Review of the facility's policy titled, Comprehensive Care Plans, dated 08/22/2022 showed that it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the resident's comprehensive assessment. It further showed that the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set assessment (MDS). RESIDENT 73 Review on 11/17/2022 at 3:22 PM of Resident 73's care plan showed interventions to include set up and cue to feed self, place food on utensil and place in residents' hand, offer glasses to drink and encourage fluid intake, and offer finger foods. For dressing to have resident choose clothes and cue to initiate hands and arms into sleeves, cue to initiate feet/legs into pant holes, cue to assist pulling up pants, with a created date of 04/02/2022. During an observation on 11/18/2022 at 12:44 PM, Staff P, Certified Nursing Assistant (CNA) delivered a lunch tray to Resident 73. Staff P assisted the resident to move up in bed, set up the lunch tray, opened items and exited the room. Resident 73 ate the meal without any further assistance. During an interview on 11/18/2022 at 12:48 PM, Staff P stated that Resident 73 wears a house gown and doesn't wear shirts and pants as a preference and that Resident 73 doesn't need any assistance with meals as they eat independently. During an interview on 11/18/2022 at 12:46 PM Staff K, CNA stated that Resident 73 wore a house gown, and prefers it. Staff K stated that the CNA's don't do restorative things with the resident. Staff K stated they had a restorative aide who did exercises or skill practice with the residents. Staff K also stated that staff set up meal trays and opened some items, but the resident ate independently. During an interview on 11/21/2022 at 11:22 PM, Staff F, MDS Registered Nurse, stated that Resident 73's care plan was not accurate and should have been updated and personalized but wasn't.RESIDENT 40 Resident 40 was admitted to the facility on [DATE] with diagnoses to include diabetes and lung disease. On 11/15/2022 at 1:55 PM, Resident 40 stated that they used oxygen when they were short of breath, mainly at nighttime. On 11/18/2022 at 6:56 AM, Resident 40 was observed lying in bed with oxygen on. Review of Resident 40's physician orders showed Resident 40 had an order for insulin (a medication used to treat diabetes) dated 04/22/2022. Further review of Resident 40's physician orders showed no order for oxygen. Resident 40's Minimum Data Set assessment, dated 09/24/2022, documented Resident 40 received insulin injections. Resident 40's Respiratory care plan, revised 04/27/2022, showed the intervention, O2 as ordered. The Respiratory care plan had no further documentation of interventions and/or instructions for oxygen use. Further review of Resident 40's care plan showed no diabetic care plan and/or interventions associated with complications of diabetes and insulin administration had been developed or implemented. On 11/21/2022 at 3:04 PM, Staff F, MDS Coordinator/RN, stated that Resident 40 did not have a diabetic care plan and she would add one. On 11/22/2022 at 2:25 PM, Staff B, DNS, stated that Resident 40 should have a care plan for oxygen use. Reference WAC 388-97-1020 (1), (2)(a) RESIDENT 66 Review of a quarterly MDS dated [DATE] showed that Resident 66 admitted to the facility on [DATE] with multiple diagnoses to include muscle weakness and difficulty walking. The MDS further showed the resident required extensive assistance. Review on 11/21/2022 at 1:00 PM of Resident 66's Care Plan and [NAME] showed pressure ulcer interventions to include: encourage and assist with turning and repositioning approximately every 2 hours. Make sure involved area is free from pressure; pillow between legs, bridge buttocks, heels floated or use heel protectors. Review of Physician's orders showed an order dated 09/29/2022 with directions to Float Heels when in bed every shift for Skin Breakdown During multiple observations on 11/17/2022 at 9:05 AM, 12:09 PM, 2:54 PM 11/18/2022 at 8:38 AM, 11:20 AM and 11/21/2022 at 8:25 AM Resident 66 was observed lying in bed or sitting in their wheelchair without any pressure relief intervention in place. During an interview on 11/18/2022 at 12:48 PM, Staff NN, Licensed Practical Nurse (LPN), stated that Resident 66 is at risk for pressure ulcers and should be wearing pressure relieving boots or sometimes staff puts a pillow under the resident to float their heels. During the joint observation of the resident Staff NN adjusted a pillow that was under Resident 66's knees stating the pillow was placed incorrectly for pressure relief. During an interview on 11/22/2022 at 11:48 AM, Staff AA, Registered Nurse/Medicare Coordinator (RN/MC), stated Resident 66 does not like to wear heel protectors but that staff does not document the refusal in the EHR. Staff AA further stated it is her expectation that a refusal should be documented, and an alternative intervention should be encouraged. During an interview on 11/22/2022 at 1:30 PM, Staff B, DNS, stated that the expectation was that the resident care plans are followed as directed. RESIDENT 36 Review of the annual MDS dated [DATE] showed that Resident 36 admitted on [DATE] and was able to make needs known. This MDS showed that Resident 36 had diagnoses to include anxiety disorder, depression, bipolar disorder and antidepressant medications were received. Review of Resident 36's care plan on 11/21/2022 showed a focused care plan for, Psychotropic drug use, related to anxiety disorder, bipolar disorder, and depression initiated on 08/03/2017 which did not identify measurable goals and included three interventions initiated on 08/03/2017. Further review showed a focused care plan for, Mood state, related to long term placement and depression initiated on 08/03/2017 which did not identify measurable goals and included four interventions initiated on 08/03/2017. Additionally, it showed a focused care plan for, Psychosocial well-being, related to other resident wandering in room at night initiated on 10/07/2020 which did not identify measurable goals, and had one intervention that showed that Resident 36 liked to keep door closed to their room and a stop sign banner across doorway to deter other residents from entering Resident 36's room (there were no observations during the survey period of a banner across Resident 36's doorway). During an interview on 11/22/2022 at 10:24 AM, Staff N, RCM stated that comprehensive care plans were to be individualized and reflect the resident's status. Staff N stated that Resident 36's care plan for psychotropic drug use initiated on 08/03/2022 did not have measurable goals. Interventions were not specific to each diagnosis mentioned in the focus care plan, side effects and target behaviors were not listed and/or specific for each diagnosis and did not meet expectations. Staff N stated that Resident 36's care plan for mood state initiated on 08/03/2017 had no measurable goals, the intervention for a stop sign banner had not been in place for quite some time and needed to be looked at to see if it was still appropriate to have in place. During an interview on 11/22/2022 at 1:53 PM, Staff B, DNS, stated that the process for comprehensive care plans included that the MDS personnel would add to the initial baseline care plan as needed after a resident's MDS assessment (done for admission, quarterly, with a change in condition, and annually) should include a focused issue of anything deemed necessary, have measurable goals, individualized to the resident to reflect their current status. Staff B stated that Resident 36's psychosocial wellbeing care plan was very generic and should have been more individualized and did not meet expectations. Please refer to F645 for additional information for Resident 36. RESIDENT 44 Resident 44 admitted to the facility on [DATE]. According to the 08/28/2022 admission MDS, the resident had obvious or likely cavities or broken teeth. Review of Resident 44's 09/09/2022 Dental Care Area Assessment (CAA), showed Resident 44's dental carries would be addressed on the resident's dental care plan. Review of Resident 44's 08/27/2022 dental care plan, the resident's obbvious or likely cavity and/or broken was not care planned. During an interview on 11/22/2022 at 9:03 AM, Staff B stated that Resident 44's obvious or likely cavityand/or broken teeth should have been reflected on the dental care plan to accurately reflect the resident 's care needs. RESIDENT 25 According to Resident 25's 03/19/2022 annual MDS and 09/19/2022 quarterly MDS, the resident was cognitively intact and had no natural teeth. Review of Resident 25's EHR showed 03/11/2022 and 09/09/2022 dental consults that stated Resident 25 had no natural teeth or dentures and was requesting new dentures be made. Review of Resident 25's dental care plan, revised 11/23/2022, showed staff documented that Resident 25 had no natural teeth and preferred not to wear dentures. During an interview on 11/21/2022 at 11:03 AM, Staff G, Social Services, and the facility liaison with dental services, acknowledged Resident 25 had never informed her she preferred not to wear dentures and indicated the care plan was inaccurate. RESIDENT 53 Review of a quarterly MDS dated [DATE] showed that Resident 53 had readmitted to the facility on [DATE] with multiple diagnoses to include chronic pain syndrome. The MDS showed that the resident was able to make needs known and was prescribed multiple medications used for the treatment of pain. Record Review of Resident 53's, Medication Administration Record dated November 2022 showed that the resident was ordered and was being administered the following pain medications: Acetaminophen (a medication used for moderate pain relief) three times a day, tramadol (a medication used to treat moderate to moderately severe pain) and fentanyl (a medication used for severe chronic pain) patch every 72 hours. Review of Resident 53's EHR showed a document titled, Belmont Care Conference, dated 7/11/2022 showed that the staff had documented resident had chronic pain. Review of Resident 53's EHR showed two documents titled, Belmont Quarterly Pain Assessment, dated 07/07/2022 and 10/07/2022 that showed the plan of care for pain management was documented as being initiated or updated. Review of Resident 53's care plan on 11/17/2022 showed that multiple care plans were created related to the residents' admitting diagnoses; however chronic pain was not addressed. During an interview on 11/17/2022 at 1:14 PM, Staff F stated that Resident 53 had a care conference a couple month ago. Staff F stated the care plan was not updated to reflect the resident's chronic pain and that it was the expectation that the comprehensive care plan would be updated. During an interview on 11/18/2022 at 11:30 AM, Staff B, DNS stated that it was the expectation that the residents care plans were updated accordingly, especially if the resident had a diagnosis of chronic pain.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 48 Resident 48 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/02/2022, showed the resident required extensive assistance of two people for bed mobility, and was always incontinent of urine. Review of Resident 48's Activities of Daily Living Care (ADL) care plan dated 02/18/2019, documented that Resident 48 used the bed pan/urinal. Further review of the Activities care plan revised 08/18/2020, documented that Resident 48 used a trapeze to assist in bed mobility and transfers. On 11/18/2022 at 10:33 AM, Staff V, Certified Nursing Assistant (CNA) and Staff W, CNA, were observed providing incontinent care to Resident 48. Staff V and Staff W stated that Resident 48 did not use a urinal. An observation on 11/21/2022 at 8:40 AM, showed no trapeze attached to Resident 48's bed and/or in their room. RESIDENT 7 Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's care plan dated 08/12/2022, showed Resident 7 had an indwelling urinary catheter (a tube carrying urine from the bladder into a bag), needed set up with her meals and help being fed, and directed staff to place food on utensil and place the utensil in the resident's hand. Resident 7's progress note dated 10/26/2022, documented Resident 7's urinary catheter was removed. An observation on 11/15/2022 at 12:40 PM, 11/17/2022 at 9:16 AM and 11/18/2022 at 8:40 AM, showed Resident 7 eating independently. During an observation on 11/17/2022 at 10:53 AM, Resident 7 transferred from the bed to the bedside commode and no catheter was observed. On 11/21/2022, Staff F, MDS/RN, stated that she was responsible for updating the care plans.Staff F stated that she had not updated Resident 48 or Resident 7's care plans. Reference WAC 388-97-1020(2)(f),(4)(b),(5)(b) Based on observation, interview and record review the facility failed to ensure care plans were reviewed, revised, implemented and accurately reflected resident care needs and/or to ensure care planning meetings with the resident or responsible party were conducted timely for 8 of 26 sampled residents (Residents 36, 11, 12, 25, 24, 44, 7 and 48 ) who were reviewed for participation in care planning and care plans (CP). Failure to conduct timely care conferences and ensure care plans accurately reflected resident care needs related to bowel status, wounds, skin conditions, fluid restrictions, active diagnoses and presence of a rectal tube, placed residents at risk of not having input in the development of their plan of care, unmet needs and a diminished quality of life. Findings included . RESIDENT 36 During an interview on 11/16/2022 at 9:31 AM Resident 36 stated they did not remember the last time they went to a care conference. Resident 36 stated that they used to go to care conferences with a family member before the family member moved away about three years ago. During a follow-up interview on 11/17/2022 at 1:13 PM, Resident 36 stated that the resident would not mind going to a care conference if offered and that there were two other family members who lived locally that could attend. Review of the annual Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 36 admitted on [DATE] and was able to make needs known. Review of Resident 36's Electronic Health Records (EHR) on 11/18/2022 showed documentation that the last care conference was held on 04/25/2022 (seven months ago) with Resident 36 in attendance and the previous care conference was held on 09/21/2021 (seven months from most recent care conference). During an interview on 11/18/2022 at 10:41 AM, Staff G, Social Services,stated that care conferences were conducted quarterly and usually family and/or responsible parties were invited by phone and residents were asked in person. Refusals were not documented, but care conferences held were. Staff G stated that Resident 36 had documented care conferences held on 05/01/2020, 03/05/2021, and 09/09/2021. Staff G stated that Resident 36 should have had quarterly care conferences done and/or refusals should have been documented and this did not meet expectations. During an interview on 11/18/2022 at 1:27 PM Staff B, Director of Nursing Services (DNS) stated that care conferences were to occur upon admission, quarterly, and with a significant change in condition. Residents and/or responsible party should be invited by phone and or in person and refusals documented in the resident's EHR. Staff B stated that Resident 36 should have had care conferences completed on a quarterly basis and that did not appear to have happened for Resident 36 and should have. RESIDENT 11 Review of the quarterly MDS dated [DATE] showed that Resident 11 readmitted on [DATE], was able to make needs known, and was always incontinent (none or insufficient control) of bowel movements. During an interview on 11/17/2022 at 10:30 AM Resident 11 stated that the resident did not always know when needing to go to the bathroom, wore an adult disposable brief and would get changed by staff when needed. Resident 11 stated that staff were aware of resident's inability to know when needing to urinate or have a bowel movement. Review the care plan on 11/21/2022 showed that Resident 11 had a focused care plan for Urinary incontinence, initiated on 04/15/2022 with an intervention that showed that Resident 11 was continent of bowels. During an interview on 11/21/2022 at 9:49 AM, Staff GG, Certified Nursing Assistant (CNA) stated that Resident 11 was usually incontinent of urine and bowel movements and had been that way for a while. During an interview on 11/22/2022 at 11:36 AM, Staff B, DNS stated that Resident 11's care plan was not reflective of the resident's bowel movement status and should have been revised shortly after Resident 11's 09/03/2022 MDS was completed, and this did not meet expectations. During an interview on 11/22/2022 at 11:36 AM, Staff B, DNS stated that Resident 11's care plan was not reflective of the resident's bowel movement status and should have been revised shortly after Resident 11's 09/03/2022 MDS was completed, and this did not meet expectations. RESIDENT 12 Review of Resident 12's 11/17/2021 and 05/26/2022 dental consults showed the resident had mal-fitting bottom dentures and a recommendation was made for the resident to be referred to a denturist to have new dentures made. Review of Resident 12's dental care plan, revised 06/27/2022, showed staff were directed to assist the resident with denture care, report difficulties chewing, and schedule dental referrals as needed. The care plan did not identify that Resident 12's lower dentures were mal-fitting or that the resident had been referred to have new dentures made. During an interview on 11/21/2022 at 9:18 AM, Staff B stated that Resident 12's dental care plan should reflect the residents report of mal-fitting lower dentures and the resident's pending referral to the denturist but acknowledged it did not. Staff B stated the care plan needed to be updated. RESIDENT 44 Review of resident 44's Physician's orders (POs) showed a 10/01/2022 order to monitor the resident's rectal fistula drain to make sure it's intact, every day and evening shift. Review of Resident 44's 08/18/2022 hospital discharge summary active problem list showed the resident had a rectal abscess and fistula. According to Resident 44's 11/15/2022 wound care note [Resident 44] reports having had 6 procedures to her perineum and has had a rectal tube in place for 5-6 years as well. Review of Resident 44's comprehensive care plan showed no indication the resident had a rectal abscess or rectal tube. No care plan had been developed/implemented, nor was there direction to staff on how to manage the rectal tube. During an interview on 11/21/2022 at 9:18 AM, Staff B stated that Resident 44's care plan did not accurately reflect the resident's care needs and needed to be updated. Review of the 11/8/2022 2:55 PM nurse's note showed the resident was assessed with one large pressure area on the back of her left leg and a very small one on the right leg were elevated with pillows to relieve pressure. Review of Resident 44's 11/15/2022 wound care notes showed the resident had pressure ulcers to the right heel, left heel, right posterior calf, and left posterior and lateral calf. Review of Resident 44's alteration in skin integrity care plan, revised 11/23/2022, showed the resident had actual pressure ulcers to the right and left heel but did not identify the pressure ulcers to the resident's right and left calves. During an interview on 11/21/2022 at 9:18 AM, Staff B stated that Resident 44's bilateral calf pressure ulcer should have been reflected on the care plan and the CP needed to be updated. Review of a 11/8/2022 2:55 PM nurse's note showed Resident 44 was assessed with an open area on her buttocks. Additionally, according to a 11/12/2022 7:50 PM nurse's note resident presenting with open area to left buttocks, smaller open area to right buttocks, treatment (cream) ongoing. Review of 11/15/2022 wound care notes showed the open areas to Resident 44's right and left buttocks were assessed to be caused by recurring hidradenitis suppurtiva (a chronic skin condition that features pea- to marble-sized lumps under the skin that can be painful and tend to enlarge and drain pus, usually occur where skin rubs together, such as in the armpits, groin, and buttocks). Review of Resident 44's alteration in skin integrity care plan, revised 11/23/2022, showed no indication the resident had open areas or a skin condition hidradenitis suppurtiva to the right and left buttocks. During an interview on 11/21/2022 at 9:18 AM, Staff B stated that Resident 44's skin condition of hidradenitis suppurtiva and multiple draining open areas to the right and left buttock should have been incorporated into the resident's plan of care, but were not. Staff B stated that the care plan needed ot be reviewed and revised. RESIDENT 24 Review of Resident 24 POs showed a 10/25/2022 order for a 1.5 Liter fluid restriction a day. Review of Resident 24's 10/08/2022 dehydration/fluid maintenance care plan, showed direction to staff to encourage fluids, and keep water within reach and encourage resident to drink frequently thoughout your shift. During an interview on 11/21/2022 at 9:18 AM, Staff B stated that residents on fluid restrictions generally should have their water pitcher removed and that the care plan needed to updated/revised. Review of Resident 24's activities of daily living (ADL) care plan, revised 10/21/2022, showed staff were directed to encourage fluids and keep fluids within reach. During an interview on 11/21/2022 at 9:18 AM, Staff B stated that the care plan needed to be updated/revised. Review of Resident 24's 10/08/2022 fall care plan showed staff were directed to ensure water pitcher is at bedside. During an interview on 11/21/2022 at 9:18 AM, Staff B stated that the care plan was inaccurate and needed to be updated/revised. Additionally, review of Resident 24's comprehensive care plan showed Resident 24's fluid restriction was not included anywhere in the plan of care. During an interview on 11/21/2022 at 9:18 AM, Staff B stated that the care plan needed to be updated/revised to accurately reflect the resident's care needs. Review of Resident 24's 10/08/2022 alteration in skin integrity care plan showed the resident had a skin tear to the left antecubital (ac). Observations on 11/16/2022 at 9:24 AM, 11/17/2022 at 9:39 AM and 11:38 AM, and 11/18/2022 at 12:21 PM, showed Resident 24 did not have a skin tear to the left ac. During an observation and interview on 11/21/2022 at 8:43 AM, Staff B observed Resident 24 and confirmed the resident did not have a skin tear to the left ac. Staff B stated that the care needed to be updated/revised. RESIDENT 25 Review of Resident 25's 11/17/2017 level II PASRR Initial Psychiatric Evaluation Summary showed the resident was determined to be a level II PASRR, had serious mental illness indicators and required specialized services. The evaluator developed a treatment plan for the facility to implement. Review of Resident 25's comprehensive CP showed no indication the resident was a level PASRR. No care plan or interventions had been developed or implemented. During an interview on 11/21/2022 at 1:37 PM, Staff G, Social Services, stated that the Resident's level II PASRR status should have been care planned and indicated the care plan needed to be updated to accurately reflect the resident's care needs.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide assistance with activities of daily living (ADLs) including bathing, transfers, bed mobility, oral care, nail care, dressing and incontinent care for 4 of 6 residents (Residents 48, 7, 6 and 44) reviewed for activities of daily living. This failure placed residents at risk for unmet needs, impaired skin integrity, poor hygiene, and a diminished quality of life. Findings included . RESIDENT 48 Resident 48 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessment, dated 10/02/2022, showed the resident required extensive assistance of two people for bed mobility, dressing and toileting, extensive assistance of one person for personal hygiene, was always incontinent of urine and had no rejection of care during the assessment period. Review of Resident 48's ADL care plan dated 02/18/2019, showed the following interventions/tasks: personal hygiene set up at sink in bathroom or with bedside table in front of resident, dressing cue to dress upper body and progress to lower body cue to assist in pulling up pants assist to complete task, two person assist for bed mobility, assist with positioning, assist to reposition every two hours, transfers using full body lift, uses wheelchair for mobility, and encourage up in wheelchair for meals. Review of Bowel and Bladder care plan, revised 12/08/2020, showed the following interventions: offer prompted toileting; bedpan/urinal when awakens in am/ after meals, incontinent of urine, keep skin clean and dry. An observation on 11/16/2022 at 9:57 AM, showed Resident 48 lying in bed on their back with yellow substance on chest, gown pulled down to stomach, dark purple substance on left side of mouth running down chin, fingernails long with dark brown substance underneath the nails and face unshaven with hair growth. Observations on 11/17/2022 at 8:05 AM, 8:57 AM, 9:53 AM, 2:03 PM, 2:36 PM, and 4:28 PM showed Resident 48 wearing a gown, lying on back with head of bed elevated. On 11/17/2022 at 4:45 PM, Staff Z, Nursing Assistant Registered, stated that Resident 48 only turns side to side, gets briefs changed, and does not get out of bed. On 11/18/2022 at 8:37 AM, Staff X, Licensed Practical Nurse (LPN), stated that she had been the only person providing care to Resident 48 that morning since her shift started at 6:00 AM. Staff X stated the only care she had provided to Resident 48 since her shift started at 6:00 AM was medication administration. At 8:38 AM, Staff W, CNA, stated that she was assigned to Resident 48 and had just arrived on the unit and had not provided any care yet to Resident 48 and it would be provided after breakfast. On 11/18/2022 at 8:53 AM, Staff W, CNA, was observed delivering Resident 48's breakfast tray to the room and set up the breakfast tray on the overbed table. Staff W did not encourage or offer to assist the resident to get out of bed for the meal or provide toileting/incontinent care. On 11/18/2022 at 10:33 AM, Staff W, CNA, and Staff V, CNA, were observed providing care to Resident 48. Staff V asked Resident 48 if they wanted to get up, Resident 48 stated yes. Staff V asked the resident again if they wanted to get up for lunch and Resident 48 said no. Resident 48 stated that they wanted to get dressed and when asked if they wanted to wear pants, the resident stated yes. Observed personal hygiene completed with resident 48 lying flat in bed. Staff W and Staff V placed the resident's shirt on and did not cue the resident to assist. Resident turned on side and wet incontinent pad was removed from beneath the resident. Resident's left buttock was bright red with the surface of the skin opened and red fluid on the incontinent pad. Staff V stated that they would put the pants on later after the nurse put cream on the buttocks. Staff V and W completed incontinent care and positioned the resident on their back and covered them with blankets. An observation on 11/18/2022 at 12:35 PM, showed Resident 48 on their back with the pants folded at the end of the bed. On 11/18/2022 at 1:54 PM, Staff W, CNA, stated that she had not had a chance to get back to Resident 48 and provide any further care since the care observed at 10:33 AM. On 11/18/2022 at 2:05 PM, Staff X, LPN, stated that she did not assess Resident 48's buttocks today because the aides did not tell her that she needed to. Staff X stated that the resident's nails were long, and she would see if someone could clip them. An observation on 11/18/2022 at 3:17 PM, showed Resident 48's pants folded at the end of the bed. On 11/18/2022 at 1:23 PM, Staff AA, Registered Nurse/Medicare Coordinator, stated that Resident 48's skin issue on his buttocks was excoriation and was caused from incontinence and constant wetness from urine. Staff AA stated that she would expect residents to receive care. three times per shift and checked for incontinence and barrier cream applied to buttocks for any resident that is incontinent RESIDENT 7 Resident 7 was admitted to the facility on [DATE]. Review of the Minimum Data Set assessment, dated 08/15/2022, showed the resident was cognitively intact and dependent on staff for bathing. On 11/15/2022 at 12:38 PM, Resident 7 stated that they were supposed to get showers twice a week, but they only get it once. On 11/17/2022 at 11:08 AM, Resident 7 stated look at my legs, this is what legs look like without showers. Observed Resident 7's legs, the skin was white with flaky skin from the feet to the knees. Review of Resident 7's shower documentation on 11/18/2022, showed the resident was only offered/provided bathing twice in the past 30 days, a documented refusal on 10/28/2022 and was bathed on 11/16/2022. On 11/18/2022, Staff Z, CNA, stated that on 11/16/2022 she did not give Resident 7 a shower, she only washed the resident up in bed. RESIDENT 44 Resident 44 admitted to the facility on [DATE]. According to the 08/28/2022 admission MDS, the resident was cognitively intact and required extensive assistance with personal hygiene. During an observation and on 11/16/2022 at 9:51 AM, Resident 44 stated their teeth were only brushed 0-1 time a week. When I ask [staff to assist with oral care, staff] say ok we will get to it, but don't come back .I have cavities on my [upper] front two teeth and they have gotten worse since I got here. Observation of Resident 44's teeth showed a heavy white build up along the resident's gumlines. Resident 44 reported she had been trying to clean her teeth with a napkin and then scratched her teeth with her fingernail and showed a white paste like substance was present under her fingernail. Observation of Resident 44's bedside table, bathroom and top of dresser showed no toothbrush was present. With the resident's permission, the contents of her drawers were observed, and no toothbrush was found. Similar observations were made on: 11/17/2022 at 9:27 AM and 12:11 PM; 11/18/2022 at 10:03 AM and 1:47 PM; and 11/21/2022 at 8:31 AM. During an observation and interview on 11/21/2022 at 8:54 AM, Staff B, Director of Nursing Services, observed Resident 44's teeth and confirmed heavy white buildup along the resident's gumline and that it did not appear the resident had been routinely provided oral care and stated the resident's oral cavity was in need of attention. Staff B confirmed that there was not a toothbrush present in the resident's room. RESIDENT 6 According to Resident 6's 09/05/2022 quarterly MDS the resident had severe cognitive deficits, was frequently incontinent of bowel and bladder and was dependent on staff for bathing. Review of Resident 6's November 2022 bathing flowsheets showed facility staff failed to offer/provide Resident 6 bathing for 13 consecutive days from 11/03/2022-11/15/2022. During an interview on 11/21/2022 at 8:06 AM, Staff B, confirmed Resident 6 was not provided bathing from 11/03/2022-11/15/2022 and stated that it was the expectation that resident be bathed per their shower, but acknowledged that did not occur. Reference WAC 388-97-1060(2)(c) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 91 HOSPITALIZATION Review of Resident 91's EHR on 11/18/2022 showed that the resident was admitted to the facility on [DATE] with diagnosis to include infection, inflammatory reaction due to internal left hip surgical repair, and cellulitis of left lower limb (Bacterial infection of the skin) and was discharged to the hospital on 9/16/2022. Record review of Resident 91's EHR on 11/18/2022 showed that the facility did not notify the medical provider on change of condition for resident 91's left hip incision decline in condition. During an interview on 11/18/2022 at 10:41 AM Staff AA, Register Nurse/Medicare Coordinator (RN/MC) stated that when the licensed nurse does the dressing change, if there was a decline or signs of infections then the nurse would promptly notify the Medical Provider of all changes. Staff AA stated he was unable to locate any documentation showing that the Medical Provider was notified of Resident 91's left hip incision decline. During an interview on 11/18/2022 at 10:51 AM, Staff B, DNS stated that the provider should have been notified of all changes. Staff B further stated that it was his expectation that all changes be communicated to the providers. Staff B stated this did not meet his expectations. Reference WAC 388-91-1060 (1) Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (resident 64) reviewed for unnecessary medications whose high blood glucose levels were not reported to the provider, for 3 of 3 residents reviewed for non-pressure skin (resident 6, 44, 24, and 48) and 1 of 2 residents (Resident 91) reviewed for hospitalization. These failures placed residents at risk for unaddressed changes in condition, worsening of medical conditions and a decreased quality of life. Findings included . RESIDENT 56 WOUND CARE During an observation and interview on 11/18/2022 at 09:04 AM, Resident 56 was noted to have a dressing on his right foot with a tube connected to a small box sitting on the floor. Resident 56 stated that they were supposed to get a medication to bring with them for the wound clinic to apply to the resident's wound at the last appointment, but it did not happen. Review of the wound clinic orders dated 11/14/2022 showed an order to apply crushed metronidazole tablet (an antifungal medication) to the wound at dressing changes. Review of a progress note dated 11/14/2022 showed Resident returned from wound care appt. Wound vac dressing (a device used in wound treatment therapy) changed at clinic. Continue dressing changes with wound clinic twice a week. Resident to receive crushed metronidazole to wound base during dressing changes at clinic to control odor. No other orders given at this time. Review of Resident 56's electronic health record (EHR) showed an order for wound vac dressing with a start date of 09/15/2022. The order showed the wound vac was to be placed and managed at the clinic. This order was updated on 09/19/2022 to show wound vac dressing to be changed Mondays at the wound clinic and Thursdays at the facility. Further Review of Resident 56's EHR showed an order from the wound clinic dated 10/27/2022 to change the wound vac dressing on Monday and Thursday at the wound clinic and to return to the wound clinic as needed. Review of Resident 56's current physician orders on 11/19/2022 showed an order for wound clinic to change the dressing on Mondays and facility staff to change the dressing on Thursdays. Review of a progress note dated 10/27/2022 showed resident returned from wound clinic with no new orders. During an interview on 11/21/2022 at 09:00 AM, Staff O, Licensed Practical Nurse, (LPN) stated that there was some confusion about the orders, and facility staff were understanding the clinic provided the medication while the clinic staff understood the facility was providing the medication. Staff O stated they should have called and verified. During an interview on 11/21/2022 at 09:30 AM, Staff N, Resident Care Manager (RCM) stated that if a resident goes out to an appointment the nurse on the floor would collect any paperwork the resident brought back and would give them to the RCM to review for new orders. Upon review of the 10/27/2022 wound clinic orders, Staff N stated that Resident 56's orders were unclear, and the wound clinic should have been contacted for clarification but was not and the current orders were not correct. During an interview on 11/18/2022 9:58 AM, Staff B, Director of Nursing Services (DNS) stated that the process for communications with the wound clinic was for the clinic to send a paper back with the resident with any new orders and the receiving nurse would update the residents record, implement the orders, and place them in medical records to be scanned. Staff B stated that staff should have contacted the clinic for clarification if there were any questions. BLOOD PRESSURE PARAMETERS Review on 11/17/2022 at 1:15 PM of Resident 56's EHR showed an order for torsemide tablet (a blood pressure medication) one time a day for congestive heart failure and hold the medication for systolic blood pressure below 100, with a start date of 11/08/2022. There was no associated blood pressure documentation located in the medical record. During an interview on 11/18/2022 at 10:12 AM, Staff M, Licensed Practical Nurse (LPN) stated that if there were parameters to follow and they were not met they would hold the medication.Staff M further stated that documentation of the blood pressures should be in the administration record but there is not a place for documenting blood pressures in Resident 56's torsemide order. During an interview on 11/18/2022 at 9:40 AM, Staff B, DNS, stated that Resident 56's torsemide should have been held if the blood pressure was out of parameter, The blood pressures should be documented in the MAR with the order but Resident 56's order for torsemide didn't have a place for blood pressures and it should have.RESIDENT 48 Resident 48 was admitted to the facility on [DATE] with a diagnosis of a stroke affecting the left side of the body. Review of the MDS assessment, dated 10/02/2022, showed the resident required extensive assistance of two people for bed mobility, toileting, and was always incontinent of urine. During an observation on 11/16/2022 at 10:03 AM, Resident 48 stated that they had a sore on their bottom and it hurt. A bandage was observed on the left arm and Resident 48 stated they did not know what happened. An observation on 11/16/2022 at 10:07 AM, showed Resident 48's swollen left foot lying flat on the bed and their left arm lying on the bed not supported by a pillow. Resident 48 stated that the foot was sore, and they could not move their left arm or leg because it was paralyzed. Review of Resident 48's care plan on 11/16/2022, showed no documentation of the swelling to the left foot. Review of the resident's Activity of Daily Living care plan, dated 02/18/2019, documented the resident was to have a pillow in bed to position the left upper arm. Review of the Pressure Injury Prevention care plan, revised 05/20/2022, showed that Resident 48 was to have barrier cream applied to skin exposed to urine. Resident 48's Weekly Skin assessment dated [DATE], showed the resident with excoriated skin to bilateral (both sides) buttocks and a skin tear to the left arm, the documentation showed no description and/or measurements of the excoriated skin or skin tear. Resident 48's Weekly Skin assessment dated [DATE], showed the resident's bilateral buttocks with open areas, and a skin tear on the left arm. The documentation showed no description and/or measurements of the open areas and skin tear. Observations on 11/17/2022 at 4:28 PM and 11/18/2022 at 10:33 AM and 12:35 PM showed no pillow under Resident 48's left arm. An observation on 11/18/2022 at 10:33 AM, showed Resident 48's left buttock bright red with the surface layer of skin removed, red fluid was observed on the draw sheet that Resident 48 was lying on. Staff W, Certified Nursing Assistant (CNA), was observed completing incontinent care but did not apply barrier cream to Resident 48's buttocks. On 11/18/2022 at 1:11 PM, Staff X, LPN, stated that Resident 48's left foot was swollen due to the way the resident laid and it was always like that. On 11/18/2022 at 1:23 PM, Staff AA, Registered Nurse/Medicare Coordinator, stated that Resident 48's excoriation on the buttocks was caused by urine and she would expect barrier cream to be applied after the resident was incontinent. On 11/21/2022 at 9:14 AM, Staff BB, Registered Nurse/Medicare Coordinator, stated that the facility's skin protocol was to complete weekly skin assessments, report skin issues to the provider, turn and reposition resident's every two hours and if a resident's skin condition was worse, report to provider. Staff BB reviewed Resident 48's weekly skin assessments and stated she would not know based on the documentation if the excoriation and/or skin tear had improved or was worse. Staff BB stated that she was not aware Resident 48 had edema to the left foot and would expect the left foot to be elevated and instructions to be on the care plan. On 11/21/2022 at 4:50 PM, Staff B, DNS, reviewed Resident 48's medical record and stated the documentation did not indicate if the skin tear and the excoriation were improving or deteriorating and he would expect skin issues to have assessments with a description of the appearance and measurements. RESIDENT 64 Review of the annual Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 64 admitted on [DATE] and was able to make needs known. This MDS further showed that Resident 64 had a diagnosis of diabetes and had received insulin (medication used to treat diabetes). Review of Resident 64's Diabetic Administration Record (DAR) dated November 2022 showed a physician order dated 12/22/2021 for blood sugar (BS) levels (blood test obtained to manage diabetes) to be checked before breakfast and supper, twice a day related to diabetes, and to notify the physician if BS level results were greater than 250. Additionally, it showed that BS levels were greater than 250 on 11/06/2022 = 261; 11/13/2022 = 266; and on 11/17/2022 = 288. During an interview on 11/18/2022 at 9:58 AM, after looking at Resident 64's November 2022 DAR, Staff L, Resident Care Manager (RCM) stated that Resident 64's BS on 11/06/2022, 11/13/2022, and 11/17/2022 were out of the parameters and the provider should have been notified. Staff L stated that they were unable to locate documentation in Resident 64's progress notes that the provider was notified, on those dates, and should have been. During an interview on 11/18/2022 at 1:39 PM Staff B, DNS stated that if a resident had an order to notify the provider of BS greater than 250, then staff should notify provider per the order. After reviewing Resident 64's electronic health records (EHR) Staff B stated that they were unable to locate documentation that the provider was notified for the dates that Resident 64's BS was out of parameters in November 2022 and there should have been. NON-PRESSURE SKIN RESIDENT 44 During and observation and interview on 11/17/2022 at 12:11 AM, Resident 44 was observed lying supine in bed with hells floated on a pillow. Resident 24 reported that staff failed to perform the morning treatment to the wound on her backside and it was sore. The resident indicated the wound was not pressure but was unsure what it was. Review of Resident 44's EHR showed the following: a 11/08/2022 nurses note that identified Resident 44 had an open area on her buttocks; and according to a 11/12/2022 7:50 PM nurse's note the resident had a Skin check completed-resident presenting with open area to [left] buttocks, smaller open area to [right] buttocks, treatment (cream) ongoing. Redness to [left] breast and abdominal folds, some lesser redness to [right] breast. Neither note included an assessment of the open areas to include size, characteristics, amount of drainage, tissue type, description of peri wound, underlying etiology/cause or measurements of the identified wounds. Review of Resident 44's EHR on 11/21/2022 showed no indication the multiple wounds identified to the right and left buttock had been reassessed or measured. Review of Resident 44's November 2022 Treatment Administration Record (TAR) showed no order to monitor or treat the identified wounds to the right and left buttocks. During an interview on 11/21/2022 at 9:10 AM, Staff B stated that resident wound measurements or a detailed description should be documented by the discovering nurse but acknowledged that did not occur. According to Staff B subsequent wound assessments were conducted by contracted wound care. Review of Resident 44's wound care notes showed the 11/08/2022 note did not include an assessment of the wound identified on the resident's buttocks. Review of the wound care note scanned in for 11/15/2022, showed it was another copy of the 11/08/2022 wound care note. Thus, as of 11/21/2022 the facility had not completed an initial assessment or measurements on the identified open areas to Resident 44's buttocks. During an interview on 11/21/2022 at 1:17 PM, Staff B stated there should have been an initial assessment of the wounds, and subsequent weekly assessments available in the resident's record by now but acknowledged there was not. RESIDENT 24 During an observation and interview on 11/16/2022 at 9:20 AM, the posterior aspect of Resident 24's bilateral hands and fingers were noted to be black/purple in color. Resident 24 denied pain and indicated she was unsure what caused it but felt it was related to blood draws. Similar observations were made on 11/17/2022 at 9:39 AM and 11:38 AM, 11/18/2022 at 12:21 PM. Review of Resident 24's 11/14/2022 weekly head-to-toe skin check showed that the bruises were not identified. Review of Resident 24's November 2022 Treatment Administration Record (TAR) showed no direction to staff to monitor the bruises to Resident 24's bilateral hands/fingers and no indication facility staff identified, assessed, or measured the bruises, despite being easily visible upon entering the resident's room. During an observation and interview on 11/21/2022 at 8:43 AM, Staff B, Director of Nursing Services, observed the back of Resident 24's hands and confirmed the back of the hands were encompassed by purple bruises. Staff B stated that he would have expected staff to have identified, assessed, documented a detailed assessment with landmarks or measured the bruises, and placed them on the TAR to monitor until resolved, but acknowledged this did not occur.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**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 and/or consistently provide monitoring, care, and services for residents with pressure ulcer/injury (areas of skin injured from prolonged pressure) for 2 of 4 residents (Residents 11 and 44) reviewed for pressure ulcers. Additionally, the facility failed to ensure Resident 11's care plan reflected pressure ulcer status. These failures placed residents at potential risk for development and/or worsening of pressure injuries. Findings included . RESIDENT 11 Observation on 11/15/2022 at 11:42 AM showed Resident 11 with a protective boot placed on the right foot. Review of the quarterly Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 11 readmitted on [DATE], was able to make needs known, was at risk of developing pressure ulcers/injuries, and had no pressure ulcers. Review of Resident 11's care plan on 11/16/2022 showed a focused activity of daily living functional care plan with an intervention initiated on 04/15/2019 to provide pressure relief to heels. It further showed a focused care plan of Decreased mobility initiated on 04/15/2019 with a goal dated 09/23/2022 that showed Resident 11 will continue to be free of pressure ulcers; however, Resident 11 had an actual pressure ulcer on the right heel. Additionally, it showed an intervention that included heels floated or use heel protectors, however, did not show documentation of a protective boot to be placed on the right foot. Observation and interview on 11/18/2022 at 8:30 AM showed Resident 11 with both heels elevated with pillows with a protective boot placed on the right foot. Staff K, Certified Nursing Assistant (CNA) stated that the left heel was intact, pink and blanchable. Staff K stated that Resident 11's [NAME] (directions to provide care) showed heels were to be floated or to use heel protectors. The [NAME] did not show there was to be a boot on the left heel. Review of the electronic health records (EHR) on 11/16/2022 showed that Resident 11 had a provider order dated 05/09/2022 that showed, Float heels or use heel lifts when in bed. Use heel protectors in room whenever [Resident 11] is in bed. Review of Resident 11's progress note dated 10/06/2022 showed that the right heel had signs of pressure injury covering heel area and showed dark bluish-red discoloration at three inches in diameter of fluid-filled bulla (blister). Review of Resident 11's weekly skin assessment dated [DATE] showed that it was left blank and showed no skin issues or wound measurements documented. The linked progress note, dated 10/19/2022, showed that the right heel stage 2 was slowly resolving (no measurements were documented). Review of Resident 11's weekly skin assessment dated [DATE] showed that the resident's right heel blister opened (no measurements were documented). Additionally, the attached progress note link dated 11/07/2022 showed, Noted area is open and not blood filled blister at this time [no measurements were documented]. Review of Resident 11's Hospice Visit Note Reports dated 10/28/2022 and 11/18/2022 showed that Resident 11 refused to have wound care provided and visits on 11/04/2022 and 11/11/2022 showed descriptions of the right heel wound; however, did not show right heel wound measurements documented. Review of Resident 11's November 2022 Treatment Administration Record (TAR) from 11/01/2022 to 11/17/2022 showed multiple blanks for skin treatments and monitoring regarding Resident 11's popped blister to right heel and placement of protective soft boot. During an interview on 11/22/2022 at 2:45 PM Staff N, Resident Care Manager (RCM) stated that pressure ulcer wounds needed a weekly assessment with measurements documented to include location, if wound was improving or getting worse, and to ensure proper treatment was being provided. Staff N stated that Resident 11's weekly skin assessment did not always show documented measurements to determine if healing and did not meet expectations. Staff N stated that the Hospice nurse had been assessing and treating Resident 11's pressure ulcer wound to the right foot. Staff N stated that there were no measurements obtained and there should have been. In continued interview, after reviewing Resident 11's November 2022 TAR, Staff N stated that there were blanks/holes in the treatment documentation, and this did not meet expectations. After reviewing the 11/16/2022 copy of Resident 11's care plan, Staff N further stated that Resident 11's care plan had a goal that was not measurable or accurate and did not reflect an actual pressure ulcer and did not meet expectations. During an interview on 11/22/2022 at 4:20 PM Staff B, Director of Nursing Services (DNS), stated that pressure ulcer wounds/skin injury measurements or at least a good description with landmarks for comparison should be assessed, monitored and documented weekly. After reviewing Resident 11's EHR to include 11/16/2022 copy of Resident 11's care plan, Staff B stated that his expectations were that measurements be documented weekly by either the Hospice nurse or facility staff. Staff B stated that Resident 11's November 2022 TAR had holes in the documentation, the care plan was not accurate and did not reflect an actual pressure ulcer and did not meet expectations. RESIDENT 44 Resident 44 admitted to the facility on [DATE]. Review of Resident 44's 08/28/2022 admission MDS showed the resident was cognitively intact, had diagnoses of morbid obesity, malnutrition, chronic pressure ulcer to the right heel and anemia, required two-person physical assistance with bed mobility, was at risk for the development of pressure injuries and had one unstageable pressure injury that was present upon admit. Review of Resident 44's November 2022 Treatment Administration Record (TAR) showed the following treatment orders: a 11/15/2022 order for Right heel: Scrub wound bed and one to three centimeters (cm) of peri wound with wound cleanser or normal saline (NS), apply skin prep to peri wound and allow to dry. Apply anasept to base of the wound. Secure with superabsorbent dressing one time a day; and a 11/08/2022 order for Left heel: cleanse with wound cleanser, NS or warm soapy water and cover with dry dressing one time a day every Tuesday and Friday; a 11/08/2022 order to monitor pressure areas on the back of left leg the largest one and the small one on the left one (sic) Monitor until healed two times a day for pressure areas. Review of Resident 44's EHR showed 11/8/2022 2:55 PM nurses note that assessed the resident with one large pressure area on the back of her left leg and a very small one on the right, legs were elevated with pillows to relieve pressure, resident also has an open area on her buttocks. The note did not indicate what stage the pressure areas were, whether they were open, had drainage, identify wound bed tissue type, or include measurements. Review of Resident 44's 11/08/2022 weekly wound note showed Resident 44 had a deep tissue injury to the left heel and a stage III (Full thickness) pressure injury to the right heel. The following treatment recommendations were made: Right Heel- scrub wound bed and 1-3cm of peri wound with wound cleanser or NS, apply skin prep to peri wound and allow to dry. Apply anasept (an antimicrobial wound gel) to base of the wound and secure with superabsorbent dressing. Change daily and as needed for accidental removal, saturation and/or soiling. Left Heel-scrub wound bed and 1-3cm of peri wound with wound cleanser or NS. Apply skin prep to peri wound and allow to dry. Apply dry coversite/bordered gauze (composite dressing, combining physically distinct components) twice a week and as needed. The pressure areas to Resident 44's right and left calves identified in the 11/08/2022 nurse's note were not identified or assessed in the 11/08/2022 weekly wound note. Review of resident 44's November 2022 TAR on 11/20/2022, showed no treatment orders in place for the resident's right and left calf pressure areas, nor was there any direction to staff to monitor the areas. Record review showed a 11/08/2022 treatment order for Resident 44's left heel as follows: Left heel- cleanse with normal saline, wound cleanser or warm soapy water and cover with dry dressing one time a day every Tuesday and Friday. The wound care team recommended on 11/08/2022 scrubbing the wound bed and 1-3cm of peri wound with wound cleanser or normal saline, applying skin prep to peri wound and allowing too dry before applying a dry coversite/bordered twice a week and as needed. Review of Resident 44'sEHR showed no documentation indication why the wound care team's treatment recommendations were not implemented. Review of the treatment order showed it was input by Staff OO, Licensed Practical Nurse. During an observation and interview on 11/22/2022 at10:50 AM, when asked to see Resident 44's anasept gel that was used for wound care, Staff O, Licensed Practical Nurse, brought writer to Resident 44's bedside and identified a tube of hydrogel wound gel as what was used. However, the resident's order was for anasept gel, which is an antimicrobial (agent that kills microorganisms or stops their growth) hydrogel is not. Further review of the EHR showed no weekly wound assessments/measurements/notes were present for 11/15/2022. As of 11/21/2022 the facility still had no documentation of an assessment of the pressure areas identified on 11/08/2022 to Resident 44's right and left calves.There was no indication if they were open, what stage they were, tissue type, presence, or absence of drainage, nor were they on the resident 's TAR to treat and/or monitor. During an interview on 11/22/2022 at 10:58 AM, Staff OO, confirmed the 11/08/2022 treatment order for Resident 44's left heel directed staff to cover with a dry dressing rather than a composite dressing as recommended. Staff OO indicated she made a transcription error. Additionally, Staff OO acknowledged Resident 44 's heel wounds were to have anasept applied to the heel wound beds. Staff OO then looked up hydrogel (the wound gel the facility was using) and confirmed it was not a therapeutic interchange with anasept, as anasept is a antimicrobial and hydrogel was not. When asked if the facility had any documentation to support staff had assessed/measured the pressure areas identified to the right and left calves on 11/08/2022, Staff OO stated there was and opened a wound care note that was scanned into the resident's EHR on 11/15/2022, but it showed to be another copy of the resident's 11/08/2022 wound note which did not include an assessment of the resident's bilateral calf pressure areas. During an interview on 11/22/2022 9:07 AM, Staff B confirmed that Resident 44's heel wounds were being treated with the incorrect dressing, incorrect wound gel, there was no direction on the TAR directing staff to monitor the areas and no documentation was present in the resident's EHR showing that staff had assessed/measured/staged the pressure areas identified to Resident 44's bilateral calves on 11/08/2022, approximately two weeks prior. Staff B indicated the resident was seen by wound care on 11/15/2022 and they would obtain the note. When asked if the floor nurses had access to the 11/15/2022 note Staff B stated, No and acknowledged without access to the assessment facility nurses had limited ability to determine if the wounds were improving or declining and indicated it should have been available in the residents record, but was not. Reference WAC 388-97-1760(1)(2) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 73 During an observation and interview on 11/16/2022 at 10:55 AM Resident 73 stated they do not get out of bed much. Both feet were extended with toes pointing to the footboard of the bed, when asked if the resident could flex their ankles, Resident 73 was unable to fully flex her left ankle. Review of the admission nursing assessment dated [DATE] showed Resident 73 was marked for limitation in lower extremities but did not specify the limitation. During an Interview on 11/18/2022 at 12:44 PM, Staff P, CNA stated that the CNA's don't do restorative things with Resident 73, though we let the resident do as much as they can on their own. Staff P further stated that the facility had a restorative aide who did the range of motion and exercises. Review on 11/21/2022 at 2:05 PM of the Restorative documentation for October 2022 showed Resident 73 had a program to include active range of motion exercises 5 days a week and lower extremity exercises for left lower extremity 5 days a week. Documentation showed Resident 73 received active range of motion on Oct. 12, 2022 and Oct. 13, 2022 and no documented lower extremity programs were completed in the month of October 2022. During an interview on 11/21/2022 at 11:22 PM Staff F, MDS/RN, acting restorative supervisor stated that nurse aides were also doing some restorative and that the one restorative aide often was pulled to work as a CNA on the floor and was on vacation from mid-October to mid-November and no restorative was being done during those times. Reference WAC 388-97-1060(3)(d), (j)(ix) Based on interview, observation and record review, the facility failed to provide restorative nursing programs consistently to prevent further decrease in range of motion (ROM) and/or maintain mobility for 6 of 6 residents (Residents 48, 73, 28, 12, 6 and 25) and failed to consistently apply an orthotic (brace to position the hand) for 1 of 6 residents (Resident 48) reviewed for range of motion. This failure placed residents at risk for decreased mobility, decreased ROM, pain, and a diminished quality of life. Findings included . RESIDENT 48 Resident 48 was admitted to the facility on [DATE] with a stroke and left sided hemiplegia (paralysis on one side of the body). Review of the Minimum Data Set assessment (MDS), dated [DATE], showed the resident had impaired range of motion on the upper and lower extremities and required extensive assistance with activities of daily living (ADL). On 11/16/2022 at 10:07 AM, Resident 48, stated that they were unable to move their left arm or leg because it was paralyzed. Observation of Resident 48 showed the resident lying on their back with the left leg pulled up towards their stomach and the left heel resting on the back of the thigh, the left hand was without an orthotic. Review of Resident 48's physical therapy evaluation and plan of treatment, dated 12/10/2020, showed Resident 48 was referred to physical therapy for left knee contracture (a fixed tightening of muscle, tendon or ligaments that prevents normal movement of an associated body part) management and had left knee ROM to -60-degree extension. Review of Resident 48's ADL care plan, revised 10/13/2021, showed a goal of: will maintain highest level of ADL function with participation in restorative nursing programs (RNP). Further review of the care plan showed the following interventions assigned to the restorative nursing assistant (RA): assist resident seven days/week X 15 minutes very slow gentle passive ROM all joints and passive ROM to all extremities, all planes X 15 minutes five-six days/week. The care plan further showed the resident was to wear a left hand orthotic during waking hours. On 11/17/2022 at 8:57 AM, 11:14 AM, 4:28 PM and on 11/18/2022 at 8:53 AM, 10:33 AM, 12:42 PM and 1:51 PM, Resident 48 was observed without an orthotic on their left hand. An observation during care on 11/18/2022 at 10:33 AM, showed Resident 48's left leg pulled up toward their stomach, bent at the knee. Staff V, Certified Nursing Assistant (CNA), stated that she was not able to straighten the left leg at all. On 11/18/2022 at 1:54 PM, Staff W, CNA, stated that she was not aware Resident 48 had an orthotic for their hand. On 11/18/2022 at 1:11 PM, Staff X, Licensed Practical Nurse, stated that she had been caring for Resident 48 since October and had not seen an orthotic on the left hand. Review of Resident 48's restorative nursing documentation, dated October 2022 through November 2022, showed Resident 48 had a RNP for passive ROM five days per week X 15 min all planes. The documentation further showed Resident 48 received the service three days from Oct.1, 2022, through Nov.21, 2022. On 11/21/2022 at 11:15 AM, Staff T, RA, stated that she was the only RA and was responsible for the provision/completion of the RNP for all 49 residents receiving restorative services. Staff T stated that due to the number of programs she was unable to complete the required programs consistently. She further stated that she took a vacation for a month from Oct. 15, 2022 and returned Nov. 15, 2022. Staff T stated that residents are placed on restorative programs by physical therapy and Staff F, Registered Nurse (RN) acting Restorative Supervisor, monitored, evaluated, and made changes to the programs if needed. On 11/21/2022 at 2:09 PM, Staff F, stated that the RNP were a collaboration between her and therapy. Staff F stated that she reviewed the RNP on a quarterly basis. Staff F stated that the RNP were not completed consistently due to Staff T, RA, being pulled to the floor to work as a nursing assistant and stated that Staff T, RA, was on vacation for a month from Oct. 15, 2022 through Nov. 15, 2022, and no staff completed the RNP during her absences. Staff F stated that the therapy department had started a wellness program but not all residents attend the wellness program. Staff F reviewed Resident 48's medical record and stated she did not complete Resident 48's quarterly restorative program review. Staff F stated that she had not evaluated Resident 48's left knee contracture and was not aware of any staff that had evaluated or monitored Resident 48's left knee contracture. On 11/22/2022 at 3:18 PM, Staff U, Director of Rehabilitation/Physical Therapist Assistant (PTA), stated that the therapy department provided a wellness program. Staff U stated that the wellness program was an open gym time that residents could independently access the therapy gym and therapists provided assistance with equipment. Staff U stated that the wellness program was a supplemental program to restorative programs and stated that the therapists do not provide or complete the restorative programs. Staff U stated that the therapy department did not provide ongoing contracture evaluation, the therapists are involved with contracture evaluation and/or monitoring of residents on active caseload only. Staff U stated that the last evaluation that therapy completed for Resident 48 was 12/10/2020. On 11/22/2022 at 2:48 PM, Staff B, Director of Nursing Services, stated that he was aware Staff T, RA, had went on vacation and did not ensure staff completed the restorative programs. Staff B further stated that he did not have staff to cover for Staff T, RA, when she was pulled to the floor to work as a Nursing Assistant. Staff B reviewed Resident 48's medical record and said there was no documentation that showed monitoring or evaluation of Resident 48's left knee contracture and the care plan directed the staff to turn and reposition the resident but did not have any specific direction on the positioning of the resident's left leg. Staff B stated that he was not aware of any program or system in the facility to monitor contractures. Staff B stated that Resident 48's contracture could worsen if they did not receive their restorative program. Review of Resident 48's Physical Therapy Evaluation, dated 11/29/2022, showed Resident 48 required skilled Physical Therapy to establish a positioning device and protocol for bed and to establish an upgrade on the wheelchair. Resident 48's knee was measured at Extension/Flexion 80-130 degrees. On 11/29/2022 at 2:44 PM, Staff U, Rehabilitation Director, PTA, reviewed Resident 48's Physical Therapy Evaluation dated 12/10/2020 and 11/29/2022 and said Resident 48 had lost 20 degrees of extension in their left knee. RESIDENT 12 Resident 12 admitted to the facility on [DATE]. According to the 10/15/2022 quarterly MDS, the resident had limited functional ROM to one lower extremity and did not receive a restorative ROM program. Review of the activities of daily living (ADL)/rehabilitation care plan, revised 11/22/2022, showed a goal of maintaining highest level of ADL function with participation in RNPs. Staff were directed to provide the following RNPs: active ROM to bilateral upper extremities and lower extremities for 15 minutes five days per week or Omni cycle on level 1-2 x 15 minutes five to six days per week. Review of Resident 12's October and November 2022 restorative flowsheets showed, from 10/15/2022 through 11/17/2022 (34 days), Resident 12's RNPs were not offered or provided. RESIDENT 28 Resident 28 admitted to the facility on [DATE]. According to the 11/13/2022 quarterly MDS, the resident had limited functional ROM to one lower extremity and did not receive a restorative ROM program. Review of Resident 28's ADL/rehabilitation care plan, revised 11/22/2022, showed a goal of maintaining strength and mobility with participation in RNPs. Staff were directed to provide active ROM to bilateral upper extremities and lower extremities for 15 minutes five days per week or Omni cycle on level 1-2 x 15 minutes five to six days per week. Review of Resident 28's October and November 2022 restorative flowsheets showed, from 10/15/2022 through 11/15/2022 (32 days), Resident 28's RNPs were not offered or provided. RESIDENT 25 Resident 25 admitted to the facility on [DATE]. According to the 09/19/2022 quarterly MDS, the resident had limited functional ROM to one lower extremity and did not receive a restorative ROM program. Review of Resident 25's ADL/rehabilitation care plan, revised 11/22/2022, showed a goal of maintaining the highest level of ADL function with participation in RNPs. Staff were directed to provide an Omni cycle program on level 2 x 15 minutes three to five days per week and standing in the parallel bars 2 times for 1 minute two to three times per week. Review of Resident 25's October and November 2022 restorative flowsheets showed, from 10/15/2022 through 11/15/2022 (32 days), Resident 25's RNPs were not offered or provided. RESIDENT 6 Resident 6 admitted to the facility on [DATE]. According to the 09/05/2022 quarterly MDS, the resident had no functional limitations in ROM and did not receive restorative services. Review of Resident 6's ADL/rehabilitation care plan, revised 11/22/2022, showed a goal of maintaining the highest level of ADL function with participation in RNPs. Staff were directed to provide an Omni cycle program on level 1-2 x 15 minutes two to three days per week. Review of Resident 6's October and November 2022 restorative flowsheets showed, from 10/15/2022 through 11/15/2022 (32 days), Resident 6's RNP was not offered or provided. During an interview on 11/29/2022 at 10:31 AM, when asked why the Residents 12, 28, 25 and 6 were not provided their RNPs at the frequency they were assessed to require, Staff B, Director of Nursing Services, explained the facility's restorative aide was on vacation for a month, and due to staffing issues, the facility did not have any staff available to provide restorative services. .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 7 Resident 7 was admitted to the facility on [DATE]. Review of the Minimum Data Set assessment dated [DATE], showed the resident was cognitively intact. On 11/15/2022 at 2:12 PM, Resident 7 stated that their weight was down to 161 lbs from their normal weight of over 200 LBS because of the food at the facility. Review of Resident 7's Nutrition at Risk assessment dated [DATE], showed that the goals were to monitor for a baseline weight then the goal for was for no significant weight changes. Review of Resident 7's weight record showed a recorded weight of 205.8 lbs on 08/12/2022, 190.8 lbs on 09/07/2022 and 175 lbs on 11/15/2022. On 11/21/2022 at 9:02 AM, Staff BB, Registered Nurse/Medicare Coordinator, stated that the facility would refer a resident to the Registered Dietician (RD) and physician if they had a weight loss. Staff BB reviewed Resident 7's weight record and stated that the physician and RD should have been notified of Resident 7's weight loss. Staff BB stated that there was not one person overseeing the resident's weights at this time, the nursing assistants documented the weights into the electronic medical record and if she happened to notice the weights or if she looked at a resident and noticed edema and/or weight loss she would have responded. On 11/21/2022 at 3:18 PM, Staff B, Director of Nursing Services, reviewed Resident 7's weight record and stated the staff should have notified the RD and physician regarding the weight loss. Reference WAC 388-97-1060(3)(h)(i) Based on observation, interview and record review, the facility failed to monitor and accurately document fluid restrictions (a diet which limits the amount of daily fluid intake) for 1 of 1 resident (Resident 24) reviewed for hydration. Additionally, the facility failed to ensure residents with significant weight loss were identified, assessed and that interventions were implemented, for 3 of 7 residents (Residents 66, 24 and 7) reviewed for nutrition. These failures placed residents at risk for alterations in fluid volume status, unidentified weight loss/gain, delayed interventions and other negative outcomes. RESIDENT 66 Review of a quarterly Minimum Data Set (MDS) ,dated 10/01/2022, showed Resident 66 admitted to the facility on [DATE] with multiple diagnoses to include urinary tract infection, sepsis (a blood infection) and dysphagia (a condition with difficulty in swallowing food or liquid). Review of the September 2022 through November 2022 weight flowsheet showed on 09/28/2022 Resident 66 weighed 219lbs, on 10/03/2022 Resident 66 weighed 214lbs, on 11/02/2022 Resident 66 weighed 206.2lbs and on 11/21/2022 Resident 66 weighed 202.8lbs. Review of Resident 66's care plan dated 09/28/2022 under Nutritional Status showed the following: malnutrition at risk and monitor weight stability. Notify MD/family/dietician of weight loss/gains. During an interview on 11/16/2022 at 9:34 AM Resident 66 stated, I lost weight, I don't know how much, I think about 30 pounds. During an interview on 11/18/2022 at 11:13 AM, Staff MM, Certified Nursing Assistant (CNA) stated it was the CNA's responsibility to document what percent of each meal was consumed and the resident's weight in the electronic health record (EHR) and if there was a drastic change the information would be reported to the nurse. During a joint interview and record review on 11/22/2022 at 11:52 AM, Staff AA, Registered Nurse/Medicare Coordinator (RN/MC), acknowledged Resident 66 had significant weight loss over the past three months and stated the physician nor dietician were notified but should have been. Staff AA further stated it was her expectation that the nurse would have documented in the EHR and informed the charge nurse so that the physician could have been notified for interventions. During an interview on 11/22/2022 at 1:19 PM, Staff B, Director of Nursing Services (DNS), stated the way the situation was handled did not meet his expectation. Additionally, Staff B stated the expectation for residents that have significant weight loss was that any nurse or charge nurse contact the Physician and the Registered Dietician. RESIDENT 24 NUTRITION Resident 24 admitted to the facility on [DATE]. According to the 10/10/2022 admission MDS, the resident was cognitively intact, had a diagnosis of malnutrition, required physical assistance with eating and was on a therapeutic diet. Review of Resident 24's Physician's orders showed the resident had a 10/18/2022 order for a no added salt, regular texture, and thin liquid diet and a 10/07/2022 order for daily weights for 28 days. Resident 24's 10/12/2022 Nutrition at Risk (NAR) assessment showed the Regitstered Dietician (RD) assessed Resident 24's intake was fair. The resident reported improved intake. Weight had been stable since admit and consistent with a normal body mass, however, was falsely elevated related to generalized lower extremity edema. The resident indicated she was ok with weight loss back to usual body weight of 130 lbs. The RD stated that some weight fluctuation was expected due to the resident receiving intravenous fluid while hospitalized . The RD assessed that Resident 24 remained at risk for malnutrition and recommended continuing to monitor weights. Review of Resident 24's weight flowsheet showed the resident experienced significant weight loss of greater than 10 % in less than 30 days. Resident 24's weights were as follows: on 10/24/0222- 154.8 lbs.; 11/01/2022- 150.4 lbs. (-4 lbs.); 11/04/2022- 142 lbs. (-12.8 lbs. or 8.27 % in 12 days); 11/09/2022- 138.8 lbs. (-16 lbs.; -10.34 % in 17 days); and on 11/14/2022- 130.8 lbs. (-24 lbs. or -15.5% in 22 days). Review of Resident 24's EHR showed no documentation or indication facility staff identified Resident 24's significant weight loss, assessed the resident, referred the resident to the RD, or implemented nutritional interventions. During an interview on 11/18/2022 at 2:37 PM, Staff B, DNS, explained that resident weights were reviewed weekly by the RD, and if a resident triggered for a significant weight gain or loss (gain or loss of greater than 5% of body mass in 30 days), the resident would be assessed in the weekly NAR meeting. During an interview on 11/21/2022 at 9:11 AM, when asked if the facility had identified Resident 24's significant weight loss of 15.5 % in 22 days and assessed the resident's nutrition/hydration status Staff B, DNS, stated, No. HYDRATION During an observation and interview on 11/17/2022 at 9:39 AM, Resident 24 was observed sitting in a wheelchair with her legs extended out onto the bed for elevation. The resident stated that she had to elevate her legs because she had edema up past her knees. The resident further explained that she was on a fluid restriction and water pills (diuretic medication) and the edema was much improved. Observation of Resident 24's immediate area showed there was no water pitcher present. Review of Resident 24's Physician's orders showed the following orders: a 10/06/2022 order for spironolactone (a diuretic) once daily, hold for systolic blood pressure (SBP) less than 100; a 10/06/2022 order for bumetanide (a diuretic) once daily, Hold for SBP less than 100; and a 10/07/2022 order for daily weights times 28 days for congestive heart failure; and a 10/25/2022 order for a 1.5 Liter fluid restriction a day.The fluids were to be divided between nursing and the kitchen as follows: Kitchen- 720 ml per day or 240 ml per meal; Nursing- 420 ml on day shift, 240 ml on evening shift and 120 ml on night shift. Review of Resident 24's 10/08/2022 diuretic/fluid maintenance care plan, showed the resident was at risk for dehydration secondary to diuretic use and identified the following interventions: administer medication(s) as ordered; encourage fluids, keep water within reach and encourage resident to drink frequently throughout shift; report coughing, difficulty swallowing to nurse; let the licensed nurse know of decreased intake or output during your shift; and monitor for dehydration. The care plan did identify the resident was on a fluid restriction and that all fluids were to be provided by dietary or nursing. Additionally, the interventions in place directly conflicted with the Physician ordered fluid restriction. Review of Resident 24's November 2022 Medication Administration Record (MAR) showed a 10/25/202 order for a 1.5 liter per day fluid restriction with the Kitchen allotted 720 ml per day or 240 ml per meal and Nursing- 420 ml on day shift, 240 ml on evening shift and 120 ml on night shift. A space was provided for each shift to record the amount of fluid provided on that shift. There was no place provided or direction to total the resident total intake (amount drank with meals + amount provided by nursing) which precluded staff from determining if the resident was adherent with the fluid restriction or exceeding it daily. During an interview on 11/21/2022 at 9:18 AM, Staff B, DNS, explained the purpose of staff recording a resident's fluid intake when they are on a fluid restriction, was to assess if the resident was adherent with the restriction or exceeding it. When asked if that could be determined without someone calculating the 24 hour total intake Staff B stated No. After reviewing Resident 24's EHR ,Staff B confirmed staff were not totaling the resident's 24-hour fluid intake and that the interventions on the fluid maintenance care plan, provided direction to staff that was in direct conflict with the PO fluid restriction.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure adequate staffing to provide restorative nursing programs (RNP) for 10 of 10 residents (Residents 48, 7, 38, 34, 27, 73, 28, 12, 6 and 25) reviewed for sufficient staffing. This failure placed residents at risk for unmet care needs, decreased mobility and a diminished quality of life. Findings included . Review of the Facility Assessment, dated 09/21/2022, showed that the facility would supply nursing personnel in sufficient numbers to provide nursing care to all residents in accordance with resident care plans. Review of the September, October, and November 2022 RNP flowsheets for Residents 48, 7, 38, 27, 73, 28, 12,6 and 25, showed the facility failed to consistently provide the residents' RNP per recommendations and/or schedule. STAFF INTERVIEWS On 11/21/2022 at 11:15 AM, Staff T, RA, stated that she was the only RA and was responsible for the provision/completion of the RNP for all 49 residents receiving restorative services. Staff T stated that due to the number of programs she was unable to complete the required programs consistently. She further stated that she took a vacation for a month from October 15,2022 and returned November 15th, 2022. On 11/21/2022 at 2:09 PM, Staff F, Registered Nurse/Restorative Supervisor, stated that the RNP were not completed consistently due to Staff T, RA, being pulled to the floor to work as a Nursing Assistant and Staff T was on vacation for a month from October 15,2022 through November 15, 2022, and no staff completed the RNP during her absences. Staff F stated that the Director of Nursing Services was aware that the restorative programs were not being completed when the RA was working on the floor as a Nursing Assistant and when the RA was on vacation. On 11/22/2022 at 2:48 PM, Staff B, Director of Nursing Services, stated that he was aware Staff T, RA, went on vacation and did not ensure staff completed the restorative programs. Staff B stated he was aware the residents had not received their RNP. Staff B stated that the RAtold him she needed help with the RNP. Staff B stated that he did not have staff to cover for Staff T when she was pulled to the floor to work as a Nursing Assistant. Refer to F688 Reference WAC 388-97-1080 (1)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Dental Services (Tag F0791)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure dental services were provided for 2 of 4 Medicaid residents (Residents 12 and 25) reviewed for dental services. Failure to follow up on dental referrals and timely assistance with appointment scheduling extended the time residents had to use ill-fitting dentures and/or go without dentures. These failures placed residents at risk for difficulty chewing, oral pain, decreased self-image and diminished quality of life. Findings included . RESIDENT 25 During an interview on 11/16/2022 at 8:57 AM, Resident 25 reported her dentures had been missing for over a year. Resident 25 stated that she already had been seen by the facility dentist and was supposed to have a new set of dentures made but had not heard anything since. Review of Resident 25's 09/19/2022 quarterly Minimum Data Set (MDS), an assessment tool, showed the resident was cognitively intact, required physical assistance with hygiene including oral care and was edentulous (had no natural teeth.) According to the 11/23/2022 dental care plan, Resident 25 preferred not to wear dentures. However, a 09/14/2022 intervention read Seen by Sound Dental Care: resident now requesting upper/lower dentures . Review of resident 25's 02/09/2021 dental consult showed the resident lost her dentures at the hospital and wanted new upper /lower dentures made. The dentist recommended a referral to a denturist. Review of Resident 25's Electronic Health Record (EHR) showed no documentation or indication that the facility followed up on the referral, scheduled the appointment or that Resident 25 had been seen. Review of Resident 25's 03/11/2022 dental consult showed the resident was again assessed with natural teeth or dentures, was requesting new dentures and a recommendation was made to refer Resident 25 to a denturist. Review of Resident 25's Electronic Health Record (EHR) showed no documentation or indication that the facility followed up on the referral, scheduled the appointment or that Resident 25 had been seen. Resident 25 was seen again by the facility dental service on 09/09/2022, over a year and a half after the initial recommendation to see a denturist. Review of the dental consult showed the resident was assessed without natural teeth or dentures. According to the consult Resident 25 was requesting new upper and lower dentures and a recommendation was again made to refer Resident 25 to a denturist. Review of Resident 25's EHR showed a 9/14/2022 6:15 PM progress note, that indicated the resident was seen by the facility's dental service and the following was assessed resident was edentulous; staff assist with brushing/swabbing or giving reminders of cleaning gums. A recommendation was again made to refer Resident 25 to a denturist for new upper/lower dentures. During an interview on 11/17/2022 at 2:13 PM, Staff G, Social Services, explained that after residents are seen by the in-house dentist, all the dental consults are sent to her and then she ferrets them out to nursing for follow up. Staff G indicated she needed time to investigate what occurred with Resident 25's denturist referrals. During an interview on 11/17/2022 at 2:55 PM, Staff G provided a 07/29/2021 care conference (5 months after initial referral) note that indicated the resident was reluctant to go to an outside dentist. Staff G indicated the resident was informed that the in-house dentist was pursuing a license as a denturist and the resident agreed to have the in house provider make the dentures. According to Staff G the in-house dentist just completed training but was unsure when they would start making dentures. Staff G acknowledged that she did not inform Resident 25 that it would take well over a year before the facility dentist would complete schooling. RESIDENT 12 Resident 12 admitted to the facility on [DATE]. According to the 10/15/2022 quarterly MDS, the resident was cognitively intact, and had no natural teeth. Review of Resident 12's dental care plan, revised 06/27/2022, showed staff were directed to assist the resident with denture care, report difficulties chewing, and schedule dental referrals as needed. Review of a 11/17/2021 dental consult showed the following direction was given Please refer to a different dentist her last dentist recommended implants this is not what she want, requests re-align of lower dentures, upper are fine. Review of Resident 12's EHR showed staff scheduled appointments twice, but due to illness Resident 12 was unable to attend. Review of a 05/26/2022 dental hygienist consult showed Resident 12 requested an appointment to get new dentures Review of Residents 12's EHR showed no documentation or indication facility staff attempted to re-schedule the resident's denture appointment over the next 5 months. During an interview on 11/26/2022 at 9:46 AM, Staff G indicated having forwarded all consults to nursing after the facility dentist/hygienist visited in June 2022. When asked if she could find any documentation that nursing had followed up on the referral in the last five months Staff G stated, No, I caught it when I was preparing for this next dental visit. Staff G indicated she informed Resident 12 that the house dentist was pursuing a denturist license and was agreeable to have the facility dentist make her dentures. During an interview on 11/21/2022 at 2:00 PM, Resident 12 reported Staff G had informed her the facility dentist was taking extra classes and would be able to make dentures So I said Ok. When asked if Staff G had provided a timetable as to how long that would /could take Resident 12 stated No. During an interview on 11/21/2022 at 8:27 PM, when asked if staff should be informing residents that the facility dentist can make their dentures up to a year and a half before they are finished school instead of scheduling an appointment with a local denturist, Staff B, Director of Nursing Services stated, No and acknowledged Resident 25 and 12 did not receive timely dental services. Reference WAC 388-97-1060(1), (3)(j)(vii)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of recorded food temperatures, the facility to prepare food in a manner that conserved nutritive value, palatability and that ensured residents were served meals that were appetizzing and at appropriate temperatures. Facility staffs' failure to follow written recipes for preparation of pureed food and to utilize equipment in a manner that maintained the temperatures of hot food at or above 140 degrees prior to, and during meal service, resulted in significant temperature declines for hot food, and meals that were not palatable when served cold. This failure placed the residents at risk for decreased satisfaction with meals. Findings included . RESIDENT COUNCIL During a meeting with attendees of Resident Council on 11/15/2022, residents complained that vegatables are served cold and food was not cooked or re-heated all the way through. When asked how frequently food was cold when served, the group came to a census of five out seven days during the week. Several residents indicated they had already addressed this several months ago with the dietary manager but the issue has not been resolved. Review of the June and August 2022 Resident Council minutes showed in June residents requested that the kitchen Make food hotter and in August requested staff close the doors on the food carts because Food has been cold. During an interview on 11/16/2022 at 8:55 AM, Resident 25 stated, The vegatables are cold, the food is good but sometimes it is cold when we get it. Staff QQ, Cook, was observed on 11/18/2022 at 11:07 AM, preparing pureed peas and carrots. Staff QQ poured an unmeasured amount of peas and carrots, including fluid, from a can into a blender. Staff QQ then proceeded to add more two more un-measured spatula [NAME] and blended the peas and carrots for approximately 15-20 seconds. Staff QQ then poured directly from the container, an unmeasured amount of thickener into the blender and blended the mixture for an additioner 30 seconds. Staff QQ then looked at the mixture and stated more water was needed and poured in an unmeasured amount of water into the blender. Staff QQ then blended the mixture for 30-45 seconds, poured it into a metal container and placed it on the steam table. Staff QQ then repeated the process to make a second batch. During an interview on 11/18/2022 at 11:28 AM, when asked how she knew what amount of peas and carrots, thickener and fluid/water to use Staff QQ stated, 20 years of experience. When asked if there was a recipe for it Staff QQ shook her head indicating no. At 11:30 AM, dietary staff were observed placing trays with resident tray cards on them into the the meal carts. The staff proceeded to place resident's tapiococa pudding and cartons of milk onto the trays. At 12:18 PM, temperatures were taken of hot food at the start of the meal service by Staff QQ. The temperatures were as follows: tomato basil soup=142 degrees Fahrenheit (dF), pureed tomato soup= 148 dF, grilled cheese sandwiches-152 dF, pureed bread= 134 dF, pureed peas and carrots= 137 dF, and chicken patties=205 dF. Despite multiple food items were already below 140 dF and several just over 140 dF, once the temperatures were recorded food service began. After watching tray line from 12:18 PM to 12:43 PM, the first two meal carts left the kitchen, greater than 70 minutes after staff began placing milk and tapioca pudding on resident trays in the meal carts. Upon exiting the kitchen on 11/18/2022 at 12:43 PM, Staff J was asked to put a test tray on the last meal cart to provide to the surveyour after last resident tray was passed. A test tray was not provided. During an interview on 11/18/2022 at 3:03 PM, when asked if the cook should be following a recipe when making pureed food, to ensure appropriate texture, concentration (nutritional value) and palatability were maintained Staff J stated that they probably should. Staff J also acknowledged serving food whose holding temperature was below 140 dF on the steam table and placing cold products (e.g., tapioca pudding, milk) on meal trays up to 70 minutes prior to delivery, could cause the colds not to be cold and hot food to both be lukewarm by the time the resident receives it. Reference WAC 388-97-1100(1)(2) .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to ensure prepared food and/or leftovers were labeled and dated prior to storing, and to have a system in place that ensured sanitization of cookware, silverware, dishes and serving areas. The facility's failure to consistently label leftovers, and to periodically test the sanitizer concentrations of the sanitizer buckets the sanitizing and low temperature dishwasher (chemical sanitization), precluded staff from ensuring adequate concentrations of sanitizer were maintained to sanitize cookware, dishes, and environmental surfaces. These failures placed residents at risk for food-borne illness. Findings included . According to the facility's undated Leftovers policy, all leftovers will be properly covered and labeled with name of the product and the date it was prepared. According to the facility's 11/18/2022 Dishwasher Temperature policy, it is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions, for low temperature dishwashers' chemical solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift, and for effective contact time according to manufacturer's guidance. Initial observations of the dietary department on 11/15/2022 between 9:55 AM and 10:17 AM, with Staff J, Dietary Manager, the following was observed: Walk in Refrigerator-observation of the walk-in refrigerator showed: an unlabeled container dated 11/11, which Staff J indicated was pureed pears; an unlabeled container dated 11/13, which Staff J identified as pureed bread and two unlabeled large transparent plastic containers dated 11/13 that Staff j identified as egg salad and tuna. During an interview at this time Staff J acknowledged that all containers were required to be labeled and dated but were not. A sanitizer bucket was observed on the counter in the meal preparation area, when asked what the facility used for sanitizer Staff J indicated the facility used quat, when asked to test the concentration of the solution Staff J indicated staff didn't use test strips to test the sanitizer concentration because they knew how to mix it. Upon request Staff J did test the solution and it was within acceptable limits at 100 parts per million (ppm). Observation of the cabinet above the meal preparation area showed a incomplete flowsheet where staff were to record sanitizer solution concentration. During observation of meal preparation and service on 11/18/2022 at 9:49 AM, Staff J was observed washing dishes. When asked about the type of dishwasher it was Staff J stated that it was a low temperature chemical dishwasher. When asked to run a strip through the dishwasher to test the sanitizer concentration Staff J stated the facility did not do that. When asked how the facility validated the dishwasher had the correct concentration of sanitizer solution and contact time to ensure sanitization of the cookware and dishes Staff J motioned to a piece of paper taped to the wall and stated the vendor does it once a month. During an interview on 11/21/2022 at 11:03 AM Staff A, Administrator, confirmed that dietary personnel should be testing the sanitizer concentration of the low temperature dishwasher at least once per shift, but failed to do so. Reference WAC 388-97-1100(3) .

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• 92 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• Grade F (33/100). Below average facility with significant concerns.

Bottom line: Trust Score of 33/100 indicates significant concerns. Thoroughly evaluate alternatives.

Email me this report

About This Facility

What is Belmont Terrace's CMS Rating?

CMS assigns BELMONT TERRACE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Washington, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Belmont Terrace Staffed?

CMS rates BELMONT TERRACE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 50%, compared to the Washington average of 46%. RN turnover specifically is 59%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Belmont Terrace?

State health inspectors documented 92 deficiencies at BELMONT TERRACE during 2022 to 2025. These included: 1 that caused actual resident harm and 91 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Belmont Terrace?

BELMONT TERRACE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by THE ENSIGN GROUP, a chain that manages multiple nursing homes. With 102 certified beds and approximately 74 residents (about 73% occupancy), it is a mid-sized facility located in BREMERTON, Washington.

How Does Belmont Terrace Compare to Other Washington Nursing Homes?

Compared to the 100 nursing homes in Washington, BELMONT TERRACE's overall rating (1 stars) is below the state average of 3.2, staff turnover (50%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Belmont Terrace?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Belmont Terrace Safe?

Based on CMS inspection data, BELMONT TERRACE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Washington. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Belmont Terrace Stick Around?

BELMONT TERRACE has a staff turnover rate of 50%, which is about average for Washington nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Belmont Terrace Ever Fined?

BELMONT TERRACE has been fined $9,750 across 1 penalty action. This is below the Washington average of $33,176. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Belmont Terrace on Any Federal Watch List?

BELMONT TERRACE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 102
Avg. Residents: 74
Occupancy: 72.7%
Ownership: For profit - Limited Liability company
Chain: THE ENSIGN GROUP
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
1 Actual Harm citation: -5
92 Deficiencies: -10
Fines ($9,750): -2
Final Score: 33/100

Nearby Alternatives

LIFE CARE CENTER OF PORT ORCHA... 5-star BAINBRIDGE ISLAND HEALTH & REH... 5-star NORTHWOODS LODGE 5-star

View all in BREMERTON →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 505290