LINDEN GROVE HEALTH CARE CENTER
For profit - Limited Liability company
130 Beds
GENESIS HEALTHCARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#177 of 190 in WA
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Linden Grove Health Care Center has received a Trust Grade of F, indicating poor quality and significant concerns about care. It ranks #177 out of 190 facilities in Washington, placing it in the bottom half, and #21 out of 21 in Pierce County, suggesting there are no better local options. The facility is worsening, with issues increasing from 26 in 2024 to 28 in 2025. Staffing is rated average with a 3/5 star rating, but a turnover rate of 49% is concerning, as it is close to the state average of 46%. Additionally, the facility has accumulated $134,350 in fines, which is higher than 79% of Washington facilities, indicating repeated compliance problems. Notably, a critical incident involved a resident suffering an opioid overdose due to a medication error, requiring hospitalization and life-saving intervention. Another serious finding involved a resident with cognitive impairment who exited the facility unsupervised and fell on a freeway ramp, leading to hospitalization. Furthermore, the facility failed to provide consistent restorative services to residents, resulting in decreased mobility for one individual. Overall, while the staffing situation is somewhat stable, the numerous serious and critical incidents raise significant concerns about the quality of care provided at this facility.
- Trust Score
- F
- In Washington
- #177/190
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 49% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $134,350 in fines. Higher than 81% of Washington facilities, suggesting repeated compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 37 minutes of Registered Nurse (RN) attention daily — about average for Washington. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 95 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 7%
Review needed
26 → 28 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 26 issues
2025: 28 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Washington average (3.2)
Significant quality concerns identified by CMS
Staff Turnover: 49%
Near Washington avg (46%)
Higher turnover may affect care consistency
Federal Fines: $134,350
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: GENESIS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 95 deficiencies on record
1 life-threatening 3 actual harm
Aug 2025
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0760
(Tag F0760)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that 1 of 6 residents (Resident 1) was free from a significa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that 1 of 6 residents (Resident 1) was free from a significant medication error that resulted in opioid overdose and hospitalization in an intensive care unit, requiring administration of Narcan (a life-saving opioid-reversing medication). In addition, the facility failed to ensure correct medication administration documentation for 6 of 6 residents (Residents 1, 2, 3, 4, 5, and 6) reviewed for medication errors. On 08/14/2025 at 2:37 PM, the facility was notified of an Immediate Jeopardy at Code of Federal Regulations (CFR) 483.45(f)(2), F760, Free of any significant medication errors, related to the facility's failure to ensure that a resident (Resident 1) was not subject to significant medication errors. The significant medication error resulted in Resident 1 being found unresponsive with abnormal vital signs, requiring hospitalization and life-saving interventions to reverse the effects of medication that was given in error. The facility had removed the immediacy on 08/03/2025 by implementing a removal plan that included removal of the staff member that was identified as having a pattern of inconsistent documentation around opioid medication administration, re-educating all licensed nursing staff on the current standards of nursing practice related to safe and accurate medication administration, performing an expanded audit of other residents' medication administration records, and enlisting the assistance of the contracted pharmacy to perform an on-site medication administration audit.Findings included . Review of facility policies titled, Administering Medications, revised April 2019, and Controlled Substances, revised November 2022, showed that medication administration must be documented in the narcotic log book as well as the eMAR (electronic medication administration record). In addition, the policies showed that staff must verify the resident's identity before administering medication, and that the individual administering the medication must verify three times that they are administering to the right resident, the right medication, right dosage, right time and right method of administration before giving the medication. Review of the medical record showed that Resident 1 was admitted on [DATE] with a complex medical history and diagnoses to include chronic pain, obesity and need for assistance with personal care. Review of a facility progress note, dated 07/31/2025 at 7:19 AM, showed that Resident 1 was found unresponsive with abnormal vital signs to include low blood pressure, slow breathing, low blood oxygen saturation level, and a rapid heart rate. Staff could not wake Resident 1. The facility called 911 for emergency response, and Resident 1 was hospitalized from [DATE] to 08/08/2025. Review of hospital emergency department records, dated 07/31/2025, showed that Resident 1 tested positive for oxycodone and morphine (opioid/narcotic, Schedule II controlled substance pain medications). The hospital records further showed that Resident 1 required intensive care unit level of care, while hospitalized , a Narcan intravenous infusion, and breathing support. In addition, an emergency room progress note, dated 07/31/2025 at 9:38 AM, showed that the hospital staff spoke with the facility over the phone, and facility staff stated, the last time [Resident 1] took an opioid ‘wasn't documented' and that ‘[they] needed to ask someone else.' The progress note went on to show that the facility staff then reported that [Resident 1] took one five milligram (mg) oxycodone on 07/29/2025 and [they] ‘didn't know why that wasn't in the book.' Facility staff also reported that Resident 1 absolutely does not have access to opioids. Review of the physician's orders, dated August 2025, showed that Resident 1 had orders for oxycodone five mg every eight hours as needed for pain. Further review of the historical physician's orders, from Resident 1's facility admission [DATE] to 08-01-2025), showed that Resident 1 never had an order for morphine while in the facility. During interview on 08/01/2025 at 5:09 PM, Collateral Contact 1 stated that Resident 1 had never taken morphine, and that they had only taken oxycodone for pain. Collateral Contact 1 further stated that Resident 1 had recently had a new roommate move in, and they took morphine. Collateral Contact 1 stated that they believed the facility staff accidentally gave Resident 1 their roommate's morphine. Review of the facility incident investigation, dated 07/31/2025, showed that Resident 1's roommate, Resident 2, had orders for morphine - both scheduled and as-needed, and that there was an extra dose signed out of Resident 2's narcotic log, by Staff B, Licensed Practical Nurse (LPN), that was unaccounted for. When Staff B was questioned about the extra dose of morphine, Staff B stated they did not know why there was an extra dose signed out. When Resident 2 was interviewed, they stated that they had not missed any of their scheduled doses of morphine. The investigation showed that it was reasonable to conclude that a medication error had occurred, in which Staff B had given Resident 2's morphine to Resident 1. In an interview on 08/14/2025 at 1:23 PM, Resident 1 stated that they were given their roommate's morphine. Resident 1 stated that they remembered asking for oxycodone, and the nurse brought them a cup with two pills. Resident 1 stated they normally only took one oxycodone at a time, but they took the medication that the nurse gave them. Resident 1 stated that after that, they remembered not feeling well, and did not remember much beyond that. Resident 1 stated that they felt safe being back in the facility, because they thought staff will be more careful after making such a mistake. Resident 1 stated they would be more alert to what they were being given by the nursing staff, and if something looked unfamiliar, they would question it. Review of the facility incident investigation, dated 07/31/2025, showed that a trend of incorrect medication administration documentation was identified with Staff B, LPN, as well as with other nurses. Residents 1, 2, 3, 4, 5 and 6 had missing documentation in their electronic medication administration records (eMARs) when compared to their narcotic log pages in the narcotic log book. Review of the narcotic log showed that Resident 1 received doses of oxycodone on 07/02/2025 at 3:00 AM and 8:00 PM; 07/03/2025 at 9:00 PM; 07/07/2025 at 9:00 PM; 07/08/2025 at 9:00 PM; 07/12/2025 at an illegible time; 07/13/2025 at 8:00 PM; 07/17/2025 at 8:00 PM; 07/21/2025 at 8:00 PM; 07/22/2025 at 8:00 PM; 07/24/2025 at 8:00 PM; 07/25/2025 at 8:00 PM; 07/26/2025 at 8:00 PM; 07/27/2025 at 8:00 PM 07/29/2025 at 8:00 PM and an illegible time, none of which were documented on Resident 1's eMAR. Review of the narcotic log showed that Resident 2 received doses of morphine on 07/27/2025 at 10:00 AM; 07/28/2025 at 9:30 AM; 07/29/2025 at 2:00 AM; 07/31/2025 at 2:00 AM and 07/31/2025 at an illegible time, none of which were documented on Resident 2's eMAR. The 07/31/2025 administrations are notable because Staff B, LPN, signed out both doses of morphine on 07/31/2025: 2:00 AM and the illegible time. Resident 2 was able to have this dose of morphine every six hours, as needed, so the next dose after 2:00 AM would not have been eligible for administration until 8:00 AM. Staff B, LPN, was off shift at 6:30 AM, prior to it being time for Resident 2 to receive another dose of morphine. Review of the narcotic log showed that Resident 3 received doses of oxycodone on 07/31/2025 at 7:30 AM, 4:30 PM and 8:00 PM; 08/01/2025 at 12:01 AM, 4:00 AM, 4:30 PM and 9:00 PM; 08/03/2025 at 4:00 AM, none of which were documented in Resident 3's eMAR. Review of the narcotic log showed that Resident 4 received a dose of lorazepam (a Schedule 4 controlled narcotic medication to treat anxiety) on 08/02/2025 at 11:02 PM, which was not documented in Resident 4's eMAR. Review of the narcotic log showed that Resident 5 received doses of clonazepam (a Schedule 4 controlled narcotic medication to treat anxiety) on 07/22/2025 at 6:00 PM; 07/24/2025 at 4:00 AM and 8:00 PM; 07/26/2025 at 10:00 AM; 07/27/2025 at 9:00 PM; 07/28/2025 at 9:00 PM; 07/30/2025 at 9:00 PM; 07/31/2025 at 8:00 PM, and oxycodone on 07/26/2025 at 4:00 AM and 10:00 AM; 07/27/2025 at 4:00 AM and 7:00 PM; 07/28/2025 at 1:00 AM; 07/29/2025 at 4:00 PM and 10:00 PM; 07/30/2025 at 4:00 AM, 9:00 AM and 5:00 PM; 07/31/2025 at 6:00 PM; 08/01/2025 at 1:00 AM; 08/03/2025 at 8:43 AM, none of which were documented in Resident 5's eMAR. Review of the narcotic log showed that Resident 6 received doses of oxycodone on 07/31/2025 at 6:00 PM and 08/01/2025 at 2:00 AM, neither of which were documented in Resident 6's eMAR. In an interview on 08/14/2025 at 2:30 PM Staff A, Director of Nursing Services (DNS), stated that when Staff B, LPN, was questioned about why the extra dose of morphine was signed out of Resident 2's narcotic book, Staff B, LPN, stated I don't know. Staff A, DNS, stated that based on the facility investigation and pattern of incorrect narcotic administration documentation, Staff B, LPN's, employment was terminated. Reference WAC 388-97-1060 (3)(k)(iii).
May 2025
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess, identify, monitor, and adequately supervise resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess, identify, monitor, and adequately supervise residents at risk of elopement for 1 of 3 sample resident (Resident 1) reviewed for accident hazards. Resident 1, who had a cognitive impairment and lacked safety awareness, experienced harm when they exited the facility unsupervised, was subsequently observed by a bystander to fall on a freeway ramp, hit their head, and was transported by Emergency Services (EMS) personnel to a hospital for evaluation. This failure placed residents at risk for potential injury, negative outcome, and decreased quality of life.
Findings included
Review of a facility's policy titled, Elopements, dated 03/22/2022, noted the facility was to utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, that included identification and assessment of risk, identification and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary.
Resident 1 was admitted to the facility on [DATE] with multiple diagnoses, including stroke, dementia and encephalopathy (damage or disease that affects the brain that can cause confusion, memory loss, and other changes). The Minimum Data Assessment, dated 05/01/2025, noted that Resident 1 required staff assistance for activities of daily living.
Review of Resident 1's care plan, dated 04/26/2025, documented the resident was at risk for falls and injury due to cognitive loss and lack of safety awareness. An addition to the care plan, dated 04/28/2025, documented Resident 1 had impairment or decline in their cognitive function or impaired thought processes related to dementia.
Review of a nursing note, dated 05/01/2025 at 5:58 PM, documented Resident 1 wanted to leave and was upset that no one had checked on him. THe nursing note stated the resident started to fall, was assisted to a chair, assessed and taken to their room.
A nursing note, dated 05/06/2025 at 4:57 PM, documented Resident 1 was last checked on at around 2:00 PM on 05/06/2025 and was not in the room when nursing checked on them around 4:00 PM. The nurse documented that they did not see the resident and was not aware of which resident was allowed to visit out or which one was not. The nurse noted the resident had previously attempted to leave, wanted to discharge, almost fell, and that the resident was very confused.
Review of hospital documentation dated 05/06/2025, noted EMS was called at 3:41 PM after bystanders saw Resident 1 stumble while walking on a freeway ramp, fall, and hit their head. EMS arrived to find the resident sitting on the shoulder of the freeway on-ramp. EMS staff documented the resident was occasionally able to answer questions and talk in full normal sentences but then would say things that were not based in reality. The resident had abrasions and bruising on their body consistent with falls that were in different stages of healing. The resident was not able to give any medical history or say where they had come from. The resident told EMS staff that they had fallen because they had had a change in vision and their balance was off.
Review of hospital notes, dated 05/06/2025, showed hospital staff contacted the facility due to the location of where Resident 1 was found. Hospital staff documented that facility staff were not aware that the resident was gone and, after several calls, it was determined the resident had not been seen at the facility since around 2:00 or 3:00 PM, when somebody had seen them walking down the hallway.
Review of a nursing note, dated 05/06/2025 at 5:42 PM, showed facility staff received a call from the hospital that Resident 1 had been found on the ground outside the facility and had been taken to the hospital, and requested information regarding the resident, including their medication list. The provider was notified.
Review of the facility investigation initiated on 05/06/2025, identified risks that included the accuracy of an elopement evaluation on admission; that nursing did not immediately look for the resident when they were not visualized in their room; and that staff in the Reception area did not notice the resident walk out the door.
On 05/08/2025 at 1:30 PM, when asked, Staff C, a Licensed Practical Nurse and a Resident Care Manager, said if a resident was missing they would start looking, first indoors and then if not found they would look outside. When asked about Resident 1, Staff C said they had heard that the resident was missing and then they got a call from the hospital.
On 05/22/2025 at 12:16 PM, Staff D, a certified nursing assistant, said when a resident is not in their room, they check the hall and the other rooms and then let the nurse know and then everyone checks and looks everywhere.
On 05/22/2025 Staff D said they worked with Resident 1 on 05/06/2025, the night they left. Staff D said Resident 1 had been showered earlier and then their tray was brought in. Staff D said when they went back to get the tray, Resident 1 was not in the room and it was sometime later they figured out Resident 1 was not there.
On 05/22/2025 at 3:04 PM, Staff B, the facility Director of Nursing Services, said they were shocked when the hospital called to say, we think we have one of your residents. Staff B said they had identified there was a problem with the risk assessment, and that Resident 1's assessment did not include factors from their history that would have triggered an elopement risk evaluation. Staff B also said they determined that there was a delay in beginning to look for the resident, and also that staff covering the reception area were not as familiar with the residents the day Resident 1 walked out of the facility.
On 05/22/2025 at 3:50 PM, Staff A, the facility Administrator, said they have identified processes to focus on for improvement.
Reference WAC 388-97-1060(3)(g)
.
Jan 2025
24 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to periodically review a resident's advanced directive (AD, a legal ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to periodically review a resident's advanced directive (AD, a legal document that states your wishes for medical care if you are unable to make decisions for yourself) and obtain and maintain court-appointed guardianship (legal process where a court appoints someone to make decisions for a person who is unable to do so for themselves) documentation for 1 of 2 sampled residents (Resident 77) when reviewed for advanced directive. This failure placed the resident at risk of not having an established decision maker, lack of ability to direct care, and a diminished quality of life.
Findings included .
Review of the electronic health record (EHR) showed Resident 77 admitted to the facility on [DATE] and was able to make needs known. The quarterly minimum data set assessment (MDS), an assessment tool, dated 11/15/2024, showed Resident 77 had diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning), depression, and Osteoarthritis (a condition that causes pain, stiffness, and reduced movement in the joints).
Review of Resident 77's EHR showed the following three Social Services Assessment and Documentation forms:
-Form dated 02/14/2024 showed no AD was in place due to Resident 77 was unable to sign AD documentation at that time related to cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses).
-Form dated 05/16/2024 showed no AD was in place due to Resident 77 was unable to sign AD documentation at that time related to cognition.
-Form dated 01/14/2025 showed there was a court-appointed guardian, and documents were requested for medical records.
Review of Resident 77's EHR showed no AD for healthcare or court-appointed guardianship documentation.
During an interview on 01/27/2025 at 11:27 AM, Staff F, Social Services (SS), stated Resident 77 should have had an AD review in August 2024 and in November 2024 and that did not happen. Staff F stated Resident 77's family member had stated they were the resident's legal guardian; however, they were unable to locate that documentation in the resident's medical record.
During an interview on 01/27/2025 at 11:48 AM, Staff D, Business Office Manager (BOM), stated they should have followed up with Resident 77's family member to obtain guardianship paperwork, documented attempts to obtain them, and this did not meet expectations.
During an interview on 01/27/2025 at 1:25 PM, Staff A, Administrator, stated AD was to be reviewed upon admission, quarterly, and as needed. Staff A stated Social Services were responsible for obtaining AD.
Reference WAC 388-97-0280 (3)(c)(i-ii), -0300 (1)(b)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observations and interview, the facility failed to provide a safe, sanitary, and homelike environment for 1 of 4 samp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observations and interview, the facility failed to provide a safe, sanitary, and homelike environment for 1 of 4 sampled residents (Resident 62) reviewed for environment. Failure to ensure a wheelchair was in good repair placed the resident at risk for infections, injuries, and diminished quality of life.
Findings included .
Review of the electronic health record (EHR) showed that Resident 62 readmitted to the facility on [DATE] with diagnoses to include cancer and depression and was able to make needs known.
Observation and interview on 01/23/2025 at 9:30 AM showed both armrests on Resident 62's wheelchair had multiple cracked areas in the vinyl with exposed beige material underneath which created an uncleanable surface. Resident 62 stated it was their personal wheelchair and eventually the material on the armrests just cracked.
Follow-up observation and interview on 01/29/2025 at 10:54 AM showed Resident 62's wheelchair armrests continue to be in disrepair. Resident 62 stated both armrests on their wheelchair were rough to the touch. Resident 62 stated staff had seen them on their wheelchair and should have seen that the armrests needed to be fixed or replaced.
During an interview and joint observation on 01/29/2025 at 10:59 AM Staff E, Licensed Practical Nurse, stated Resident 62's wheelchair armrests were both torn, cracked, rough to the touch, and not a cleanable surface. Staff E stated the wheelchair needed to be removed and maintenance and physical therapy informed for wheelchair armrests to be fixed/replaced.
During an interview on 01/29/2025, Staff B, Director of Nursing Services, stated the condition of Resident 62's wheelchair armrests did not meet expectations.
Reference WAC 388-97-0880
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review the facility failed to ensure a resident was free from neglect when it preve...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review the facility failed to ensure a resident was free from neglect when it prevented transfer out of a power wheelchair for three nights, prevented wound care during that time and caused distress related to transfer assistance from staff for 1 of 7 sampled residents (Resident 78) reviewed for abuse/neglect. This failure placed facility residents at risk of not receiving required care and services and a decreased quality of life.
Findings included .
Review of facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated September 2022, showed all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management . All allegations are thoroughly investigated. The administrator initiates investigations.
Resident 78
Review of the electronic health record (EHR) showed Resident 78 admitted to the facility on [DATE] with diagnoses of palliative care (end-of-life), osteomyelitis (infection of the bone), and diabetes (too much sugar in the blood). Resident 78 was able to make needs known.
Review of the care plan, initiated 08/02/2024, showed Resident 78 was dependent on staff for transfers in/out of bed with a mechanical lift.
During an interview and observation on 01/22/2025 at 10:46 AM, Resident 78 stated they were left in their power wheelchair for three nights because the facility could not locate a piece of equipment needed to transfer them into bed. Resident 78 stated they would not be left in the same situation, so they always kept the equipment in bed with them. Observation showed Resident 78 took a piece of metal with pins out from under the covers.
During an interview on 01/29/2025 at 11:34 AM, Staff P, Certified Nursing Assistant (CNA), stated Resident 78 had told them the mechanical part was missing, and they were sleeping in their power wheelchair at night. Staff P stated they reported the incident to Staff N, Licensed Practical Nurse (LPN).
During an interview on 01/29/2025 at 12:14 PM, Staff N, LPN, stated they were on vacation during the time Resident 78 was sleeping in their wheelchair at night. Staff N stated Resident 78 required a special part to be able to use the mechanical lift because the resident was an amputee. Staff N stated when told of Resident 78's allegation the staff checked on Resident 78's wounds to ensure they had not worsened, located the missing piece of equipment, then transferred Resident 78 into bed. Staff N stated they considered Resident 78's statements to be an allegation of neglect, and they had spoken with Staff B, Director of Nursing Services (DNS), about the allegations.
During an interview on 01/29/2025 at 12:18 PM, Staff B, DNS, stated they were aware of an issue of locating the mechanical equipment needed to transfer Resident 78. Staff B stated they were unaware Resident 78 had stated they slept in their wheelchair for three nights.
During an interview on 01/29/2025 at 12:31 PM, Staff F, Social Services, stated Resident 78 made an allegation of neglect when they filled out a grievance form and put it in the social services grievance box. Staff F stated they informed Staff B, DNS, of the allegations.
During an interview on 01/29/2025, Staff B, DNS, stated allegations of abuse/neglect should be reported to the DNS and the resident should be protected from further abuse/neglect while an investigation was conducted. Staff B stated being left in a wheelchair to sleep for three nights would be considered an allegation of neglect.
Refer to F609 for additional information.
Reference WAC 388-97-0640 (1).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 13
Review of Resident 13's EHR showed the resident readmitted to the facility on [DATE] with diagnoses to include heart...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 13
Review of Resident 13's EHR showed the resident readmitted to the facility on [DATE] with diagnoses to include heart failure, chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems) and was able to make needs known.
Review of the discharge minimum data set assessment (MDS), an assessment tool, dated 08/15/2024, and the entry tracking record MDS, dated [DATE], showed Resident 13 was transferred from the facility to the hospital on [DATE] and readmitted to the facility on [DATE].
During an interview on 01/28/2025 at 10:32 AM, Staff E, Licensed Practical Nurse, stated Resident 13 was provided with verbal notification for transfer to the hospital on [DATE]. Staff E stated they did not provide written notification for transfers to the hospital to residents and/or responsible party, only verbal notifications.
During an interview on 01/28/2025 at 1:59 PM, Staff B, Director of Nursing Services, stated they were unable to tell by the documentation in Resident 13's EHR if a written hospital transfer form notification was sent to the hospital with the resident on 08/15/2024 or provided to the resident and it should have been. Staff B stated to check with Social Services related to the Ombuds program notifications.
During an interview on 01/28/2025 at 2:14 PM, Staff F, Social Services (SS), stated the Ombuds program was not provided a written notice of transfer for Resident 13's transfer to the hospital on [DATE] and should have been.
Reference WAC 388-97-0120 (2)(a-d), -0140(1)(a)(b)(c)(i-iii)
Based on interview and record review, the facility failed to provide written notification of the reason for hospital transfer to the resident or responsible party and/or Washington State Long-Term Care Ombudsman program (Ombuds) for 2 of 4 sampled residents (Resident 81 & 13) reviewed for hospitalization. This failure placed the resident at risk for not knowing rights regarding transfer and discharge from the facility, and diminished protection from been inappropriately discharged .
Findings included .
Review of the electronic health record (EHR) showed Resident 81 admitted to the facility on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain) and diabetes (too much sugar in the blood). Resident 81 was able to make needs known.
Review of Resident 81's EHR showed a hospitalization on 01/21/2025, and readmission to the facility on [DATE]. The EHR did not show documentation a notice of transfer was provided to Resident 81 or their representative.
During an interview on 01/23/2025 at 12:52 PM, Staff C, Assistant Director of Nursing (ADON), stated the resident/resident representative did not receive a written notice of transfer as they should have. Staff C stated nursing should have provided notice upon transfer or sent certified mail to the resident representative.
During an interview on 01/28/2025 at 2:27 PM, Staff A, Administrator, stated the expectation was that residents received written notification at the time of transfer.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 13
Review of Resident 13's EHR showed the resident readmitted to the facility on [DATE] with diagnoses to include heart...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 13
Review of Resident 13's EHR showed the resident readmitted to the facility on [DATE] with diagnoses to include heart failure, chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems) and was able to make needs known.
Review of the discharge minimum data set assessment (MDS), an assessment tool, dated 08/15/2024, and the entry tracking record MDS, dated [DATE], showed Resident 13 was transferred from the facility to the hospital on [DATE] and readmitted to the facility on [DATE].
During an interview on 01/28/2025 at 1:15 PM, Staff D, BOM, stated they did not see a bed hold form/documentation in Resident 13's EHR and there should have been.
During an interview on 01/28/2025 at 1:59 PM, Staff B, Director of Nursing Services, stated bed holds were to be offered to all residents when transferred to the hospital and there should have been a bed hold located in Resident 13's EHR for the transfer to the hospital on [DATE].
Reference WAC 388-97-0120 (4)
Based on interview and record review, the facility failed to provide written bed hold notice at the time of transfer to the hospital for 2 of 4 sampled residents (Residents 81 and 13) reviewed for hospitalization. This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life.
Findings included .
Review of the electronic health record (EHR) showed Resident 81 admitted to the facility on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain) and diabetes (too much sugar in the blood). Resident 81 was able to make needs known.
Review of Resident 81's EHR showed a hospitalization on 01/21/2025, and readmission to the facility on [DATE]. The EHR did not show documentation or progress notes related to a bed hold for the hospitalization.
During an interview on 01/23/2025 at 12:46 PM, Staff D, Business Office Manager (BOM), stated it was their responsibility to follow up on bed holds; however, this one was not completed due to the weekend.
During an interview on 01/23/2025 at 12:52 PM, Staff C, Assistant Director of Nursing (ADON), stated residents should receive a bed hold packet at the time of transfer if they were alert and oriented. Staff C stated a bed hold was not offered but should have been.
During an interview on 01/28/2025 at 2:27 PM, Staff A, Administrator, stated the expectation was that bed holds were done at the time of the resident transfer or within 24 hours and documentation scanned into the medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to accurately assess the status for 1 of 5 sampled residents (Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to accurately assess the status for 1 of 5 sampled residents (Resident 41) reviewed for Pre-admission Screening and Resident Review (PASARR, a mental health screening tool). This failure had the potential to place the resident at risk for not receiving the care and services required to meet their needs.
Findings included .
Review of electronic health record (EHR) showed Resident 41 was admitted to the facility on [DATE] with diagnoses to include anxiety, chronic obstructive pulmonary disease (disease that blocks airflow and make it difficult to breath), depression, and personality disorder (mental and behavioral disorder associated with significant distress or disability and have negative impact on the quality of life). Resident 41 was able to communicate needs.
Review of the PASARR, dated 05/07/2020, showed Resident 41 had a level 2 evaluation and required special interventions and follow up by a provider.
Review of the minimum data set assessment (MDS), an assessment tool, dated 12/02/2024, showed Resident 41 was coded as not having a level 2 PASRR and not having serious mental illness.
During an interview on 01/29/2025 at 9:09 AM, Staff S, Social Service Director, stated Resident 41 received a level 2 PASARR and the MDS was coded wrong.
During an interview on 01/29/2025 at 9:32 AM, Staff A, Administrator, stated the MDS should have been coded as a level 2 and the MDS needed to be changed.
Reference WAC 388-97-1000(1)(b)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**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 (PASARR, a men...
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**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 (PASARR, a mental health screening tool) assessments were accurately or timely completed for 2 of 7 sampled residents (Residents 92 & 360) reviewed for PASARRs and unnecessary medications. This failure placed the residents at risk for unidentified mental health care needs and a diminished quality of life.
Findings included .
Resident 92
Review of the electronic health record (EHR) showed that Resident 92 admitted to the facility on [DATE] and was able to make needs known.
Review of the admission minimum data set assessment (MDS), an assessment tool, dated 09/26/2024, showed Resident 92 had diagnoses of depression and insomnia. It showed Resident 92 received antianxiety, antidepressant, and hypnotic (used to induce sleep) medications.
The quarterly MDS dated [DATE] showed Resident 92 had diagnoses of depression, anxiety disorder, and insomnia (sleeplessness).
Review of Resident 92's level 1 PASARR, dated 09/17/2024, completed by the hospital case manager, showed Resident 92 had no serious mental illness (SMI) indicators marked on the form and no level 2 evaluation indicated.
Review of Resident 92's level 1 PASRR, dated 12/10/2024, completed by the facility's Social Services Director, showed the resident had SMI indicators marked on the form for depressive and anxiety disorders. The form showed that a level 2 evaluation referral was required.
During an interview on 01/24/2025 at 11:37 AM, Staff F, Social Services, stated Resident 92's 12/19/2024 level 1 PASARR was not accurate because the resident had a diagnosis of depression and received a medication for anxiety and that was not reflected on the form. Staff F stated the 12/10/2024 level 1 PASARR for Resident 92's referral for a level 2 PASARR was late and should have been referred upon admission.
During an interview on 01/24/2025 at 12:00 PM, Staff B, Director of Nursing Services (DNS), stated PASARRs were to be obtained prior to admission and reviewed by social services for accuracy. Staff B stated if PASARRs were inaccurate then social services would complete another one upon admission. Staff B stated Resident 92's level 1 PASARRs did not meet expectations due to accuracy and timeliness of referral.
Resident 360
Review of the EHR showed that Resident 360 admitted to the facility on [DATE] with diagnoses to include a broken left upper thigh bone and kidney disease. Resident 360 was able to make needs known.
Review of Resident 360's level 1 PASARR dated 01/15/2025 showed the resident admitted to the facility on [DATE] and had no SMI indicators marked on the form and no level 2 evaluation indicated. This form was completed one day after admission. Review showed no level 1 PASRR completed prior to admission or upon admission.
During an interview on 01/29/2025 at 9:51 AM, Staff S, Social Service Director, stated Resident 360's 01/15/2025 level 1 PASARR did not meet expectations because it was completed late.
During an interview on 01/29/2025 at 9:55 AM, Staff B, DNS, stated Resident 360's 01/15/2025 level 1 PASARR should have been completed prior to admission or upon admission and this did not meet expectations.
Reference WAC 388-97-1915 (1)(2)(a-c)
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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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for 2 of 24 sampled residents (Residents 39 & 84) whose care plans were reviewed. Failure to develop and implement care plans that were individualized, and accurately reflected resident care needs related to impaired vision and smoking status placed residents at risk of unmet care needs and potential negative outcomes.
Findings included .
Resident 39
Review of the electronic health record (EHR) showed Resident 39 admitted to the facility on [DATE] with diagnoses to include heart failure, diabetes (too much sugar in the blood), and anxiety disorder. Resident 39 was able to make needs known.
Review of the annual minimum data set assessment (MDS), an assessment tool, dated 09/07/2024 showed in Section B that Resident 39 had impaired vision with no corrective lenses. It showed in Section V that Resident 39's care area assessment was triggered to have a care plan for visual function developed.
Review of the quarterly MDS dated [DATE] showed Resident 92 had impaired vision with no corrective lenses.
Review of Resident 39's current care plan, reviewed on 01/22/2025, did not show a care plan for impaired vison.
During an interview on 01/28/2025 at 1:45 PM, Staff O, MDS Nurse, stated Resident 39's care plan did not meet expectations because there should have been a care plan for impaired vision.
During an interview on 01/28/2025 at 1:52 PM, Staff B, Director of Nursing Services (DNS) stated Resident 39 should have had a care plan that addressed impaired vision.
Resident 84
Review of the EHR showed that Resident 84 admitted to the facility on [DATE] with diagnoses to include anemia and anxiety disorder. Resident 84 was able to make needs known.
Review of Resident 84's admission MDS dated [DATE] showed Resident 84 did not use tobacco.
Review of the facility's Resident Smoker List, undated, provided on 01/22/2025, showed Resident 84 smoked.
Review of Resident 84's smoking evaluation dated 11/21/2024 showed the resident smoked.
Review of Resident 84's current care plan, reviewed on 01/22/2025, did not show a care plan for smoking.
During an interview on 01/28/2025 at 10:54 AM, Staff E, Licensed Practical Nurse, stated residents' who smoked should have a smoking care plan to monitor for ashes on resident's clothes or wheelchair and to monitor for burn holes on clothing or burns on the skin. Staff E stated Resident 84 smoked; however, smoking was not addressed on the resident's care plan, and it should have been.
During an interview on 01/28/2025 at 2:46 PM, Staff B, Director of Nursing Services, stated Resident 84 should of had a smoking care plan in place prior to 01/28/2025 and this did not meet expectations.
Reference WAC 388-97-1020(1), (2)(a)(b)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed conduct timely care planning meetings with residents or responsible ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed conduct timely care planning meetings with residents or responsible party for 2 of 4 sampled residents (Residents 48 & 77) reviewed for care planning. These failures placed residents at risk for unmet needs, care not provided as directed, and a diminished quality of life.
Findings included .
Resident 48
Review of the electronic health record (EHR) showed Resident 48 readmitted on [DATE] with multiple diagnoses to include heart and lung disease, fibromyalgia (a chronic condition characterized by widespread musculoskeletal pain and fatigue), quadriplegia (paralysis or loss of ability to move all four limbs) and depression. Resident 48 was able to make needs known and was dependent on staff for activities of daily living.
During an interview at 01/22/2025 at 1:21 PM, Resident 48 stated they did not recall having a recent care conference.
During an interview on 01/23/2025 at 12:11 AM, Staff S, Social Service Director, stated Resident 48's last care conference was on 05/10/2023. Staff S stated this did not meet expectations as care conferences should be held quarterly.
Resident 77
Review of the EHR showed Resident 77 admitted to the facility on [DATE] and was able to make needs known. Resident 77 had diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning), depression, and osteoarthritis (a condition that causes pain, stiffness, and reduced movement in the joints).
During an interview on 01/23/2025 at 10:10 AM, Resident 77 stated they did not recall attending a care conference.
During an interview on 01/23/2025 at 12:11 AM, Staff S, Social Service Director, stated Resident 77's last care conference was on 02/12/2024. Staff S stated this did not meet expectations as care conferences should be held quarterly.
During an interview on 01/28/2025 at 2:25 PM, Staff A, Administrator, stated they were unaware of any missed or late care conferences. Staff A stated the expectation was that care conferences were to be conducted every three months unless there were extenuating circumstances.
Reference WAC 388-97-1020(2)(c)(d)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to meet professional standards of practice for diagnos...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to meet professional standards of practice for diagnosing residents with mental health disorders 1 of 5 sampled residents (Resident 2) reviewed for use of unnecessary medications. This failure placed the resident at risk for unmet needs, complications, and diminished quality of life.
Findings included .
Review of electronic health record (EHR) showed Resident 2 was admitted to the facility on [DATE] with diagnoses to included diabetes (high sugar in the blood), heart failure, depression and suicidal ideation. Resident 2 was able to communicate needs.
Review of the EHR showed Resident 2 received a level 2 Pre-admission Screening and Resident Review (PASARR, a mental health screening tool). Review of the PASARR level 2 showed, 2) why is [Resident 2] on quetiapine (psychoactive medication)? Admiting MD (physician) note states this is for 'schizophrenia' (mental disorder that affects a person's ability to think, feel and behave clearly), but there is no indication that [Resident 2] has this dx (diagnosis) anywhere in the records.
Review of the History and Physical form, signed 04/17/2022 showed Resident 2 had no diagnosis or history of schizophrenia.
Review of Resident 2's order summaries from a previous facility, dated 09/16/2022, showed the medication quetiapine was prescribed for major depressive disorder.
Review of pharmacy consultation report dated 07/13/2023 showed Per CMS [Center for Medicare and Medicaid Services], schizophrenia diagnosis must be supported with DSM-5 [Statistical Manual of Mental Disorders - Fifth edition, a manual that provides information on diagnosis of mental health disorders] supportive assessment. SOM [State Operations Manual, guidance to surveyors to regulate nursing homes] states: Schizophrenia must be diagnosed by a qualified practician, using evidence-based criteria and professional standards, such as the diagnostic and Statistical Manual of Mental Disorders-Fifth edition (DSM-5) and documented in the medical record.
During an interview on 01/22/2025 at 12:20 PM, Resident 2 stated I wish I can talk to someone with a sad facial expression and no eye contact.
During an interview on 01/27/2025 at 12:43 PM, Staff R, Resident Care Manager, stated Resident 2 came from a different facility. When asked about the schizophrenia diagnosis, Staff R was not able to provide additional evidence of why Resident 2 had this diagnosis.
During an interview on 01/29/2025 at 11:32 AM, Staff B, Director of Nursing Services, stated they would look for supporting documentation, but was not able to provide any.
Reference WAC 388-97-1620(2)(b)(i)(ii), (6)(b)(i)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to ensure a mobility device was available for 1 of 5 sa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to ensure a mobility device was available for 1 of 5 sampled residents (Resident 4) when reviewed for mobility. The facility failed to implement a bowel program for 2 of 5 sampled residents (Residents 24 and 108) reviewed for bowel management. These failures placed the residents at risk for unmet needs, worsening condition, and decreased quality of life.
Findings included .
<Mobility Device>
Resident 4
Review of the electronic health record (EHR) showed Resident 4 was admitted to the facility on [DATE] with diagnoses to include malignant melanoma (skin cells that become cancerous), malnutrition, depression and diabetes (high sugar in blood). Resident 4 was able to make needs known.
Observations on 01/22/2025 and 01/24/2025 showed Resident 4 lying in bed, naked.
During an interview on 01/23/2025 at 9:40 AM, Resident 4 stated they did not get out of bed because the facility had not provided them a wheelchair which matched their height. Resident 4 stated they would like to be outside of the room and see the other residents.
During an interview on 01/24/2025 at 1:14 PM, Staff R, Resident Care Manager, stated Resident 4 required a wheelchair which fit their height, and they did not currently have one.
During an interview on 01/29/2025 at 8:30 AM, Staff B, Director of Nursing Services, stated the residents were offered to go out of their rooms and Resident 4's status of no wheelchair to fit their height or way to get out of their room did not meet expectations.
<Bowel Management>
Resident 24
Review of the EHR showed Resident 24 admitted to the facility on [DATE] with diagnoses that included chronic pain and other psychoactive (affecting the brain) substance dependence.
Review of the quarterly minimum data set assessment (MDS), an assessment tool, dated 12/16/2024, showed Resident 24 was incontinent of bowel and bladder. The MDS showed Resident 24 could voice their needs and preferences.
Review of the provider orders showed Resident 24 had orders for the following medications for constipation: Colace two times daily, Senna Plus in the evening, milk of magnesia (MOM) as needed if no bowel movement in three days, Dulcolax suppository as needed if no result from MOM by next shift, Fleet Enema as needed if no result from Dulcolax within 2 hours.
Review of the January 2025 bowel monitoring task showed Resident 24 did not have a bowel movement form 01/01/2025 through 01/05/2025.
Review of the medication administration record (MAR) for January 2025 showed Resident 24 was administered MOM on 01/05/2025 at 12:25 PM. The next documented bowel movement was 01/06/2025 at 08:04 PM, greater than 24 hours after administration of MOM. Review showed Dulcolax or Fleet Enema were not administered per provider order.
Review of the January 2025 bowel monitoring task showed that Resident 24 had no bowel movement from 01/17/2025, through 01/20/2025. Review of the MAR showed no MOM, Dulcolax, or Fleet enema were documented as provided.
Resident 108
Review of the EHR showed Resident 108 admitted to the facility on [DATE] with diagnoses that included major depressive disorder and anxiety disorder.
Review of the quarterly MDS, dated [DATE], showed Resident 108 was frequently incontinent of bowel and bladder. The MDS showed Resident 108 could voice their needs and preferences.
Review of provider orders, dated 02/04/2023, showed Resident 108 had orders for the following constipation medications: Miralax powder daily, MOM as needed if no bowel movement in 3 days, Dulcolax suppository if no result from MOM by next shift, Fleet Enema if no result from Dulcolax within two hours.
Review of the January 2025 bowel monitoring task showed Resident 108 did not have a bowel movement from 01/01/2025 through 01/05/2025.
Review of the MAR for January 2025 showed MOM was administered on 01/05/2025 at 1:09 PM for constipation.
Review of the EHR showed Resident 108 had a large bowel movement on 01/06/2025 at 11:39PM, more than 24 hours after the administration of MOM. Review of the EHR showed Dulcolax or fleet enema were not administered per provider order.
During an interview on 01/27/2025 at 12:10 PM, Resident 108 stated they only received bowel medications when they asked for it and it was not offered. Resident 108 stated they were supposed to have a bowel movement at least every three days.
During an interview on 01/27/2025 at 10:57 AM, Staff E, Licensed Practical Nurse (LPN), stated if a resident did not have a medium or large bowel movement for greater than 72 hours, the facility charting system would alert the staff, who would then follow the bowel protocol per providers orders. Staff E stated if a resident did not have a bowel movement for more than 72 hours, it would show up on the dashboard where all the nurses could see it and they could initiate the protocol. Staff E stated the information on who needed bowel medications was filled out on a paper form that was passed from nurse to nurse until the resident had a bowel movement. Staff E stated the nurses would document what medication was given with the date and time.
During an interview on 01/28/2025 at 10:16AM, Staff B, Director of Nursing Services (DNS), stated their expectation was the nurse would assess the resident and initiate the bowel protocol per providers orders if a resident did not have a bowel movement for more than 72 hours.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to ensure risk factors were consistently monitored and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to ensure risk factors were consistently monitored and addressed to minimize the risk for accident hazards for 2 of 7 residents (Residents 94 and 86) when reviewed for accident hazards. The failures to consistently monitor and ensure a wanderguard devices was functional for Resident 94 and to identify and minimize the risk factors for falls for Resident 86 placed them at risk for potential injury, negative outcomes and decreased quality of life.
Findings included .
Review of a facility's policy titled, Tab Alarms, Bed Alarms, Wanderguard System, dated 12/12/2024, showed the wanderguard (a wearable device used to monitor and alert caregivers when a resident with dementia or cognitive impairment attempts to leave a safe area) would be used for residents at risk for elopement (when a resident identified as wandering leaves the facility without staff knowledge or authorization). A plan of care must be formulated with the Interdisciplinary Team (Nursing, Physical Therapy, Occupational Therapy, Dietary, Activities, Social Worker and Resident/Family) to determine the need for the device and documented in the resident's care plan. In addition, the wanderguard bracelets were to be checked (monitored) daily.
Resident 94
Review of the quarterly Minimum Data Set (MDS, a required assessment tool), dated 01/01/2025, showed Resident 94 admitted on [DATE] with multiple diagnoses to include heart disease, stroke, dementia, anxiety and depression. The MDS showed the resident had significant level of cognition impairment and was dependent on staff for assistance with activities of daily living (ADLs)
Review of Resident 94's Elopement Risk, form, dated 11/25/2024, showed they were able to ambulate (walk) or self-propel a wheelchair independently, had a history of actual elopement or attempted elopement, and wandered to places that placed the resident at significant risk of getting to potentially dangerous places (i.e. outside the facility). An additional elopement assessment dated [DATE], conducted by a facility's Licensed Nurse (LN), had checked a box on the document that showed the resident exhibited a behavior that may result in exit -seeking behavior, - hovering near exits.
Review of Resident 94's current care plan, multiple dates, showed Resident 94 had impaired / decline in cognitive function impaired thought processes related to the condition, dementia, had short term memory loss, impaired decision making and had a wanderguard placed. Interventions included for staff LNs to ensure the wanderguard was functioning properly every shift.
Review of Resident 94's past incident reports showed on three separate occasions the resident had successfully eloped to outside the facility. On 11/24/2024 the resident had signed themselves out of the facility. Per the incident report the front door receptionist noted it was not a normal occurrence and called the nurse's station whereas a nurse came to assist and brought the resident back in from a sidewalk. A repeat elopement assessment was conducted on 11/25/2024 and the wanderguard was placed. The second elopement occurred on 01/06/2025 whereas the resident was found by a community member at a nearby apartment complex from the facility. The wanderguard was noted to be in place and was tested to be functional upon the resident's return; however, the document indicated the Alarm off. The third elopement incident was dated 01/18/2025 and a description of the event documented that another facility resident had called the nurse's station to inform staff that Resident 92 was walking away from the building. A nurse walked outside to retrieve the resident and brought them back inside. The resident's wanderguard was tested again and found to be functioning; however, the incident documented that the nursing staff had not heard the alarm that was set off from the facility's front door.
Review of Resident 94's treatment administration record (TAR) for December 2024 and January 2025 showed a provider's order dated 12/24/2024 for the LNs to check the function of the wanderguard every shift. Review of the December 2024 TAR wanderguard order showed the LN's had not documented they had checked (initialed) off the wanderguard was functional for evening and night shift. A continued review of the January 2025 TAR showed multiple dates throughout January of blank documentation entries that the LNs had checked the function of the resident's wanderguard. The January 2025 missing entries included 01/07/2025- (day shift), 01/08/2025- evening and night shift, 01/20/2025-day shift, 01/26/2025- evening and night shift, and 01/27/2025 evening shift.
During an interview and observation on 01/28/2025 at 10:57 AM, Staff N, Licensed Practical Nurse (LPN), was asked whether they had tested Resident 94's wanderguard on their shift yet and what the procedure they used to determine whether the device was functional. Staff N responded they had not tested the device today but stated they would usually place the resident into a wheelchair and wheel them to a nearby hallway exit door that had a wanderguard sensor receiver to test the device. Staff N stated the resident's wrist wanderguard would then be placed by the exit door sensor which would alarm. Staff N was observed to position the resident by the exit door sensor and held the resident's wrist with the wanderguard to and against the wanderguard door sensor; however, no alarm was generated or was audible. Staff N was directed to find a portable hand held wanderguard scanner (tester) and to test the resident's wanderguard. A portable handheld wanderguard scanner was eventually found after several minutes, but again this device also did not appear to generate a positive functionality test.
During an interview and observation on 01/28/2025 at 11:14 AM, Staff B, Director of Nursing (DNS), stated they would test a brand new wanderguard at the facility's front door. Staff B was then observed to pass the device by the facility's front of the door wanderguard sensor, however, no audible alarm was generated until Staff B passed the device a short distance pass the sensor toward the front or exterior portion of the door.
Observation on 01/28/2025 at 1:21 PM showed Staff B informed Staff N to remove Resident 94's wrist wanderguard. The resident's wanderguard was then re-checked by Staff B at the exit hallway door and an audible alarm was generated when it was passed through or out the door to the exterior (outside). Staff B stated the wanderguards were not to be checked in this manner, but rather with the handheld wanderguard scanner. Staff B directed Staff N to find another wanderguard scanner and one was found in another medication cart which achieved a positive functionality check and produced a green light flash.
During an interview on 1/28/2025 at 11:42 AM, Staff B, Director of Nursing Services (DNS), stated the expectation would be for Staff LNs to check and ensure the resident's wanderguard was functional as per the provider's orders every shift and document in the TAR. Staff B stated it was their expectation the LNs were knowledgeable and educated on the correct wanderguard testing procedures.
Resident 86
Review of the EHR showed Resident 86 was admitted to the facility on [DATE] with diagnoses to include intracranial hemorrhage in brain (bleeding in the brain), anxiety, depression and aphasia (inability to verbally communicate). Resident 86 was not able to communicate their needs.
Multiple observations on 01/23/2025 and 01/27/2025 showed Resident 86 sat in a tilt in space wheelchair in front of the nurse's station and frequently reached or gestured towards staff and passersby.
Review of EHR showed Resident 86 had 3 falls: on 11/13/2024 at 7:20 PM in the dining room, 12/22/2024 at 6:45 PM in the resident's room, and 01/17/2025 at 9:40 PM in the dining room.
Review of the fall investigation for the fall on 12/22/2024 showed a new intervention to assist the resident to bed after administration of evening medications.
Review of the care plan showed the intervention for the 12/22/2024 fall was not included in the resident's care plan and Resident 86 had a repeat fall in the dining room.
During an interview on 01/24/2025 at 1:14 PM, Staff R, Resident Care Manager, stated part of the process after a fall was to update the care plan.
Reference WAC 388-97-1060(3)(g)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to ensure the facility's Registered Dietician's (RD) recommendations...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to ensure the facility's Registered Dietician's (RD) recommendations were administered as ordered to prevent continued weight loss for 1 of 3 sample residents (Resident 73) reviewed for nutrition. This failure placed the residents at risk for unmet nutritional needs and continued weight loss.
Findings included .
Review of the quarterly Minimum Data Set (MDS, a required assessment tool) dated 12/12/2024 showed that Resident 73 admitted on [DATE] with diagnoses to include heart and lung disease, hospice (end of life care), dementia (progressive decline in brain functions), and malnutrition.
Review of the electronic health record (EHR) showed the resident was able to make needs known, received hospice care (care provided to sick or terminally ill residents), was dependent and required substantial/maximal assistance by staff to assist with meals.
Review of a Registered Dietitian (RD) assessment dated [DATE] showed Resident 73 would benefit from increased protein supplementation for increased needs due to newly identified pressure wounds (skin sores that develop due to prolonged pressure due to immobility and exacerbated by lack of essential nutrients like protein, vitamins and minerals). The RD documentation showed the resident had an order for the licensed nurses (LNs) to administer Med Pass 2.0 (a fortified nutritional shake, to supplement calories and protein) as necessary for supplementing the resident's intake when it was less than 50%. The RD assessment notes showed Resident 73 required one-on-one assistance with meals and would need continued assistance and encouragement for intake at meals and supplemental Med Pass 2.0 for better nutritional intake.
Review of Resident 73's current care plan, multiple dates, showed the resident was at nutritional risk due to poor food and fluid intake due to poor intake of fluids and food. Several interventions included for staff to provide the house supplement (Med Pass 2.0) as ordered.
Review of Resident 73's EHR task section for dietary intake showed the facility staff had documented multiple entries the resident had eaten less than 25-50% of their meals.
Review of Resident 73's December 2024 and January 2025 medication administration records (MARs) showed a provider's order dated 6/14/2024 for the LNs to administer
Med Pass 2.0 as needed for supplementing intake and optimizing nutrition if oral intake was less than 50% and to offer 240 milliliters (mls). The December 2024 and January 2025 MAR showed no documentation that the Med Pass 2.0 was administered to the resident.
Review of Resident 73's EHR clinical notes dated 12/29/2024, 01/01/2025, and 01/13/2025 showed the resident refused or ate 0% of the last three meals/snacks provided; however, the EHR showed no refusal or offer Med Pass 2.0 being documented as being offered. On 01/22/2025 an additional clinical note was documented by the RD for the order for Med Pass 2.0 for oral intake less than 50% and the resident's dietary intake remained poor, a new recommendation was made to change the med pass from as necessary to routine 120 ml twice a day to provide additional calories and protein to meals.
During an interview on 01/22/2025 at 12:55 PM, Resident 73's family member stated the resident had lost weight and had observed the facility staff appeared to be rushed during mealtimes whenever they (facility staff) were to feed the resident.
During an interview on 01/23/2025 at 2:42 PM, Staff E, Licensed Practical Nurse (LPN), stated the expectation would be the Certified Nurse Aide (CNA) who assisted with feeding the resident and who had recorded their intake less than 25-50% intake would inform the LN. The expectation then would be for the LN to administer the as necessary (PRN) Med Pass nutritional supplement as ordered.
During an interview on 01/23/2025 at 2:45 PM, Staff C, Assistant Director of Nursing (ADON), stated if the resident had a poor intake (less than 25%) and was recorded it would then show up on the resident's EHR dashboard to update the LN who could then provide the needed intervention (Med pass nutritional supplementation) as indicated in the resident's PRN orders.
During a telephonic interview on 01/30/2025 at 11:15 AM, Staff G, RD, stated their expectation would be for the LN to administer and document the resident's Med Pass supplement as ordered whenever the resident had less than 50% of their dietary intake.
Reference WAC 388-97-1060 (3)(h)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with provider o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with provider orders for 1 of 2 sampled residents (Resident 59) reviewed for respiratory care. Failure to follow provider's orders for oxygen (O2) therapy placed residents at risk for unmet needs and potential negative outcomes.
Findings included .
Review of the electronic health record (EHR) showed Resident 59 admitted to the facility on [DATE] with diagnoses that included dementia (a condition affecting memory, thinking and social abilities) and asthma. Resident 59 used oxygen therapy.
Review of current provider orders, dated January 2025, showed Oxygen at 1-2 liters per minute by nasal canula every day and night shift.
Observations throughout the day on 01/23/2025 and 01/24/2025 showed an unused O2 concentrator with no oxygen tubing in the corner of the room. Resident 59 was not observed wearing a nasal canula or using oxygen.
During an interview on 01/24/2025 at 1:03 PM, Resident 59 stated they had not used oxygen while admitted to the facility.
Review of the January 2025 Medication Adminstration Record showed staff signed off daily that Resident 59 was utilizing oxygen as ordered.
During an interview on 01/24/2025 at 1:07 PM, Staff U, Registered Nurse (RN), stated they had signed the oxygen was administered on 01/24/2025 and in the past because the Resident 59's O2 saturation levels were always above 92%.
During an interview on 01/24/2025 at 1:18 PM, Staff B, Director of Nursing (DNS), stated the expectation was that the provider orders were followed, and staff should not have been signing if the resident was not using the oxygen.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to provide pain medication per provider's order to ensure a resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to provide pain medication per provider's order to ensure a resident was able to participate in physical therapy services for 1 of 5 sampled residents (Resident 24) reviewed for position and mobility. This failure placed residents at risk of decreased mobility, increased pain, unidentified and unmet care needs, and a diminished quality of life.
Findings included .
Review of the facility's document Pain Protocol, dated October 2022, showed the nursing staff would assess each individual for pain upon admission to the facility, at the quarterly review, whenever there was a significant change in condition, and when there was onset of new pain or worsening of existing pain.
Review of the electronic health record (EHR) showed Resident 24 admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (a chronic neurological disorder), pressure ulcer of right hip (a deep wound that may impact muscle, tendons, ligaments, and bone), chronic pain (pain lasting three months or longer), paraplegia (weakness or paralysis to the lower limbs), muscle weakness, need for assistance with personal care, pain in joints of right hand, and contracture (a permanent tightening of the muscles) of the right hand.
Review of the quarterly minimum data set (MDS, an assessment tool), dated 12/16/2024, showed Resident 24 was able to make needs known.
Review of the care plan dated 06/08/2017 showed, Evaluate and medicate for pain, as appropriate, prior to activity or rehabilitation program.
Review of the provider's orders showed Resident 24 had an order for a fentanyl patch (a pain medication) every 72 hours, dated 05/29/2024, an order for oxycodone (a pian medication) every 6 hours, dated 06/19/2023, and an order for morphine sulfate (a pain medication) every 8 hours as needed for pain, dated 02/21/2024.
Review of the EHR showed Resident 24's last pain assessment was completed on 03/26/2024.
Review of the restorative flow sheets (tracking of services to exercise joints) showed Resident 24 refused the restorative program multiple times due to pain during October 2024, November 2024, and December 2024. Review showed the resident refused services due to pain on the following dates: 10/22/2024, 10/24/2024,10/31/2024, 11/06/2024, 11/07/2024, 11/11/2024, 11/12/2024, 11/16/2024, 12/10/2024, 12/11/2024, 12/12/2024, 12/16/2024, 12/19/2024, and 12/24/2024.
Review of the October 2024, November 2024, and December 2024 medication administration record (MAR) showed pain medication was not administered to Resident 24 for 12 of the 14 refusals for pain or discomfort. Review showed non-pharmacological interventions (methods to reduce pain without medication) were not offered to Resident 24 for pain for these refusals.
Review of the January 2025 MAR showed out of 19 occurrences of pain rated 6-8 (moderate to severe pain), Resident 24 was not offered pain medication or non-pharmacological interventions for 15 occurrences.
During an interview on 01/27/2025 at 10:57 AM, Staff E, Licensed Practical Nurse (LPN), stated if a resident refused care due to pain, they would educate and have conversations with the resident. Staff E stated the staff would offer as needed pain medication or cream.
During an interview on 01/27/2025 at 1:38 PM, Staff M, Certified Nursing Assistant (CNA), stated the resident had pain with their care often and they reported it to the nurse when it occurred.
During an interview on 01/27/2025 at 2:39 PM, Resident 24 stated if they had pain during care, they would notify staff by using their call light and the nurse would bring their pain medication. Resident 24 stated if they had pain during restorative and therapy sessions, they massaged the painful area and tried to get through the pain. Resident 24 stated they felt their pain medications were not effective enough to control their pain and felt the pain medication was starting to wear off.
During an interview on 01/28/2025 at 10:00 AM Staff K, Director of Rehabilitation Services, stated Resident 24 complained of tightness in their joints, and not pain. Staff K stated Resident 24's wound caused discomfort, and the resident refused full range of motion due to their pain.
During an interview on 01/28/2025 at 10:14 AM, Staff C, Assistant Director of Nursing (ADON), stated if a resident consistently refused therapy due to pain, the staff would talk with the resident, assess if pain was a potential concern, and inform therapy.
During an interview on 01/28/2025 at 10:16 AM Staff B, Director of Nursing, stated staff would perform a pain assessment for a change in condition or a change in pain level.
During an interview on 01/28/2025 at 11:38 AM, Staff L, LPN, stated if a resident refused their restorative program due to pain, the nurses would assess pain levels and administer as needed pain medications.
During an interview on 01/28/2025 at 2:38 PM, Staff C, ADON, stated Resident 24 should have been offered pain medication before their restorative or therapy sessions. Staff C stated Resident 24 should be offered pain medications when they complained of pain.
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
**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...
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**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 and/or to have clearly documented rationale for not following the recommendation for 1 of 5 sampled residents (Resident 92) reviewed for unnecessary medication use. This failure placed the resident at risk for experiencing adverse side effects, medical complications, and a decreased quality of life.
Findings included .
Review of the electronic health record (EHR) showed Resident 92 admitted to the facility on [DATE] and was able to make needs known. The quarterly minimum data set assessment (MDS), an assessment tool, dated 12/19/2024 showed Resident 92 had diagnoses of depression, anxiety disorder, and insomnia (sleeplessness).
Review of Resident 92's provider orders showed an order dated 09/19/2024 for Clonazepam (antianxiety medication) 0.5 milligrams (mg) two times a day for anxiety and an order dated 11/15/2024 for Zolpidem Tartrate (a hypnotic medication used to treat sleeplessness/insomnia) 5 mg as needed for severe intermittent insomnia at bedtime for six months.
Review of Resident 92's pharmacist consultation report recommendation from 10/09/2024 through 10/10/2024, signed by the provider on 10/18/2024, showed to reduce future risk of falls consider the recommendation to reduce clonazepam to 0.5 mg to once a day in the evening with future discontinuation of the medication, if able. The form showed the provider declined the recommendation and did not wish to implement any changes due to a handwritten note that showed working with mental health has the rest of the sentence was not legible.
Review of Resident 92's pharmacist consultation report recommendation from 11/11/2024 through 11/13/2024, signed by the provider but not dated, showed Resident 92 had an order for Zolpidem Tartrate 5 mg one tablet by mouth as needed for sleeplessness/insomnia. It showed to consider discontinuing the as needed (PRN) Zolpidem or if the medication could not be discontinued at that time, document the indication for use, the intended duration of therapy, and the rationale for the extended period. Review showed an example as X [times] 6 months for severe intermittent insomnia. The rationale for the recommendation showed, CMS [Centers for Medicare and Medicaid Services] requires that PRN orders for non-antipsychotic psychotropic drugs be limited to 14 days unless the prescriber had required documentation for extended use. It showed the provider accepted the recommendation with the following modifications, See Attachment However, there was no form attached to the report.
Review of Resident 92's form tiled, PRN Psychotropic Review, signed by the provider on 11/15/2024, showed the rationale to extend Zolpidem 5 mg six months was due to a Failed GDR. [Gradual dose reduction, a trial to discontinue or reduce medication use] Severe intermittent insomnia. This document did not show directions for the medication (i.e. frequency or route the medication was to be provided).
Review of Resident 92's January 2025 medication administration records (MAR) from 01/01/2025 - 01/23/2025 showed the resident was provided clonazepam 0.5 mg two time a day for anxiety and PRN Zolpidem Tartrate 5 mg by mouth for severe intermittent insomnia at bedtime for 6 months. Documentation showed Resident 92 received Zolpidem 10 out of 23 days.
During an interview on 01/24/2025 at 12:12 PM, Staff E, Licensed Practical Nurse (LPN), stated Resident 92 admitted to the facility on [DATE] and they were unable to locate documentation in Resident 92's EHR that a GDR for Zolpidem Tartrate had been conducted. Staff E stated there should have been documentation to clearly show that a GDR was done for Zolpidem; however, the provider scripts (instruction orders for the medication) showed the order had been used continuously.
During an interview on 01/24/2025 at 1:30 PM, Staff B, Director of Nursing Services, stated they were unable to locate documentation in the mental health provider note dated 10/12/2024 that showed Resident 92's Clonazepam use was discussed/reviewed for a GDR. Staff B stated Resident 92 was being provided Clonazepam twice a day and the provider note dated 10/19/2024 did not address the pharmacy recommendation for a decrease in Clonazepam. Staff B stated they needed to obtain provider clarification for the rationale of not following pharmacy's October 2024 recommendation and this should have been clarified and addressed sooner.
In continued interview on 01/24/2025 at 1:30 PM, Staff B stated Resident 92 received as needed Zolpidem Tartrate regularly in November and December 2024 and continued to receive it in January 2025. Staff B stated they were unable to locate documentation to show a GDR was conducted for Zolpidem Tartrate per Resident 92's November 2024 pharmacy recommendation and this did not meet expectations.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to conduct gradual dose reduction (GDR, a trial attempt to discontin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to conduct gradual dose reduction (GDR, a trial attempt to discontinue a medication) were free from excessive dosages and durations without adequate monitoring and indications for use, or in the presence of adverse consequences, related to the use of psychoactive (affecting the mind) medications for 1 of 5 sampled residents (Resident 94) and failed to monitor for psychoactive medication side effects for 2 of 5 sampled residents (Residents 87 and 92) when reviewed for unnecessary medication use. The facility's failure to monitor behaviors and side effects and conduct GDR related to use of psychoactive medications placed the residents at risk for adverse side effects, medical complications, and a diminished quality of life.
Findings included .
<Gradual Dose Reduction>
Review of a policy titled, Tapering Medications and Gradual Drug Dose Reduction, dated July 2022, showed after medications were ordered for a resident, the staff and provider shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences. All medications shall be considered for possible tapering. Tapering that are applicable to psychotropic (affecting the mind) medications were to be referred to as GDRs. Residents who used psychotropic medications shall receive GDRs and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.
Resident 94
Review of the quarterly minimum data set (MDS, a required assessment tool), dated 01/01/2025, showed Resident 94 admitted on [DATE] with multiple diagnoses to include heart disease, stroke, dementia, anxiety, and depression. The MDS showed the resident with significant level of cognition (brain) impairment and was dependent on staff for assistance with activities of daily living (ADLs).
Review of Resident 94's January 2025 medication administration record (MAR) showed a provider had ordered two psychotropic medications: Clonazepam (a psychotropic medication used to prevent and treat anxiety disorders) on 10/07/2024 and duloxetine (a psychotropic medication used to treat depression) ordered on 10/08/2024.
Review of Resident 94's current care plan showed the resident was at risk for complications related to the use of psychotropic medications: duloxetine and clonazepam. The goal was for the resident to have the smallest most effective dose without side effects. Interventions included for licensed staff to conduct a GDR as ordered and obtain a psychiatrist evaluation (a meeting with a psychiatrist to evaluate a resident's mental health and develop a treatment plan) as ordered.
During an interview on 01/28/2025 at 12:37 PM, Staff S, Social Services Director (SSD), stated the facility staff had held a recent interdisciplinary (IDT) meeting that discussed Resident 94's behavioral health needs, and a report was forwarded to the Director of Nursing Services.
Review of Resident 94's electronic health record (EHR) showed no GDR was conducted since admission or a psychiatrist evaluation.
During an interview on 01/28/2025 at 1:13 PM, Staff C, Assistant Director of Nursing (ADON), stated Resident 94, when initially admitted to the facility, was placed into hospice and their behavioral health (BH) services dropped off and there was no follow through with BH/GDRs. Staff C stated when the resident graduated from hospice services, the BH service was never restarted but it should have been.
<Behavioral/Side Effect Monitoring>
Resident 87
Review of EHR showed Resident 87 admitted to the facility on [DATE] with diagnoses to include dementia (a condition affecting memory, thinking and social abilities). Resident 87 required moderate assistance and was able to make needs known.
Review of Resident 87's current physician's orders, January 2025, showed an order for risperidone (an antipsychotic medication).
Review of the December 2024 and January 2025 MAR showed staff were to check orthostatic blood pressure twice monthly related to the use of the risperidone when lying and sitting. Review showed no documented blood pressure readings.
During an interview on 01/27/2025 at 2:00 PM, Staff B, Director of Nursing Services (DNS), stated the expectation was that staff were obtaining and documenting orthostatic blood pressures for those residents who were receiving antipsychotic medication.
Resident 92
Review of the EHR showed that Resident 92 admitted to the facility on [DATE] and was able to make needs known.
Review of the quarterly MDS dated [DATE] showed Resident 92 had diagnoses of atrial fibrillation (irregular heart rate), high blood pressure, insomnia (sleeplessness), and received a hypnotic medication (used to include sleep).
Review of Resident 92's provider's orders showed an order dated 11/15/2024 for Zolpidem Tartrate (hypnotic medication) as needed for severe intermittent insomnia at bedtime. An order dated 09/19/2024 showed to monitor side effects related to hypnotic drug use with side effects listed every shift. An order dated 09/19/2024 showed to Monitor hours of Sleep 6+ hours at night for hypnotic drug use, document non-drug interventions used and showed listed non-pharmacological interventions, every shift, and document results if (+) effective or (-) ineffective every shift.
Review of Resident 92's January 2025 MAR from 01/01/2025 - 01/24/2025 showed Zolpidem Tartrate was provided 10 times out of 23 opportunities. It showed the order to monitor side effects had a Y documented four times; however, it did not show which side effect from the list was observed. It showed the order to monitor (#, number) of hours of slept all had 0 (zero) documented for all shifts, and it showed non-drug interventions were documented 0 or NA (not applicable) and area for results (R) showed 0 or NA documented.
During an interview on 01/27/2025 at 9:26 AM, Staff E, Licensed Practical Nurse (LPN), stated Resident 92's January 2025 MAR showed the resident had side effects four times but did not show what the side effects were and should have. Staff E stated that hours of sleep were not documented on the January 2025 MAR and should have been. Staff E stated that non-pharmacological interventions were documented 0 or NA even though Resident 92 received the hypnotic medication 12 times, and this did not meet expectations.
During an interview on 01/27/2025 at 9:39 AM, Staff B, Director of Nursing Services (DNS), stated Resident 92's documentation for monitoring hypnotic medication use, to include side effects, non-drug use interventions, and hours of sleep, did not did not meet expectations.
Reference WAC 388-97-1060(3)(k)(i)
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to have psychotropic medication (medications that affec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to have psychotropic medication (medications that affect a person's mental state) consents completed, signed, and in place prior to residents receiving these medications for 3 of 5 sampled residents (Residents 92, 87, and 2) reviewed for unnecessary medication use. This failure placed the resident or their legal representatives at risk for lack of knowledge to make an informed decision regarding the use of the medication, adverse side effects, and a diminished quality of life.
Findings included .
Resident 92
Review of the electronic health record (EHR) showed Resident 92 admitted to the facility on [DATE] and was able to make needs known. The quarterly minimum data set assessment (MDS), an assessment tool, dated 12/19/2024, showed Resident 92 had diagnoses of depression, anxiety disorder, and insomnia (sleeplessness).
Review of Resident 92's January 2025 medication administration records (MAR) from 01/01/2025 - 01/23/2025 showed the resident was prescribed and provided Zolpidem Tartrate (a hypnotic medication used to induce sleep) as needed for severe intermittent insomnia and Escitalopram Oxalate (an antidepressant medication) one time a day for depression.
Review of Resident 92's psychotropic medication administration disclosure/informed consent dated 09/19/2024 for Zolpidem Tartrate showed an area to document the frequency the medication should be provided; however, the frequency was not documented.
Review of Resident 92's EHR showed no consent was completed and in place for the use of Escitalopram Oxalate.
During an interview on 01/24/2025 at 12:12 PM, Staff E, Licensed Practical Nurse (LPN), stated an informed consent was to be obtained prior to a resident being provided a psychotropic medication. Staff E stated Resident 92's informed consent for Zolpidem Tartrate should have had the frequency of the medication documented. Staff E stated they were unable to locate an informed consent for the use of Resident 92's provider ordered Escitalopram Oxalate medication and there should have been one obtained.
During an interview on 01/24/2025 at 1:30 PM, Staff B, Director of Nursing Services (DNS), stated Resident 92's consent for Zolpidem Tartrate was missing the frequency and it should have been documented on the form. Staff B stated they were unable to locate a consent for Resident 92's Escitalopram Oxalate medication and this did not meet expectations.
Resident 87
Review of EHR showed Resident 87 admitted to the facility on [DATE] with diagnoses to include dementia (a condition affecting memory, thinking and social abilities). Resident 87 required moderate assistance and was able to make needs known.
Review of EHR showed Resident 87 had a provider's order dated 01/20/2025 for risperidone (an antipsychotic medication). Review showed no consent was on file for the medication.
Review of Resident 87's January 2025 MAR showed the resident was received risperidone per provider's orders.
During an interview on 01/27/2025 at 1:56 PM, Staff B, DNS, stated they were unable to locate any documentation related to the consent. Staff B stated the expectation was that a signed consent or verbal acknowledgement should be on file prior to administration of antipsychotic medications.
Resident 2
Review of the EHR showed Resident 2 was admitted to the facility on [DATE] with diagnoses to included diabetes (high sugar in the blood), heart failure, depression and suicidal ideations. Resident 2 was able to communicate needs.
During an interview on 01/22/2025 at 12:20 PM, Resident 2 stated, I wish I can talk to someone with sad facial expression and no eye contact.
Review of provider's orders showed an order for Trazodone (an antidepressant medication) dated 11/25/2024 to be given for insomnia.
Review of the EHR showed no verbal or written consent obtained prior administration of this medication.
During an interview on 01/27/2025 at 12:43, Staff R, Resident Care Manager, was not able to find consent for the medication.
Reference WAC 388-97-1020(4) (a-b)
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to obtain provider's order, assessment and consent for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to obtain provider's order, assessment and consent for the use of low bed for 3 of 3 sampled residents (Residents 86, 74 and 89) reviewed for use of physical restraints. This failure placed the residents at risk for injury, unmet needs and a diminished quality of life.
Findings included .
Review of the facility's policy titled Use of Restraints, revised April 2017, showed, (1) Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body [ .] (9) Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative.
Resident 86
Review of the electronic health record (EHR) showed Resident 86 was admitted to the facility on [DATE] with diagnoses to include intracranial hemorrhage in brain (bleeding in the brain), anxiety, depression, and aphasia (inability to verbally communicate). Resident 86 was not able to communicate their needs. Resident 86 was assessed to be a fall risk and required the assistance of staff for mobility.
Observation on 01/22/2025 at 9:15 AM, showed Resident 86 in their room laying on a bed that was lowered to the floor.
Review of Resident 86's care plan showed an intervention bed in low position initiated on 08/26/2024.
Review of Resident 86's EHR showed no consent, order, or assessment about the low bed.
Resident 74
Review of the EHR showed Resident 74 was admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), depression, and osteopenia (a condition that occurs when the body doesn't make new bone as quickly as it reabsorbs old bone). Resident 74 was assessed to be a fall risk and required the assistance of staff for mobility.
Observation on 01/24/2025 at 10:22 AM showed Resident 74 in a low bed in their room.
Review of the Resident 74's EHR showed no order, assessment, or consent for the use of the low bed.
Resident 89
Review of the EHR showed Resident 89 was admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety, and palliative care (approach aimed at optimizing quality of life). Resident 89 was assessed to be a fall risk and required the assistance of staff for mobility.
Observation on 01/24/2025 at 10:15 AM showed Resident 89 in a low bed in their room.
Review of the Resident 89's EHR showed no order, assessment, or consent for the use of the low bed.
During an interview on 01/28/2025 at 10:19 AM, Staff B, Director of Nursing Services, stated a low bed could be considered a restraint and needed to have consent, assessment, order and care plan. Staff B stated the lack of these on the above-mentioned residents did not meet expectations.
This is a recurring deficiency previously cited in the Statement of Deficiencies dated 12/05/2024.
Reference WAC 388-97-0620
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 77
Review of the EHR showed Resident 77 admitted to the facility on [DATE] and was able to make needs known. The quarte...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 77
Review of the EHR showed Resident 77 admitted to the facility on [DATE] and was able to make needs known. The quarterly MDS, dated [DATE], showed Resident 77 had diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning), depression, and osteoarthritis (a condition that causes pain, stiffness, and reduced movement in the joints).
During an interview on 01/22/2025 at 11:50 AM, Resident 77 stated about five months ago a man creeped into their room, the man had a mental problem, and staff were aware.
During a follow-up interview on 01/23/2024 at 10:04 AM, Resident 77 stated about six months ago they heard the door to their room shaking, a white man with white hair kicked the door open, they told the man to get out, and they told staff about it.
Review of the facility's incident reporting log from August 2024 through January 24, 2025, showed no incident logged for a resident-to-resident altercation for Resident 77.
Review of the facility's grievance/concern log from August 2024 through January 20, 2025, showed no grievance/concern logged for a resident-to-resident altercation for Resident 77.
Review of Resident 77's provider progress note dated 10/02/2024 showed, On 9/28/2024, [Resident 77] had a verbal altercation with a patient with Alzheimer's who attempted to enter [Resident 77's] room without permission.
During an interview on 01/27/2025 at 10:08 AM, Staff E, Licensed Practical Nurse (LPN), stated if a resident-to-resident altercation occurred related to a resident trying to enter another resident's room without their permission then an incident report investigation should be implemented, both residents placed on alert charting, and be monitored for psychological harm related to the intruder. Staff E stated care plans should be updated with interventions to prevent further occurrence. Staff E stated they did not know if Resident 77's incident on 09/28/2024 was investigated; however, Resident 77's care plan showed no new interventions related to that altercation or for an intruder and there should have been some type of interventions after the incident. Staff E stated that Resident 77's 09/28/2024 resident-to-resident altercation should have been investigated.
During an interview on 01/27/2025 at 10:31 AM, Staff B, DNS, stated Resident 77's resident-to-resident altercation incident on 09/28/2024 did not appear to have been investigated. Staff B stated it should have been investigated and risk management opened. Staff B stated they would have needed to know if Resident 77 was fearful at the time because they knew the resident had a history of trauma that could play into the situation. Staff B stated they did not see any interventions related to preventing an intruder or related to a resident-to-resident altercation and there should have been.
During an interview on 01/27/2025 at 1:57 PM, Staff A, Administrator, stated they did not recall Resident 77's 09/28/2024 incident or that an incident report or grievance was logged for Resident 77's resident-to-resident altercation on 09/28/2024.
Resident 360
Review of the EHR showed that Resident 360 admitted to the facility on [DATE] with diagnoses to include a broken left upper thigh bone, kidney disease, and Crohn's disease (a bowel disease that affects the lining of the digestive tract and can cause stomach cramping and pain). Resident 360 was able to make needs known.
During an interview on 01/29/2025 at 9:36 A, Resident 360 stated when they first arrived at the facility they were upset because they had an issue with getting their as needed pain medication and staff were aware of it.
Review of Resident 360's provider telehealth visit progress note dated 01/15/2025 at 6:28 PM showed that Resident 360 had informed the provider that they had not received their pain medication since 7:00 AM this morning. It further showed Resident 360 had admitted to the facility on [DATE] from the hospital and took Dilaudid (a medication used to treat moderate to severe pain) for back and leg pain; however, no script was sent from the hospital. It showed the plan was a prescription for Dilaudid 4 milligrams (mg) orally every three hours as needed Dispense: 4 tablet, Refills: 0.
Review of Resident 360's January 2025 medication administration record (MAR) showed an order for Dilaudid oral tablet 4 mg give 1.5 tablet by mouth every three hours as needed for pain with a start date of 01/14/2025 at 4:00 PM and it was discontinued on 01/15/2025 at 7:50 PM. It showed another order for Dilaudid oral tablet 4 mg give one tablet by mouth every three hours as needed for pain with a start date of 01/14/2025 at 4:00 PM and it was discontinued on 01/15/2025 at 7:50 PM; however, documentation showed that the medication Dilaudid was never provided.
Review of Resident 360's EHR on 01/28/2025 showed no explanation as to why the resident did not receive the as needed pain medication Dilaudid per provider's orders or documentation to show potential neglect related to not receiving the as needed pain medication had been investigated.
During an interview on 01/29/2025 at 11:14 AM, Staff E, LPN, stated they did not see follow-up documentation related to Resident 360's 01/15/2025 provider telehealth visit progress note that showed the allegation of not receiving as needed pain medication had been addressed and it should have been. Staff E stated there should have been an investigation to rule out neglect.
During an interview on 01/29/2025 at 11:31 AM, Staff B, DNS, stated they were not aware of the provider telehealth visit progress note dated 01/15/2025 that showed Resident 360 reported not receiving their as needed pain medication. Staff B stated no incident was logged as reported for Resident 360's telehealth visit incident, and this did not meet expectations. Staff B stated that Resident 360's allegation should have been investigated.
Based on interview and record review, the facility failed to identify and investigate allegations of abuse/neglect for 6 of 7 sampled residents (Residents 78, 48, 77, 360, 2, and 66) when reviewed for abuse/neglect. These failures placed residents at risk of continued abuse/neglect and a diminished quality of life.
Findings included .
Review of facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated September 2022, showed all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management . 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediatly to the administrator and other officials according to state law. 2. The administrator or individual making the allegation immediatly reports his or her suspicion to the following persons or agencies: the state licensing/certification agency, local/state ombudsman, resident's representative, adult protective services, law enforcement officals, the resident's attending physician and the facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury . All allegations are thoroughly investigated. The administrator initiates investigations.
Review of a facility policy titled, Accidents and Incidents - Investigating and Reporting, dated July 2017, showed all accidents or incidents involving residents, employees, visitors, vendors, etc, occurring on premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident.
Resident 78
Review of the electronic health record (EHR) showed Resident 78 admitted to the facility on [DATE] with diagnoses of palliative care (end-of-life), osteomyelitis (infection of the bone), and diabetes (too much sugar in the blood). Resident 78 was able to make needs known.
Review of the care plan, initiated 08/02/2024, showed Resident 78 was dependent on staff for transfers in/out of bed with a mechanical lift.
During an interview and observation on 01/22/2025 at 10:46 AM, Resident 78 stated they were left in their power wheelchair for three nights because the facility could not locate a piece of equipment needed to transfer them into bed. Resident 78 stated they would not be left in the same situation, so they always kept the equipment in bed with them. Observation showed Resident 78 took a piece of metal with pins out from under the covers.
Review of the facility's accident/incident log showed no entry for this event.
During an interview on 01/29/2025 at 11:34 AM, Staff P, Certified Nursing Assistant (CNA), stated Resident 78 had told them the mechanical part was missing, and they were sleeping in their power wheelchair at night. Staff P stated they reported the incident to Staff N, Licensed Practical Nurse (LPN).
During an interview on 01/29/2025 at 12:14 PM, Staff N, LPN, stated they were on vacation during the time Resident 78 was sleeping in their wheelchair at night. Staff N stated Resident 78 required a special part to be able to use the mechanical lift because the resident was an amputee. Staff N stated when told of Resident 78's allegation the staff checked on Resident 78's wounds to ensure they had not worsened, located the missing piece of equipment, then transferred Resident 78 into bed. Staff N stated they considered Resident 78's statements to be an allegation of neglect, and they had spoken with Staff B, Director of Nursing Services (DNS), about the allegations.
During an interview on 01/29/2025 at 12:18 PM, Staff B, DNS, stated they were aware of an issue of locating the mechanical equipment needed to transfer Resident 78. Staff B stated the mechanical piece was located and new ones were ordered. Staff B stated an investigation was not initiated, a grievance was completed for the event, and they were unaware Resident 78 had stated they slept in their wheelchair for three nights.
During an interview on 01/29/2025 at 12:31 PM, Staff F, Social Services, stated when the facility received an allegation of abuse/neglect the DNS was informed and an investigation was conducted. Staff F stated Resident 78 made an allegation of neglect when they filled out a grievance form and put it in the social services grievance box. Staff F stated they informed Staff B, DNS, of the allegations and had assumed an investigation was started.
Review of the Grievance/Complaint Resolution Report, dated 01/19/2025, showed Resident 78 had completed a grievance form with the nature of the complaint/concern as missing equipment for transfers to bed, three days slept in wheelchair, and no bandage change because of lack of transfer. Department findings showed the concern was received on 01/23/2025 and the resolution was the equipment was located, a review of wound care, and new equipment was ordered. The grievance did not identify the concern being an allegation of neglect and was completed on 01/23/2025.
During an interview on 01/29/2025, Staff B, DNS, stated allegations of abuse/neglect should be reported to the DNS and the resident should be protected from further abuse/neglect while an investigation was conducted. Staff B stated being left in a wheelchair to sleep for three nights would be considered an allegation of neglect. Staff B stated Resident 78 wrote the allegation on a grievance on 01/19/2025, but the social services department did not check the box it was placed in until 01/23/2025. Staff B stated staff responded to the allegation by ensuring wound care had been provided and the mechanical equipment had already been located by the time the grievance was reviewed. Staff B stated an investigation should have been more thorough to rule in/out neglect.
Resident 48
Review of the quarterly minimum data set assessment (MDS) dated [DATE], showed Resident 48 readmitted on [DATE] with multiple diagnoses to include heart and lung disease, quadriplegia (paralysis or loss of ability to move all four limbs), anxiety, and depression. The MDS showed Resident 48 was able to make needs known, used an electric power wheelchair for mobilization, and was dependent on staff for activities of daily living.
During an interview on 01/22/2025 at 2:35 PM, Resident 48 stated the facility staff had removed them from their electric wheelchair recently and placed them into a manual wheelchair due to a safety issue. Resident 48 stated a staff at the facility saw them in the middle of the road while they used their electric power wheelchair for transportation. The resident further stated they were not in the middle of the road but were driving on the side of the road and wanted their electric wheelchair back because the manual one they currently were in was uncomfortable and it did not fit their body correctly.
Review of Resident 48's progress note dated 1/13/2025 showed a nursing note that documented, This morning at appox. 0850 (AM), Resident (48) was observed in a power wheelchair in roadway going toward cul de sac (street) area with bus and another car behind the resident. Reported to DNS (Director of Nursing). Referral to physical therapy for power wheelchair assessment for safety evaluation.
Review of a Resident 48's document titled, Resident Agreement: Rules for Safe and Effective Operation of Power Mobility Device (PMD) dated 10/21/2024 showed a signed form that documented the resident understood when operating the PMD, it was only to be operated on sidewalks and special care taken on driveways and car thoroughfares. An additional form dated 10/21/2024 showed Resident 48 had a power-mobility driving assessment / education tool conducted at the facility and displayed adequate skill and safety to utilize a power mobility device inside and outside the facility.
Review of the facility's incident log entries for 1/13/2025 to 1/22/2025 showed no incident was documented that was related to Resident 48's recent electric wheelchair safety incident that was used for their transportation on a roadway.
During an interview on 01/24/2025 at 8:50 AM, Staff K, Director of Rehabilitation (DOR), stated a facility staff had witnessed Resident 48 operating their electric power wheelchair in an unsafe manner and that it was removed from them and a manual wheelchair was temporarily provided until an evaluation could take place and an interdisciplinary (IDT) meeting held to discuss the electric power wheelchair plan.
During an interview on 01/24/2025 at 9:05 AM, Staff C, Assistant Director of Nursing (ADON), stated that they probably should have done an incident report on Resident 48's poor safety judgment (unsafe electric wheel operation in a roadway); however, they just conduct an interdisciplinary meeting note.
During an interview on 01/24/2025 at 9:18 AM, Staff B, DNS, stated the unsafe operating of an electric wheelchair incident (operating a power wheelchair by Resident 48 in the middle of a road and in front of a bus) should have had an incident report generated and placed into the state log to address it immediately so that a thorough investigation was conducted.
Resident 66
Review of the EHR showed Resident 66 was admitted to the facility on [DATE] with diagnosis to include fracture of right tibia (shin bone), diabetes (high blood sugar) and colostomy (surgically created opening in the abdomen through which waste from large intestine can be expelled). Resident 66 was able to communicate needs.
During an interview on 01/22/2025 at 9:26 AM, Resident 66 stated they were left uncovered for about 45 minutes the previous day, it was cold, the nurse was snippy, and it took a long time to get pain medication. Resident 66 stated they reported this to the night shift nurse who covered them with a blanket.
Review of the incident log and grievance log for January 2025 on 01/27/2025 showed no investigation logged under Resident 66's name.
During an interview on 01/27/2025 at 10:28 AM, Staff F, Social Service, stated the night nurse should have reported the allegation and followed the facility protocol for allegations.
Resident 2
Review of the EHR showed Resident 2 was admitted to the facility on [DATE] with diagnoses to included diabetes, heart failure, depression, and suicidal ideations. Resident 2 was able to communicate needs.
During an interview on 01/22/2025 at 12:13 PM, Resident 2 stated the staff were unkind, they talked loudly, and said nasty things that the resident could hear. When Resident 2 was asked if they reported this to the staff, Resident 2 stated No, because when I did last time, I got people riled up.
Resident 2's statements were reported to Staff A, Administrator, on 01/22/2025 at 3:10 PM.
Review of the incident log and grievance log for January 2025 on 01/27/2025 showed no investigation logged under Resident 2's name.
During an interview on 01/27/2025 at 10:30 AM, Staff F, Social Services, stated when there was an allegation from a resident, other residents were interviewed and an investigation was initiated.
During an interview on 01/27/2025 at 12:25 PM, Staff R, Resident Care Manager, stated the process when there was an allegation from a resident was to fill out a grievance and the number one priority was to make sure the resident was safe.
During an interview on 01/29/2025 at 8:32 AM, Staff B, DNS, stated they were not aware of the allegations, and it should have been identified and reported.
Reference WAC 388-97-0640(5)(a)
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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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to ensure an ordered intervention (Low Air Loss Mattre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to ensure an ordered intervention (Low Air Loss Mattress - LALM, a mattress used to redistribute pressure evenly and can help prevent pressure ulcers, also known as bedsores) was being monitored and used as directed in the prevention of pressure ulcers for 3 of 7 residents (Residents 73, 83, and 18) when reviewed for pressure wound related interventions. This failure prevented the facility implementing the plan of care that included the needed intervention (LALM) to promote wound healing and prevent decline.
Findings included .
The National Pressure Ulcer Advisory Panel (NPUAP) dated 02/20/18, described/defined that a suspected deep tissue injury as: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This injury can result from prolonged pressure and may either resolve or develop into further tissue loss.
Findings included .
Review of the quarterly Minimum Data Set (MDS, a required assessment tool) dated 12/12/2024 showed Resident 73 admitted on [DATE] with diagnoses to include heart and lung disease, hospice (care provided to sick or terminally ill residents), dementia, and malnutrition. The electronic health record (EHR) showed the resident was able to make needs known, received hospice care, was dependent on staff for all activities of daily living (ADLs) and had pressure ulcers to buttocks area and both heels.
Review of Resident 73's provider's order dated 01/17/2025 showed licensed nurses (LNs) were to monitor functioning and setting of LALM every shift. Resident 73's treatment administration record (TAR) showed LNs were documenting they were monitoring functioning and the settings of the LALM every shift.
Review of the care plan, dated 11/14/2024, showed Resident 73 had actual skin breakdown to the sacral (buttocks area) related to decreased activity, limited mobility and generalized weakness. Several interventions to assist in healing the resident's wound skin impairment included for the use of an air mattress for pressure reduction.
During an interview and observation on 01/24/2025 at 1:24 PM, Staff H, Licensed Practical Nurse (LPN), stated Resident 73 required wound/skin care to both heels. Resident 73 was observed in bed, the head of the bed was slightly raised, and foam soft booties were noted on the resident's lower extremities (heels) and were slightly elevated. Staff H stated the wound care to the resident's buttocks was already conducted in the early AM by an outside wound care provider; however, Staff H stated they still needed to conduct skin care to the resident's lower extremities (heels). An LALM was observed in use and was inflated with the device set at 200 lbs. When asked whether Resident 73 weighed 200 lbs. Staff H stated the resident did not weight that amount and that the LALM setting was incorrect based on the resident's weight.
Review of Resident 73's EHR dated 11/01/2024 showed the resident last weight was 126.8 lbs.
During interview on 01/24/2025 at 1:15 PM, Staff E, Licensed Practical Nurse (LPN), stated the resident's air mattress was set up by the facility's maintenance department personnel and it should be set and locked for the resident's current weight. Staff E stated the licensed nurses were to monitor and check the settings every shift; however, during a review of the resident's EHR no settings were documented per Staff E.
During an interview on 01/24/2025 at 1:23 PM, Staff J, Maintenance Assistant (MA), stated they would set up the resident's LALM mattresses whenever they were notified a resident needed one and would view or eyeball the residents to get a range that the mattress needed to be inflated to. Staff J stated they usually set and locked the mattress settings based on the closest to the resident's weight range (i.e. 150-200 lbs.)
During an interview and observation on 01/24/2025 at 2:09 PM, Staff E entered two additional facility resident rooms (Resident's 83 and 18), and who both had providers orders for LALM usage, revealed incorrect LALM weight settings based on their current weights. Resident 83's last weight reviewed within the resident's EHR dated 01/03/2025 was documented as 83 lbs.; however, the LALM setting was observed to be set at 200 lbs. Resident 18's EHR documented a weight of 90 lbs.; however, the LALM setting was locked at 400 lbs. Staff E stated both resident's LALM setting were incorrect based on their weights and would need to be changed to the correct setting.
During an interview on 01/24/2025 at 1:34 PM, Staff C, Assistant Director of Nursing (ADON), stated their expectation would be once an order was received from the provider for the use of an LALM, the maintenance staff was directed to set up the resident's mattress based on the residents' weights and the LNs were to ensure the LALM were being monitored and set at the correct settings.
Reference WAC 388-97--1060(3)(b)(j)(viii)
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
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Based on observation, interview, and record review, the facility failed to ensure there was a registered nurse (RN) working a minimum of eight hours each day for 60 of 92 days when reviewed for staf...
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Based on observation, interview, and record review, the facility failed to ensure there was a registered nurse (RN) working a minimum of eight hours each day for 60 of 92 days when reviewed for staffing. This failure placed the residents at risk for delayed assessments/treatments and a diminished quality of care.
Findings included .
Review of the working nursing schedule for the month of July 2024 showed no RN scheduled for 23 of 31 days.
Review of the working nursing schedule for the month of August 2024 showed no RN scheduled for 19 of 31 days.
Review of the working nursing schedule for the month of September 2024 showed no RN scheduled for 18 of 30 days.
During an interview on 01/29/2025 at 9:36 AM, Staff Q, Staffing Coordinator, stated they did their best with the RN nurses that were available and were scheduled, and the facility just did not have enough.
During an interview on 01/30/2025 at 10:15 AM, via electronic communication, Staff B, Director of Nursing Services, stated the expectation was for the staffing coordinator to prioritize RN coverage. Staff B stated not having the minimum eight hour daily RN coverage did not meet expectation.
Reference WAC 388-97-1080(3)(a)
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 48
Review of the quarterly minimum data set assessment (MDS), dated [DATE], showed Resident 48 readmitted on [DATE] wit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 48
Review of the quarterly minimum data set assessment (MDS), dated [DATE], showed Resident 48 readmitted on [DATE] with multiple diagnoses to include heart and lung disease, fibromyalgia (a chronic condition characterized by widespread musculoskeletal pain and fatigue), quadriplegia (paralysis or loss of ability to move all four limbs), radiculopathy (a condition whereas one or more nerve roots in the spinal column becomes compressed and irritated), anxiety and depression. The electronic health record (EHR) showed Resident 48 was able to make needs known and was dependent on staff for all activities of daily living.
Review of Resident 48's current care plan, multiple dates, showed the resident exhibited or was at risk for alterations in comfort related to chronic pain and musculoskeletal disorder. Interventions on the care plan documented licensed nurses (LN) were to monitor for pain and attempt NPI to alleviate pain and document effectiveness.
Review of Resident 48's MAR for January 2025 showed a provider's order dated 09/24/2024 for staff to administer oxycodone (a medication used to treat moderate to severe pain) every four hours as needed for chronic pain and an additional order dated 10/18/2021 for the LN staff to administer acetaminophen (a medication used to treat mild pain) every 4 hours as needed for mild pain. Multiple entries showed that the LNs had administered pain medications as directed; however, the non-pharmacological interventions that were ordered were not being consistently documented within Resident 48's MAR.
Review of January 2025 MAR showed an additional provider's order dated 01/13/2025 for the LNs to document nonpharmacological interventions (NPIs) to include, A. Repositioning, B. Relaxation, C. Food/Fluid, D. Massage, E. Exercise, F. Immobilization of joint, G. Other, write in progress note as needed Document results, R. Results non-pharm (-) ineffective (+) effective. The document showed no documentation of any LN initials to indicate NPI were administered on the January 20025 MAR.
Resident 94
Review of the quarterly MDS, dated [DATE], showed Resident 94 admitted on [DATE] with multiple diagnoses to include heart disease and stroke, osteomyelitis, dementia (a progressive decline in mental functions), anxiety and depression. The MDS showed the resident with significant level of cognition impairment and was dependent on staff for assistance with activities of daily living (ADLs)
Review of the MAR dated January 2025 showed a provider's order dated 10/07/2024 for staff to administer Hydrocodone-Acetaminophen 1 tablet (a medication used to treat moderate pain) every eight hours as needed for moderate pain and an additional order dated 10/07/2024 for the LNs staff to administer Hydrocodone-Acetaminophen 2 tablet every eight hours as needed for moderate to severe pain. Multiple entries showed that the LNs had administered the as necessary pain medications as directed; however, the NPIs that were ordered were not being consistently documented within Resident 48's MAR.
Review of January 2025 MAR showed an additional provider's order dated 01/13/2025 for the LNs to document NPI to include, A. Repositioning, B. Relaxation, C. Food/Fluid, D. Massage, E. Exercise, F. Immobilization of joint, G. Other, write in progress note as needed Document results, R. Results non-pharm (-) ineffective (+) effective. The document showed no documentation of any LN initials to indicate NPI were administered on the January 20025 MAR.
During an interview on 01/28/2025 at 1:48 PM, Staff C, Assistant Director of Nursing (ADON), stated the expectation would be for the LNs to first attempt NPIs prior to the administration of the PRN pain medications.
Resident 92
Review of the EHR showed Resident 92 admitted to the facility on [DATE] and was able to make needs known. The quarterly MDS, dated [DATE], showed Resident 92 had diagnoses of atrial fibrillation (irregular heart rate), anxiety disorder, and insomnia (sleeplessness).
Review of Resident 92's provider's orders showed an order for a narcotic (used to treat moderate to severe pain) medication to be provided as needed for pain and an order for nonpharmacological interventions to be provided prior to use of as needed pain medication with results to be documented if effective or ineffective.
Review of Resident 92's January 2025 MAR from 01/01/2025 - 01/23/2025 showed Resident 92 received as needed narcotic pain medication 77 times and order for nonpharmacological interventions and results were blank and showed no documentation.
During an interview on 01/24/2025 at 1:06 PM, Staff T, Licensed Practical Nurse (LPN), stated Resident 92 should have had non-pharmacological interventions documented in the January 2025 MAR prior to use of a narcotic medication being provided and that did not happen for Resident 92.
During an interview on 01/24/2025 at 2:13 PM, Staff B, Director of Nursing Services (DNS), stated non-pharmacological interventions were to be offered/provided prior to giving as needed pain medications to residents, and documented in the MAR. Staff B stated Resident 92's January 2025 MAR should have had non-pharmacological interventions documented prior to the resident receiving the narcotic medication and this did not meet expectations.
Resident 360
Review of the EHR showed that Resident 360 admitted to the facility on [DATE] with diagnoses to include a broken left upper thigh bone, kidney disease, and Crohn's disease (a bowel disease that affects the lining of the digestive tract and can cause stomach cramping and pain). Resident 360 was able to make needs known.
Review of Resident 92's provider's orders showed an order dated 01/14/2025 for acetaminophen (used to treat minor aches and pains) every four hours as needed for pain and an order dated 01/15/2025 for a narcotic medication to be provided every three hours as needed for pain.
Review of the MAR dated January 2025 from 01/01/2025 - 01/28/2025 showed Resident 360 received as needed acetaminophen two times and the as needed narcotic 23 times. This MAR showed no order for non-pharmacological interventions documented for Resident 360.
During an interview on 01/29/2025 at 10:01 AM, Staff E, LPN, stated Resident 360 had no non-pharmacological interventions documented in their January 2025 MAR prior to receiving as needed pain medications and there should have been.
During an interview on 01/29/2025 at 10:13 AM, Staff C, ADON, stated there were no non-pharmacological interventions documented on Resident 360's January 2025 MAR and there should have been, and this did not meet expectations.
Based on interview and record review, the facility failed to provide non-pharmacological (non-medicated) interventions (NPI) prior to as needed (PRN) pain medications for 6 of 8 sampled residents (Residents 78, 48, 94, 92, 360, and 87) when reviewed for unnecessary medications. These failures placed residents at risk for taking unnecessary medications, avoidable side effects, and a diminished quality of life.
Findings included .
Resident 78
Review of the electronic health record (EHR) showed Resident 78 admitted to the facility on [DATE] with diagnoses of palliative care (end-of-life), osteomyelitis (infection of the bone), and diabetes (too much sugar in the blood). Resident 78 was able to make needs known.
Review of current provider's orders showed Resident 78 received a narcotic pain medication PRN and NPI were to be provided prior to the use of the PRN pain medication.
Review of the medication administration record (MAR) showed Resident 78 received nearly daily PRN pain medication in December 2024 and January 2025. Review showed no NPI were provided during these months.
During an interview on 01/29/2025 at 11:49 AM, Staff B, Director of Nursing Services (DNS), stated the facility would provide NPI prior to the use of PRN pain medications to ensure the PRN pain medications were necessary. Staff B stated Resident 78 had orders for a PRN pain medication and NPI prior to the use of it. Staff B stated Resident 78 used the PRN pain medication nearly daily and NPI were not provided in the months of December 2024 and January 2025, and this did not meet their expectation.
Resident 87
Review of EHR showed Resident 87 admitted to the facility on [DATE] with a diagnosis of dementia. Resident 87 required moderate assistance and was able to make needs known.
Review of Resident 87's provider's orders showed an order dated 07/19/2024 for acetaminophen two tablets every six hours as needed for mild pain.
Review of the December 2024 MAR showed Resident 87 received acetaminophen five times. The December MAR showed no non-pharmacological interventions were documented for Resident 87.
During an interview on 01/27/2025 at 1:55 PM, Staff B, DNS, stated the expectation was that non-pharmacological interventions were attempted and documented prior to administering pain medications.
Reference WAC 388-97-1060 (3)(k)(i)
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected multiple residents
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Based on interview and record review, the facility failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program self-identified deficiencies and failed to develop/implemen...
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Based on interview and record review, the facility failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program self-identified deficiencies and failed to develop/implement effective plans of action to sustain plan of corrections for previous deficiencies. Failure to have an effectively functioning QAPI program that consistently self-identified deficient practices led to repeated deficiencies, and a pattern of deficiencies that placed residents at repeated risk for unmet needs that could negatively impact their safety, quality of life and quality of care.
Findings included .
<Self-Identify Areas of Concern>
Refer to the following citations identified during the Long Term Care survey, dated 01/29/2025, which were not identified or were identified and not addressed. (D = Isolated, E = Pattern):
REFER TO F609 (E) Reporting of Alleged Violations. The Long Term Care survey dated 01/29/2025: the facility failed to identify and investigate allegations of abuse/neglect for 6 of 7 sampled residents.
REFER TO F686 (E) Treatment/Services to Prevent/Heal Pressure Ulcer. The Long Term Care survey dated 01/29/2025: the facility failed to ensure an ordered intervention (Low Air Loss Mattress - LALM, a mattress used to redistribute pressure evenly and can help prevent pressure ulcers, also known as bedsores) was being monitored and used as directed in the prevention of pressure ulcers for 3 of 7 residents.
REFER TO F865 (E) Quality Assurance and Performance Improvement (QAPI) Program/Plan, Disclosure/Good Faith Attempt.
During an interview on 01/29/2025 at 1:34 PM, Staff A stated the above listed areas had not been a concern prior to survey.
<Sustain Plan of Corrections>
Refer to the following citations identified during survey which had ineffective plans of correction to sustain correction by the QAPI program which led to repeated deficiencies and pattern of deficiencies. (D = Isolated, E = Pattern):
REFER TO F552 (E) Right To Be Informed and make Treatment Decisions: Previous deficiency dated 11/2018 (D), 11/2019 (D), 10/2022 (D), and 01/26/2024 (D). The Long Term Care survey dated 01/29/2025: The facility failed to have psychotropic medication (medications that affect a person's mental state) consents completed, signed, and in place prior to residents receiving these medications for 3 of 5 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the facility was cited for this area and found back in compliance. Staff A stated he did not know why compliance was not maintained and would have to review.
REFER TO F578 (D) Request/Refuse/Discontinue Treatment; Formulate Advance Directive: Previous deficiency dated 11/2018 (E), 11/2019 (E), and 01/26/2024 (D). The Long Term Care survey dated 01/29/2025: The facility failed to periodically review a resident's advanced directive (AD, a legal document that states your wishes for medical care if you are unable to make decisions for yourself) and obtain and maintain a court-appointed guardianship (legal process where a court appoints someone to make decisions for a person who is unable to do so for themselves) documentation for 1 of 2 sampled residents
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO F584 (D) Safe/Clean/Comfortable/Homelike Environment: Previous deficiency dated 11/2018 (E), 11/2019 (D), and 01/26/2024 (D). The Long Term Care survey dated 01/29/2025: the facility failed to provide a safe, sanitary, and homelike environment for 1 of 4 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO F604 (D) Right To Be Free From Physical Restraints: Previous deficiency dated 12/05/2024 (D). The Long Term Care survey dated 01/29/2025: the facility failed to obtain provider's order, assessment and consent for the use of a low bed for 3 of 3 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO F623 (D) Notice Requirements Before Transfer/discharge: Previous deficiency dated 11/2019 (E) and 01/26/2024 (D). The Long Term Care survey dated 01/29/2025: the facility failed to provide written notification of the reason for transfer to the hospital to resident or responsible party for 2 of 4 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO F625 (D) Notice Of Bed Hold Policy Before/upon Transfer: Previous deficiency dated 11/2019 (E). The Long Term Care survey dated 01/29/2025: the facility failed to provide written bed hold notice at the time of transfer to the hospital for 2 of 4 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO F641 (D) Accuracy Of Assessments: Previous deficiency dated 10/2022 (D). The Long Term Care survey dated 01/29/2025: the facility failed to accurately assess the status for 1 of 5 sampled residents reviewed for Pre-admission Screening and Resident Review (PASARR, a mental health screening tool).
REFER TO F645 (D) Pre-admission Screening and Resident Review: Previous deficiency dated 01/26/2024 (D). The Long Term Care survey dated 01/29/2025: the facility failed to ensure Pre-admission Screening and Resident Review (PASARR, a mental health screening tool) assessments were accurately or timely completed for 2 of 7 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO F656 (D) Develop/Implement Comprehensive Care Plan: Previous deficiency dated 11/2019 (D) and 10/2022 (D). The Long Term Care survey dated 01/29/2025: the facility failed to develop and implement comprehensive person-centered care plans for 2 of 24 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO F657 (D) Care Plan Timing and Revision: Previous deficiency dated 11/2018 (D), 11/2019 (E), and 01/26/2024 (E). The Long Term Care survey dated 01/29/2025: the facility failed conduct timely care planning meetings with residents or responsible party for 2 of 4 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO F658 (D) Services Provided Meet Professional Standards: Previous deficiency dated 10/2022 (D). The Long Term Care survey dated 01/29/2025: the facility failed to meet professional standards of practice for 1 of 5 sampled residents reviewed for use of unnecessary medications.
REFER TO F684 (E) Quality Of Care: Previous deficiency dated 01/26/2024 (E). The Long Term Care survey dated 01/29/2025: the facility failed to ensure a mobility device was available for 1 of 5 sampled residents and failed to implement a bowel program for 2 of 5 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was aware of this area of concern depending on what it is.
REFER TO F689 (D) Free of Accident Hazards/Supervision/Devices: 11/2018 (D), 11/2019 (D), 10/2022 (E), and 01/26/2024 (D). The Long Term Care survey dated 01/29/2025: the facility failed to ensure risk factors were consistently monitored and addressed to minimize the risk for accident hazards for 2 of 7 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO F692 (D) Nutrition/Hydration Status Maintenance: Previous deficiency dated 10/2022 (D). The Long Term Care survey dated 01/29/2025: the facility failed to ensure the facility's Registered Dietician's (RD) recommendations were administered as ordered to prevent continued weight loss for 1 of 3 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO F695 (D) Respiratory/Tracheostomy Care and Suctioning: Previous deficiency dated 11/2018 (D). The Long Term Care survey dated 01/29/2025: the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO F727 (E) Registered Nurse 8 Hours/Seven days/Week, Full Time Director of Nursing Services: Previous deficiency dated 11/2019 (F) and 05/30/2024 (F). The Long Term Care survey dated 01/29/2025: the facility failed to ensure there was a registered nurse (RN) working a minimum of eight hours each day for 60 of 92 days.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was aware of this area of concern and were actively trying to recruit.
REFER TO F756 (D) Drug Regimen Review, Report Irregularities, Act on pharmacist recommendations: Previous deficiency dated 11/2018 (D). The Long Term Care survey dated 01/29/2025: the facility failed to act on the consultant pharmacist's medication regimen review (MRR) recommendations and/or to have clearly documented rationale for not following the recommendation for 1 of 5 sampled residents.
REFER TO F757 (E) Drug Regimen Is Free from Unnecessary Drugs: Previous deficiency dated 10/2022 (D), and 01/26/2024 (E). The Long Term Care survey dated 01/29/2025: the facility failed to provide non-pharmacological (non-medicated) interventions (NPI) prior to as needed (PRN) pain medications for 6 of 8 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of concerns in this area.
REFER TO F758 (D) Free from Unnecessary Psychotropic Medications/as need (PRN) use: Previous deficiency dated 10/2022 (D), and 01/26/2024 (E). The Long Term Care survey dated 01/29/2025: the facility failed to conduct gradual dose reduction (GDR, a trial attempt to discontinue a medication) were free from excessive dosages and durations without adequate monitoring and indications for use, or in the presence of adverse consequences, related to the use of psychoactive (affecting the mind) medications for 1 of 5 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of concerns in this area.
During an interview on 01/29/2025 at 1:34 PM, Staff A stated the QAA Committee meet once a quarter and sometimes monthly. Staff A stated the QAA committee know when an issue arose in any department by reviewing grievances, complaints, and results from audits. Staff A stated the QAA committee knew corrective action had been implemented by utilizing Performance Improvement Plans (PIPs) and reviewing the action plan to ensure it was implemented with audits turned in for review. When asked why there were repeated citations in various areas of concern, Staff A stated the Director of Nursing Services had been there a year; we continue to work to make improvements. We have had some key staff on leave and new staff trying to step up and help out. Staff A stated QAPI was effective in some areas; however, they needed to improve in other areas.
Reference WAC 388-97-1760(1)(2)
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Jan 2025
2 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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to ensure dressing changes were completed as ordered by the provider...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to ensure dressing changes were completed as ordered by the provider for 1 of 3 sample residents (Resident 1) reviewed for quality of care. This failure placed residents at risk of unmet needs, decline in status, and decreased quality of life.
Findings included .
Resident 1 was admitted to the facility on [DATE] with multiple diagnoses, including high blood pressure, a stroke, and one-sided paralysis. The Minimum Data Assessment, an assessment tool, dated 04/04/2024, documented Resident 1 was alert and non-verbal, and required substantial assistance with activities of daily living.
Review of Resident 1's record showed an order dated 12/20/2024 for wound care and dressing changes to one of Resident 1's feet to be done two times a day and as needed. The dressings were to be done at 7:00 AM and at 5:00 PM every day.
Review of Resident 1's Treatment Administration Record for December 2024 showed blanks or spaces without documentation for the 5:00 PM dressing change on 12/20/2024, 12/21/2024, 12/22/2024, 12/23/2024, 12/24/2024, and 12/26/2024. The 7:00 AM dressing changes showed blank spaces on 12/24/2024 and 12/25/2024. Out of 23 opportunities for timely wound care, the documentation reflected that there were 8 missed dressing changes.
On 01/23/2024 at 5:01 PM, when asked, Staff D, a Registered Nurse and the Assistant Director of Nursing, said if a dressing change was not done, nursing staff should write a progress note or something to document why it wasn't done, such as if the resident was not there, was at the hospital, out of the facility for an activity, if they refused, etc.
When asked, Staff D acknowledged that if it was not charted, the task was considered as not done. After Staff D reviewed Resident 1's Treatment Administration Record for December 2024, they agreed that it appeared the dressings were not changed on the dates with blanks and there should have been additional documentation.
Reference WAC 388-97-1060(1)
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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 F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review the facility failed to ensure medications were properly labeled and stored p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review the facility failed to ensure medications were properly labeled and stored prior to medication administration, in accordance with accepted professional standards, in 1 of 4 medication carts reviewed. This failure placed residents at risk of medication errors and potential adverse events.
Findings included .
According to Elsevier Clinical Nursing Skills & Techniques, 8th edition, p. 495 (Mosby 2014), when administering oral medications, nurses are to follow the five rights of medication administration (right patient, right drug (medication), right dose, right route, and right time), and to prepare medications for one patient at a time.
Review of the facility's policy, Medication and Treatment Administration Guidelines, revised [DATE], documented medications are to be administered in a safe and timely manner and as prescribed.
On [DATE] at 4:57 PM, Staff C, Registered Nurse (RN), was observed at a medication cart parked on 200 Hall. On top of the cart were observed multiple clear plastic medication cups that contained various pills and each had a second plastic cup on top of the pills, and handwriting on the outside of each of the plastic cups.When asked about the plastic cups, Staff C said, Oh, I know you're not supposed to do that. I never do that. My computer battery died. It's been a really busy day. When asked to clarify, Staff C said they never make them (medications) up ahead like that because it is not safe. Staff C said the medications were scheduled to be given at 5:00 PM and 6:00 PM that day. Six cups were observed, each had a single name handwritten on the outside of the cup. Staff C looked at their reference sheet and identified each resident's room numbers. Staff C said the names written on the outside of the cups were the residents' first names. No other resident identifiers were observed. In the top drawer of the medication cart was observed a small clear plastic bag, approximately 2 inches by 3 inches, that contained two white, oblong-shaped tablets and a single resident name handwritten on the outside. Staff C explained the resident was supposed to get the medication while at dialysis, but they did not eat so it was sent back with them. Staff C showed surveyor the medication card that it came from, labeled as Sevelamer (to be taken with meals to bind to dietary phosphate and prevent high levels of phosphorous), and identified the resident's room number.When asked, Staff C said that was not how they were trained to prepare and administer medications. Staff C said, No, it's not safe. Staff C was observed to put the medication cups into the top drawer of the medication cart, locked the cart, walked away and said they were going to go and tell on themself.
On [DATE] at 5:14 PM, Staff B, RN and the Director of Nurses, said Staff C had explained that their laptop battery had died and Staff C was just trying to get everything done before it shut down. Staff B said Staff C knew they should not have done it that way. Staff B said they did not go and look at the medication cups and was not aware that the medication cups were identified by residents' first names only. Staff B said that the practice observed did not meet nursing expectations for safe medication administration and acknowledged that it represented a significant safety risk to residents.
Reference WAC 388-97-1300(2)
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Dec 2024
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 F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure consents were obtained for 2 of 5 residents (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure consents were obtained for 2 of 5 residents (Residents 1 and 2) reviewed for consents for Wanderguard (a device worn on or close to the resident's body designed to alarm when the resident came within close proximity to an alarmed exit door), and failed to ensure physician orders and consents were obtained for 2 of 5 sampled residents (Residents 3 and 4) reviewed for physical restraints. This failure placed residents at risk for injury, unmet needs, and a diminished quality of life.
Findings included .
Record review of the facility's policy entitled, Use of Restraints, revised April 2017, documented, 1. Physical Restraints' are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body . 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative .
<Resident 3>
Resident 3 was admitted to the facility on [DATE], last readmitted [DATE], with multiple diagnoses. The Minimum Data Set (MDS), an assessment tool, dated 11/18/2024, documented Resident 3 was cognitively impaired and was dependent upon staff for assistance with activities of daily living.
On 12/05/2024 at 4:08 PM, Resident 3's bed was observed against the wall, and a perimeter/scoop-style mattress (built-up outside edges) observed on the bed.
An interview on 12/05/2024 at 4:09 PM with Staff D, a Registered Nurse, stated the bed was up against the wall because the resident was a high fall risk.
Record review of Resident 3's Electronic Health Record (EHR) did not show physician orders for the bed being against the wall or for the perimeter mattress.
Record review of Resident 3's EHR did not show a consent for Resident 3's bed being against the wall or for the perimeter mattress
<Resident 4>
Resident 4 was readmitted to the facility with multiple diagnoses on 11/13/2024. The MDS assessment, dated 11/19/2024, documented Resident 4 was cognitively impaired and required substantial assistance with activities of daily living.
On 12/05/2024 at 4:12 PM, Resident 4's bed was observed against the wall and a perimeter mattress observed on the bed.
An interview on 12/05/2024 at 4:13 PM with Staff E, a Registered Nurse, stated the bed was up against the wall because Resident 4 had falls.
Record review of Resident 4's EHR did not show physician orders for the bed being against the wall or for the perimeter mattress.
Record review of Resident 4's EHR did not show consent for Resident 4's bed being against the wall or for the scoop mattress
<Resident 1>
Resident 1 was admitted to the facility with multiple diagnoses on 12/22/2023. The MDS assessment, dated 10/28/2024, documented Resident 1 was cognitively impaired and required assistance with activities of daily living.
On 12/05/2024, with Staff C, a Licensed Practical Nurse and Unit Manager, Resident 1 was observed to wear a Wanderguard on their right wrist.
During an interview on 12/05/2024 at 2:43 PM, Staff C was not able to locate the consent for Resident 1's Wanderguard. Staff C said they did not believe there was a form for that and that staff would document consent in the progress notes. When asked, Staff C was not able to locate documentation of consent for Resident 1's Wanderguard in the progress notes.
Record review of Resident 1's EHR did not show a consent for Resident 1's Wanderguard.
<Resident 2>
Resident 2 was admitted to the facility with multiple diagnoses on 09/27/2024. The MDS assessment, dated 10/04/2024, documented Resident 2 was cognitively impaired and required substantial staff assistance with activities of daily living.
During an interview on 12/05/2024 at 2:43 PM with Staff C, a Licensed Practical Nurse and Unit Manager, said Resident 2 had a Wanderguard alarm placed on their person. When asked, Staff C was not able to locate the consent for Resident 2's Wanderguard. Staff C said they did not believe there was a form for that and that staff would document consent in the progress notes. When asked, Staff C was not able to locate documentation of consent for Resident 2's Wanderguard in the progress notes.
Record review of Resident 2's EHR did not show a consent for Resident 2's Wanderguard.
On 12/05/2024 at 4:50 PM, Staff B, a Registered Nurse and the Director of Nursing Services, said there was not an actual form to use for consents to devices or restraints such as beds placed against the wall, perimeter mattress, mattresses on the floor. Staff B said there had been recent changes to the facility's charting system and they had planned to do chart audits.
Reference WAC 388-97-0620
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May 2024
1 deficiency
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
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
.
Based on interview and record review, the facility failed to provide eight consecutive hours of direct care supervision by a Registered Nurse (RN) for 9 of 29 days reviewed and failed to meet the St...
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.
Based on interview and record review, the facility failed to provide eight consecutive hours of direct care supervision by a Registered Nurse (RN) for 9 of 29 days reviewed and failed to meet the State RN staffing requirement of 24-Hour RN coverage for 29 of 29 days reviewed for RN staffing. This failure placed residents at risk for delay in resident assessments, identification of changes in condition, provision of care and services outside the scope of practice of the Licensed Practical Nurse (LPN), and unmet care needs.
Findings included .
Review of the daily nursing staff forms for May 2024 provided by Staff C, Staffing Coordinator, on 05/30/2024, showed no RN coverage for the following dates: 05/04/2024, 05/05/2024, 05/10/2024, 05/11/2024, 05/12/2024, 05/18/2024, 05/19/2024, 05/25/2024, and 05/26/2024. The daily nursing staff forms for the remainder days of May 2024 showed 8-hour RN coverage only.
In an interview on 05/30/2024 at 2:15 PM, Staff B, Director of Nursing Services (DNS)/RN, said they were aware the facility did not provide 24-hour RN coverage. Staff B said there were only LPNs to work the floor and the only time there was RN coverage was when the Assistant Director of Nursing worked. Staff B said they had just hired 2 RN's and one will be working weekends. Staff B said starting on 05/24/2024 the facility started using agency to assist in covering LN and NAC positions. Staff B said the facility recently increased their pay scale to be more competitive and have revamped their employee retention tactics. Staff B said they were continuing to actively recruit RNs.
REFERENCE: WAC 388-97-1080(3)(a).
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Jan 2024
24 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0688
(Tag F0688)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to ensure two of four residents (Resident 68 and 85) re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to ensure two of four residents (Resident 68 and 85) reviewed for range of motion/mobility, consistently received restorative services (movement of joints to maintain range of motion) to maintain or prevent declines in mobility. This failure resulted in harm to Resident 68 who experienced a decrease in left hip extension and worsening of the left knee contracture (a permanent shortening of muscle and loss of joint mobility). This failure placed residents at risk of decreased motion, mobility and a decreased quality of life.
Findings included .
Review of a document titled, Restorative Nursing Services, dated July 2017, showed residents would receive restorative nursing care as needed to help promote optimal safety and independence. In addition, the following goals may include, but not limited to, supporting, and assisting the resident in adjusting or adapting to changing abilities, developing, maintaining, or strengthening his/her physiological and psychological resources, maintaining his/her dignity, independence and self-esteem and participating in the development and implementation of his/her plan of care.
Resident 68
Resident 68 was admitted to the facility on [DATE] with diagnoses of absence of right leg below knee, polyneuropathy (a malfunction of many nerves throughout the body) and other reduced mobility. The admission Minimum Data Set (MDS), a required assessment tool, dated 10/21/2022, showed Resident 68 required substantial/maximal assistance with activities of daily living.
Observation on 01/21/2024 at 2:24 PM, showed Resident 68 laid flat on their back, in bed, with a pillow under a left bent knee. Resident 68 stated that they utilized the pillow to help reduce the pain in their knee.
During an interview on 01/23/2024 at 11:24 AM, Resident 68 stated that they were upset they were no longer getting therapy because I never get out of bed anymore now that they have to use a lift to get me up. Resident 68 stated that it required two staff to get them out of bed but there was never enough help. Resident 68 stated that they had done restorative only a few times but not three days a week as discussed with therapy staff.
Review of the provider's restorative nursing program order, dated 11/14/2023, showed Resident 68 was to have bilateral lower extremity-active assisted range of motion (BLE-AAROM) exercise to pain tolerance. Repositioning strategies to off load pressure and facilitate comfort were included.
Review of a care plan, dated 11/21/2023, showed a focus area for restorative range of motion (ROM), and that Resident 68 was at risk for decrease in ROM. The goal was for the resident to maintain the current AAROM in affected joint to prevent the progression and/or development of contractures. Interventions included that the resident would work with the restorative nursing aide, (RNA), on Monday, Wednesday, and Fridays, and that the restorative nursing program meeting was to occur weekly on Fridays. RNA would assist resident with AAROM to BLE, three times a week as tolerated.
During an interview on 01/23/2024 at 9:47 AM, Staff Q, RNA, stated they conducted restorative Mondays, Wednesdays and Fridays and they were the shower aide on Tuesday and Thursdays. When asked about Resident 68's participation, Staff Q stated that Resident 68 actively participated each session between 10-15 minutes. Staff Q stated that they were out sick from 01/02/2024 to 01/05/2024 and had no knowledge if restorative was covered by an alternate staff during that time.
Review of the Resident 68's restorative care flow sheets for December 2023 and January 2024, showed that the resident had multiple dates they did not receive restorative care. The December 2023 dates included: 12/04/2023, 12/06/2023, 12/13/2023, 12/18/2023, 12/20/2023, 12/25/2023 and 12/27/2023. The January 2024 dates included 01/01/2024, 01/03/2024, 01/05/2024, 01/08/2024, 01/12/2024, 01/15/2024, 01/19/2024 and 01/22/2024. The restorative care flow sheets for December 2023 showed that Staff N, CNA, signed off some of the restorative tasks.
During an interview on 01/23/2024 at 2:12 PM, Staff N stated although their initials were on the restorative task, they did not facilitate any ROM exercises with Resident 68. Staff N stated that only the RNA did restorative with residents.
Review of the January 2023 active RNA task flow sheet, in the electronic health record (EHR), showed Not Applicable on 01/10/2024 for Resident 68's restorative task.
During an interview on 01/23/2024 at 11:14 AM, Staff C, Assistant Director of Nursing (ADON), stated that they did not have any restorative progress notes in the EHR yet; however, they had just met about the resident's progress as of 01/18/2023 and Resident 68 was doing well. Staff C stated that they planned to continue with care as ordered. Staff C stated that the Not Applicable on 01/10/2024 was in error and that staff were educated to document Resident Refused instead. Staff C further stated that to their knowledge that was the only refusal by the resident. Additionally, Staff C stated that the documentation only showed participation of twice in the last 30 days.
During an interview on 01/23/2024 at 11:25 AM Staff EE, Physical Therapist, stated that the only staff that facilitated restorative with residents was the RNA. Staff EE further stated CNAs should not document that the restorative task was completed.
Review of the Resident 68's restorative care flow sheets for December 2023 showed that a CNA signed off restorative on 12/08/2023, 12/22/2023, and 01/10/2024.
Review of the form Physical Therapy PT Discharge Summary, signed 11/02/2023, showed Resident 68 exceeded their goal of AAROM left hip extension at -18 degrees. The Patient & Response to Treatment section showed, Patient demonstrates little to no physical impairments as a result of skilled rehab. Prognosis to Maintain CLOF (current level of functioning) = Good with consistent staff follow-through.
Review of form Physical Therapy PT Evaluation, dated 01/26/2024, showed current reason for referral as Physical Therapy to assess current ROM for lower extremities and determine whether pt is not appropriate for return to standard chair as they had before. The evaluation showed Resident 68 had the following decreases: AAROM left hip extension from -25 to -40, AAROM left knee extension -40 to -105 degrees and Passive ROM right hip extension -5 to -25 degrees.
During an interview on 01/26/2024 at 12:25 PM, Staff G, Physical Therapist, stated that Resident 68 was discharged from Physical Therapy in November 2023 at which time they were referred to restorative. Staff G stated that based on the current evaluation Resident 68's contractures had worsened, which was a rapid decline. Staff G further stated that when restorative was being completed on a regular basis it was less likely for Resident 68 to have a rapid decline.
Resident 85
Resident 85 was admitted to the facility on [DATE] with diagnoses including stroke, heart and kidney disease, seizure disorder, malnutrition, muscle weakness and anxiety disorder. Review of the admission MDS, dated [DATE], showed Resident 85 was able to make their needs known and was dependent or required maximal substantial assistance with activities of daily living.
During an interview on 01/22/2024 at 9:50 AM, Resident 85's family member stated they were unaware whether the resident received restorative care and that the resident at times had spasticity (abnormal muscle tightness due to prolonged muscle contractions) whenever the staff got the resident out of bed and into a wheelchair.
Review of the provider's restorative nursing program order, dated 11/11/2023, showed that Resident 85 was to have right upper extremity (RUE) - passive range of motion (PROM) in all planes (describes all 4 movement directions; flexion and extension) wrist and digits to increase ROM, for functional use and decrease further contracture as tolerated by resident and was to be performed by the RNA every Monday, Wednesday, and Friday.
Review of Resident 85's care plan, dated 11/11/2023, showed a focus area for restorative ROM, and that the resident was at risk for decrease in ROM. The goal would be for the resident to maintain the current PROM to right upper extremity to prevent the progression of contractures. Interventions included that the resident would work with the RNA on Monday, Wednesday, and Fridays, and that the restorative nursing program meeting was to occur weekly on Fridays.
Review of Resident 85's flowsheet for restorative care documentation for December 2023 and January 2024, showed that the resident had multiple dates missing for restorative care. The following December 2023 dates included: 12/04/2023, 12/06/2023, 12/08/2023, 12/11/2023, 12/13/2023, 12/18/2023, 12/20/2023, 12/22/2023, 12/25/2023. The January 2024 dates included 01/03/2024, 01/05/2024, 01/08/2024 and 01/10/2024.
During an interview on 01/25/2024 at 10:12 AM, Staff Q, RNA, stated that they were out sick from 01/02/2024 to 01/05/2024 and was not aware whether the restorative care occurred for Resident 85 during that time.
During an interview on 01/25/2024 at 10:15 AM, Staff E, Resident Care Manager (RCM), stated that it was their expectation that the RNA would document whether the resident received their restorative care as ordered.
During an interview on 01/25/2024 at 10:49 AM, Staff C, ADON, stated that it was their expectation restorative care was documented if it occurred and/or if the resident refused. Staff C, ADON, further stated that the lack of documentation appeared to show that the restorative did not happen during the December 2023 and January 2024 dates but should have occurred.
Reference WAC 388-97-1060 (3)(d)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to obtain an informed consent prior to psychotropic (affecting the b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to obtain an informed consent prior to psychotropic (affecting the brain) medication usage for 1 of 5 residents (Resident 12) reviewed for unnecessary medications. This failure had the potential for the resident or their legal representatives to have lack of knowledge to make an informed decision regarding use of these medications.
Findings included .
Review of the facility's policy titled, Psychotropic Medication Use Drugs, dated July 2022, showed that residents and/or the resident's representative(s) would be informed of risks and benefits prior to initiation of a psychotropic medication and had the right to decline treatment with the psychotropic medication.
Review of the quarterly Minimum Data Set (MDS), a required assessment tool, dated 06/20/2023, showed Resident 12 admitted to the facility on [DATE] with multiple diagnoses to include psychosis (a mental disorder characterized by a disconnection from reality).
Review of the physician's order, dated 06/16/2023, showed Resident 12 was started on a psychotropic medication used to treat psychosis.
Review of Resident 12's electronic health record (EHR) showed no documentation that the resident was provided information of potential risks and benefits to make an informed decision regarding the use of a psychotropic.
During an interview on 01/24/2024 at 9:56 AM, Staff F, Residential Care Manager, stated that they were unable to locate an informed consent for Resident 40's psychotropic medication and stated, There should have been one completed.
During an interview on 01/26/2024 at 10:24 AM, Staff B, Director of Nursing Services, confirmed that there was no consent in the EHR and stated that a consent should have been obtained prior to administration of the medication.
Reference WAC 388-91-0300 (3)(a)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected 1 resident
.
Based on interview and record review, the facility failed to address grievances/concerns raised by the Resident Council group for 3 of 3 months (October 2023, November 2023, and January 2024) when r...
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Based on interview and record review, the facility failed to address grievances/concerns raised by the Resident Council group for 3 of 3 months (October 2023, November 2023, and January 2024) when reviewed for Resident Council. Failure for administrative staff to act upon grievances voiced by the Resident Council and failure to report back to the council in writing for a response, rationale and action taken on grievances placed residents at risk for continued concerns, unmet needs, and a diminished quality of life.
Findings included .
During an interview on 01/24/2024 at 9:52 AM, Resident 45, Resident Council President, stated that there had been concerns brought up in the Resident Council (RC) meetings that had not been resolved nor had the RC attendees been updated on the status of the grievances. Resident 45 stated that, most recently, residents had complained about dirty bed linen, long call lights and noisy staff on night shift; however, they were unaware if management had investigated the concerns. Resident 45 stated that when a grievance was investigated it sometimes took months and no written grievance decision was received by the resident.
Review of the RC meeting minutes for October 2023 showed that residents complained Beds were not made timely with sheets being soiled for longer than deemed acceptable and Night shift staff needs to be mindful that residents are trying to sleep and to please be quieter around the nurses station and while going down halls.
Review of the RC meeting minutes for November 2023 showed Several residents noted beds will go unmade and they will have to request the bed be made after they are up in their chair and residents reported, Longer than expected wait times during the night shift for their call light to be answered.
Review of the RC meeting minutes for January 11, 2023, showed This meeting held in lieu of December meeting to discuss November due to COVID outbreak. Facility received new Director of Nursing (DNS) and Assistant Director of Nursing however during the transition the RC concerns presented in October to the DNS went unanswered. The information was presented to the RC as the issues have not been adequately addressed. Under New Business Patient/Resident Concerns residents expressed concern of Being woken up in the middle of the night by staff such as children being too loud. Residents complained that beds would go unmade unless they specifically asked their aide to make the bed and call lights would be turned off by staff without the task requested being completed. Staff would say they would be right back; however, they did not return for a long period of time.
Review of the RC meeting minutes for January 16, 2023, showed Due to short turnaround time between the last RC meeting, concern forms were not submitted to department heads until after the 01/16/2024 meeting. Notwithstanding, these concerns will be submitted, and responses requested for the next RC meeting.
Review of the facility's Grievance Log from August 2023 through January 2024 did not show the above grievances/concerns logged.
During an interview on 01/24/2024 at 1:43 PM, Staff J, Activities Director (AD), stated that during Resident Council meetings, if there was a group concern it was documented on a concern form and then given to the appropriate department supervisor for resolution. The department supervisor would investigate the concern and either report the resolution to Staff J by the next meeting or attend the next month meeting themselves to speak to the Residents. Staff J stated that if a concern was personal then a grievance form would be completed and investigated by Staff J. When asked about the resident concerns brought forth in the October, November and January meetings related to soiled bed sheets, long call lights and loud staff on night shift, Staff J stated that they submitted grievance forms for those issues to the previous Director of Nursing; however, the issues did not get addressed. Staff J stated that they did not have copies of the forms and was not able to provide an explanation as to why they were unable to locate the form. Staff J stated that the grievances/concerns were not documented on the grievance log.
During an interview on 01/24/2024 at 11:58 AM, Staff A, Administrator, stated that since they had not had a Social Worker, they were facilitating the grievance process. Staff A stated that resident council concerns/grievances were completed by Staff J and were sometimes documented on the grievance log. Staff A stated that the concerns from the October, November and January RC meeting should have been documented and investigated. Staff A stated the facility did not provide a written decision to the resident; however, they could always review the completed form if requested.
Reference WAC 388-97-0920(1-6)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
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Based on interview and record review, the facility failed to obtain or offer assistance in formulating or periodically checking if residents had an advance directive (AD) for 2 of 24 residents (Resi...
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Based on interview and record review, the facility failed to obtain or offer assistance in formulating or periodically checking if residents had an advance directive (AD) for 2 of 24 residents (Residents 22 and 65) reviewed for AD. This failure placed the residents at risk to be denied the opportunity to direct their health care if they were to become unable to make decisions or communicate their health care preferences.
Findings included .
Resident 22
Review of Resident 22's electronic health record (EHR) showed a Physician's Orders for Life Sustaining Treatment (POLST) titled as AD. The EHR did not show documentation of the resident requesting or declining the completion of an AD nor that the facility offered assistance in the development of an AD.
Resident 65
Review of Resident 65's EHR showed a POLST titled AD. The EHR did not show documentation of the resident requesting or declining the completion of an AD nor that the facility offered assistance in the development of an AD.
During an interview on 01/25/2024 at 10:42 AM, Staff D, Social Services, stated that staff thought the POLST was the AD and that they should have been requesting the durable power of attorney (DPOA) or offering assistance to formulate one.
During an interview on 01/25/2024 at 11:48 AM, Staff A, Administrator, stated that staff should have obtained the DPOA from the resident or resident's representative. Staff A stated if the resident did not have one but wanted one, they should have been offered assistance with establishing the AD. Staff A stated that the way it was handled did not meet their expectation.
Reference WAC 388-97-0280 (3)(c)(i-ii), -0300 (1)(b), (3)(a-c)
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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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Resident 12
During an interview on 01/25/2024 at 10:45 AM, Collateral Contact JJ stated that they had reported multiple times to staff that Resident 12 was missing their clothing. Collateral Contact J...
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Resident 12
During an interview on 01/25/2024 at 10:45 AM, Collateral Contact JJ stated that they had reported multiple times to staff that Resident 12 was missing their clothing. Collateral Contact JJ stated a staff member had told them they had thrown out bags of personal clothing because they had sat to long and became moldy because they did not have laundry staff and could not keep up. Collateral Contact JJ stated that they reported this concern to management on 01/04/2024 and had received some items back, but were still missing a lot.
During an interview on 01/24/2024 at 11:22 AM, Staff Z, District Laundry Manager, stated personal laundry was received in bags with the resident names on the bag. Staff Z also stated that they were not aware on any reports of Resident 12's missing clothing.
Review of the Grievance Log for 12/2023 and 01/2024 showed no entry for Resident 12's missing personal clothing/laundry.
During an interview on 01/25/2024 at 9:40 AM, Staff A, ADM, stated that they were aware of Resident 12's missing personal clothing and had been working on locating them, but Resident 12 was still missing personal clothing items. Staff A stated that there had been an issue with the laundry department staffing. Staff A also stated they had started a grievance on 01/04/2024 and it was still ongoing as they have not found all Resident 12's clothing because an inventory list had not been completed for Resident 12 as should have been.
WAC Reference WAC 388-97-0560 (1), (1)(a), 1860 (2)(a) & 0180 (4)(c)(ii),(5)
Based on observation, interview and record review, the facility failed to provide clean sheets and/or reasonable care for personal property for 5 of 5 residents (Residents 12, 13, 35, 68 and 86) when reviewed for safe, clean, and comfortable environment. This failure placed the residents at risk for loss of personal property, a diminished sense of security, possible infections, and a diminished quality of life.
Findings included .
Clean Sheets
Observation on 01/25/2024 at 9:52 AM showed Resident 86's flat sheets contained crumbs and several stains. Resident 86 stated that their bed sheets were changed approximately every other week, sometimes longer.
Observation and interview on 01/25/2024 at 12:22 PM showed Resident 35 had stains on their flat sheet. Resident 35 stated that bed linen was changed when they got a shower and that when there was COVID on the hall showers were not given. Resident 35 further stated that they had gone two to three weeks without the bed linen changed and would prefer to have it changed once per week.
During an interview on 01/26/2024 at 9:37 AM, Resident 13 stated that bed linen was changed every couple of weeks.
Review of the Resident Council meeting minutes for October 2023 showed that residents complained that beds were not made timely with sheets being soiled for longer than deemed acceptable.
During an interview on 01/25/2024 at 12:32 PM, Staff M, Certified Nursing Assistant (CNA), stated that residents' linen should be changed when they were damp, look soiled or on a shower day. Staff M observed Resident 86's flat sheet and stated, Oh, these need to be changed.
During an interview on 01/25/2024 at 12:46 PM, Staff E, Resident Care Manager (RCM), stated that residents' bed linen should be changed whenever it was soiled and routinely on shower days. Staff E stated that residents received bed baths during COVID; however, linen should have still been changed.
Personal Property
Resident 68
During an interview on 01/23/2024 at 10:56 AM, Resident 68 stated that over the past couple of months they had several pieces of missing clothing that never came back from laundry. Resident 68 stated they had reported it to everyone that would listen; however, they were told they needed a receipt to be reimbursed for the missing items.
Review of the facility's Grievance Log from August 2023 through January 2024 did not show the above grievances/concerns logged. However, it did show 10 grievances related to laundry/missing items in August 2023, 10 grievances related to laundry/missing items in September 2023, 1 grievance related to laundry/missing item in November 2023 and 2 grievances related to laundry/missing clothing in January.
Review of Resident Council Minutes on 01/26/2024 showed that in August 2023 residents expressed concern about long turnaround time for laundry. September 2023 minutes showed that Staff S, Housekeeping Manager, attended the meeting to address concerns with a goal to have a 24-hour personal property turnaround time.
During an interview on 01/25/2024 at 2:21 PM, Staff A, Administrator (ADM), stated that in order for residents to be reimbursed for lost personal property related to laundry the item should have been on their inventory sheet and a receipt also needed to be provided to prove the item was purchased within a reasonable time frame. Staff A stated that they did not have a definition for reasonable time frame as it would be a case-by-case basis. Staff A stated that they were doing the best they could to resolve the laundry issues.
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to complete a thorough investigation on an allegation neglect for 1 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to complete a thorough investigation on an allegation neglect for 1 of 5 residents (Resident 68) reviewed for accidents and/or incidents. This failure placed residents at risk for unidentified neglect and continued exposure to neglect.
Findings included .
Review of Resident 68's admission Minimum Data Set assessment (MDS) dated [DATE], showed that the resident admitted on [DATE] with multiple diagnoses to include left hip pain and osteoarthritis left hip (a joint disease, in which the tissues in the joint break down over time).
During an interview on 01/21/2024 at 1:58 PM, Resident 68 stated that the night shift nurse on 01/19/2024 refused to give them their pain medication stating the medication could only be administered every six hours. Resident 68 stated that they believed the nurse was prejudiced against narcotic use.
During an interview on 01/21/2024 at 3:56 PM, the above detailed allegation was reported to Staff A, Administrator (ADM), Staff B, Director of Nursing (DNS), and Staff C, Assistant Director of Nursing (ADON).
Review of the facility's incident investigation, dated 01/21/2024, showed that a DSHS Surveyor had reported that Resident 68 was not given their medication on night shift of 01/19/2023. Resident stated that they asked for meds and the LN told them it was too soon. Resident further stated that [they] never came back to check on the resident or offer mediation when they were available. The incident report showed no expanded interviews documented from the other residents on the wing; however, it was noted, Other residents were interviewed to assess for widespread issues, and none were found. There was no written statement obtained from other staff assigned to the wing that shift. Further review showed that Resident 68 was not placed on alert for potential psychosocial harm.
Review of the written statement included in the investigation from the Licensed Practical Nurse (LPN) stated the medication was administered on 01/18/2024 at 10:30 PM and was requested again by the resident at midnight; however, the LPN informed the resident that the medication has a four hour window before it could be administered and was not until 01/19/2024 at 6:00 AM.
Review of the January medication administration record (MAR) showed administration of the pain medication at 6:29 AM and 1:19 PM on 01/19/2024. The MAR showed a staff discrepancy with that the LPN's initials who administered other medications on the night shift of 01/19/2024 and the LPN who provided the written statement.
Review of a Narcotic Log provided with the investigation showed a discrepancy that the pain medication was administered on 01/19/2024 at 8:16 PM by the staff member who had administered other medications on the 01/19/2024 night shift.
During an interview on 01/26/2024 at 9:48 AM, Staff B stated they had used the Narcotic Log and the staff calendar to determine who the nurse was. Staff B stated they did not ask the resident for the staff name because they didn't believe the resident would be able to provide the information. When asked about the staff discrepancy, Staff B stated that they looked at the night shift of 01/18/2024 instead the allegation date 01/19/2024 although Resident 68 did confirm the date and shift. Staff B stated that the investigation was not completed thoroughly.
Reference WAC 388-97-0640(5)
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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
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 22
Review of Resident 22's EHR showed the resident was sent to the hospital on [DATE] for respiratory issues and return...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 22
Review of Resident 22's EHR showed the resident was sent to the hospital on [DATE] for respiratory issues and returned to the facility on [DATE].
Review of Resident 22's EHR did not show documentation that the resident or their representative was notified verbally or in writing of the 11/16/2023 transfer to the hospital.
During an interview on 01/22/2024 at 2:58 PM, Staff F, Resident Care Manager, stated that the nurses on the floor were responsible for notifying the resident and their representative of transfers.
During an interview on 01/24/2024 at 12:34 PM, Staff B, Director of Nursing Services, stated that a notice of transfer form should be completed, and a copy given to the resident and their representative, but they were unable to locate one for Resident 22's 11/16/2023 transfer to the hospital and there should have been one.
Reference WAC 388-97-0120 (2)(a-d)
Based on interview and record review, the facility failed to properly notify the Office of State Long-Term Care Ombudsman (SLTCO, an advocacy group for residents in a nursing home) or the resident/resident representative of discharges for 2 of 5 residents (Residents 159 and 22) reviewed for hospitalization. These failures placed residents at risk for being inappropriately discharged , lack of access to an advocate who can inform them of their options and rights, and to ensure that the SLTCO and residnt/ resident representative was aware of facility practices and activities related to transfers and discharges.
Findings included .
Resident 159
Review of the discharge minimum data set assessment, dated 01/08/2024, showed Resident 159 admitted on [DATE] with multiple diagnoses to include heart, lung, kidney disease and diabetes. The MDS and electronic health record (EHR) showed that the resident was discharge on [DATE] to a local hospital with a return to the facility anticipated and was able to make their needs known.
Review of Resident 159's EHR did not show that the SLTCO had been notified of the discharge.
During an interview on 01/24/2024 at 11:28 AM, Staff P, Medical Records Director (MRD), stated that a written notification to the SLTCO of transfer to the hospital was a function of the social services staff and that in the past they had complied a list of resident transfer/discharges every 30 days to the SLTCO; however, they did not know if this occurred for Resident 159.
During an interview on 01/24/2024 at 11:30 AM, Staff A, Administrator, stated that the facility had a process in which the SLTCO was notified of resident transfers/discharges to the hospital; however, they stated that the Social Services staff who would notify the ombudsman was no longer employed with the facility, so they did not have documentation of the written notification for Resident 159.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) accurately reflected the current status for 2 of 5 residents (Residents 80 and 88) reviewed for PASRRs. This failure had the potential to place residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet mental health care needs.
Findings included .
Resident 80
Review of Resident 80's medical diagnosis list showed that the resident had a diagnosis of Schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) on admission dated 01/27/2023.
Review of Resident 80's PASRR, dated 01/27/2023, completed by the facility on the date of admission, showed no mental disorders checked on the form.
Review of the physician orders on 01/23/2024 showed that Resident 80 was prescribed a medication related to Schizophrenia to be administered daily.
During an interview on 01/23/2024 at 11:04 AM, Staff D, Social Service Director (SSD), stated that the PASRR was incorrect for Resident 80; however, it would be their expectation that when residents were admitted the PASRR would reflect the correct diagnosis.
During an interview on 01/23/2024 at 12:56 PM, Staff B, Director of Nursing Services (DNS), stated that it was the expectation that either the SSD or the Residential Care Manager would conduct a comprehensive care plan on behavioral issues.
Resident 88
Review of the admission minimum data set (MDS), an assessment tool, dated 10/12/2023, showed the resident admitted on [DATE] with multiple diagnoses to include alcohol abuse, post-traumatic stress disorder (PTSD, a mental illness that can develop after seeing or hearing about traumatic events), and depression. The MDS showed the resident was able to make their needs known.
Review of Resident 88's PASRR, dated 10/05/2023, completed by a local medical center's social services staff showed no PTSD diagnoses was checked on the form.
During an interview on 01/23/2024 at 11:04 AM, Staff D, Social Service Director (SSD), stated that the PASRR for Resident 88 was incorrect and that it was the expectation that when residents were admitted that the PASRR that would reflect the correct diagnosis.
Reference WAC 388-97-1975
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to thoroughly investigate a resident fall and plan new ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to thoroughly investigate a resident fall and plan new interventions to decrease the chance of a fall or reduce injury from a fall for 1 of 1 resident (Resident 81) reviewed for accidents. This failure placed residents at risk for repeated falls, avoidable injury, and a diminished quality of life.
Findings included .
Observation and interview on 01/22/2024 at 11:07 AM showed Resident 81 had a large lump with a scabbed wound on their forehead. Resident 81 stated that they had fallen and had been taken to the hospital.
Review of a 01/06/2024 progress note showed that Resident 81 had fallen, sustained a head hematoma (a large bruise) and laceration (a deep cut) and was sent to the emergency department.
Review of Resident 81's 05/15/2023 initiated care plan showed a focus area related to falling. This focus area showed that the most recently implemented intervention was dated 10/31/2023 with all other interventions dated 05/15/2023.
Review of Resident 81's interdisciplinary (relating to more than one branch of knowledge) team fall assessment dated [DATE] showed that no information was inputted and was error incomplete.
Review of the investigate report for Resident 81's 01/06/2024 fall showed that the resident was found on the floor of their bathroom in a large pool of blood, may have lost consciousness, had injury to the head, and had dried blood around the head wound. The documented intervention was to continue Resident 81's plan of care.
During an interview on 01/24/2024 at 2:10 PM, Staff C, Assistant Director of Nursing, stated they had conducted the investigation into Resident 81's 01/06/2024 fall. Staff C stated that an unwitnessed fall was investigated to rule out abuse/neglect and to determine how to reduce fall occurrence or to decrease resident injury during a fall. Staff C stated that the investigation failed to determine new interventions to decrease falls or reduce injury from falls for Resident 81. Staff C stated that Resident 81's fall history was not considered during the fall investigation, which would be required for the investigation to be thorough. Staff C stated that the investigation could have been better.
During an interview on 01/24/2024 at 2:25 PM, Staff B, Director of Nursing Services, stated that Resident 81's investigation for the fall on 01/06/2024 could have been more thorough and that new interventions were needed to reduce fall frequency or reduce injury from falls for Resident 81.
Reference WAC 388-97-1060 (3)(g)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to provide dialysis (a process to remove waste from blo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to provide dialysis (a process to remove waste from blood) care consistent with professional standards for one of one resident (Resident 40) reviewed for dialysis. This failure placed the resident at risk for adverse health outcomes, inadequate quality of care and decreased quality of life.
Findings included .
<Communication>
Review of the admission Minimum Data Set (MDS, a required assessment tool) on 01/24/2024 showed that Resident 40 was admitted on [DATE] with multiple diagnoses to include kidney disease.
Review of Resident 40's electronic health record (EHR) showed that the resident received dialysis weekly on Monday, Wednesday, and Friday.
Review form Hemodialysis Communication Record, dated 01/03/2024, showed missing and/or incomplete information which included missing vital sign information. Communication forms were unable to be located for dialysis dates 01/05/2024, 01/10/2024, 01/15/2024 and 01/17/2024.
During an interview on 01/24/2024 at 9:56 AM, Staff F, Residential Care Manager (RCM), stated that it was their expectation that all communication between the facility and dialysis center would be completed thoroughly.
During an interview on 01/26/2024 at 10:15 AM, Staff B, Director of Nursing Services (DNS), stated that the expectation was for staff to follow up to make sure all dialysis communication forms were completed, reviewed, and uploaded.
<Fluid Restriction>
Review of the EHR showed a physician's order dated 01/01/2024 to monitor fluids, not to exceed 1500 milliliters (mls) per day.
Review of Resident 40's task list showed no fluid restriction information.
During an interview on 01/23/2024 at 9:29 AM, Staff N, Certified Nursing Assistant (CNA), stated that they were not aware of any residents who had a fluid restriction. Staff N further stated that if a resident had a fluid restriction it would be in the resident's task list.
During an interview on 01/23/2024 at 9:34 AM, Staff L, Licensed Practical Nurse, stated that the CNAs were responsible for reporting the resident's fluid intake to the nurses.
During an interview on 01/24/2024 at 9:56 AM, Staff F stated that they would update the task list to reflect Resident 40's fluid restriction.
During an interview on 01/26/2024 at 10:15 AM, Staff B stated that it did not meet their expectation that the fluid restriction was not accurately documented for Resident 40.
Reference WAC 388-97-1900 (1), (6)(a-c)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure expired medications were removed/disposed of in accordance with professional standards for 1 of 3 medication carts (Nor...
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Based on observation, interview and record review, the facility failed to ensure expired medications were removed/disposed of in accordance with professional standards for 1 of 3 medication carts (North Hall medication cart #3) reviewed for Medication Storage. This failure placed residents at risk of receiving expired medications.
Findings included .
Review of the facility's documentation titled, Medication Labeling and Storage dated February 2023 showed, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.
Observation of the North Hall medication cart #3 with Staff T, Licensed Practical Nurse (LPN), on 01/21/2024 at 2:01 PM showed that the top drawer had one bottle of vitamin C, 250 milligrams (dietary supplement) expired in December 2023 and a bottle of aspirin, 81 milligrams (used to help prevent heart attacks and strokes) expired in November 2023.
During an interview on 01/21/2024 at 2:17 PM, Staff T, LPN, stated that the expired bottles of Vitamin C and Aspirin should not have been stored in the medication cart and needed to be disposed of.
During an interview on 01/23/2024 at 9:46 AM, Staff B, Director of Nursing Services, stated that they were not aware that expired bottles of medications were stored in the North Hall medication cart #3 and this did not meet expectations.
Reference WAC 388-97-1300 (2)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
.
Based on interview and record review, the facility failed to provide routine dental care for 1 of 3 residents (Resident 19) reviewed for dental. This failure placed residents at risk for difficulty ...
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Based on interview and record review, the facility failed to provide routine dental care for 1 of 3 residents (Resident 19) reviewed for dental. This failure placed residents at risk for difficulty eating, dental pain, unintended weight loss, and a diminished quality of life.
Findings included .
Review of a 10/27/2023 dental consultation showed that Resident 19 received a recommendation for full extraction of the lower teeth and new lower denture. Further review showed that Resident 19 was agreeable to this plan.
Review of a 11/20/2023 progress note showed that Resident 19 had one to three broken or decayed teeth.
During an interview on 01/23/2024 at 10:57 AM, Staff E, Resident Care Manager, stated that dental recommendations were given to the facility's appointment scheduler to have them scheduled. Staff E further stated that the facility's appointment scheduler position had transferred to several people in the previous months. Staff E stated that they were unsure whether Resident 19 had had any follow-up on the 10/27/2023 recommendations.
During an interview on 01/23/2024 at 11:28 AM, Staff P, Health Information Manager/Medical Records Director (MRD), stated that the scheduling of dental appointments had previously been handled by a staff that was no longer at the facility.
Review of the facility's appointment scheduling calendar from 10/27/2023 to 01/23/2024 showed no appointments for Resident 19.
During an interview on 01/23/2024 at 11:46 AM, Staff B, Director of Nursing Services, stated that the expectation was for dental appointments to be made within 48 hours and that the lack of follow-up on Resident 19's dental recommendations from 10/27/2023 did not meet this expectation.
Reference WAC 388-97-1060 (1), (3)(j)(vii)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review the facility failed to provide assistance and follow up on an appointment for dental care...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review the facility failed to provide assistance and follow up on an appointment for dental care services for 1 of 3 resident (Residents 49) reviewed for dental services. This failure placed the residents at potential risk for continued dental problems and decreased the quality of life.
Findings included .
Review of the quarterly Minimum Data Set (a required assessment) dated 12/19/2023 showed Resident 49 admitted on [DATE] with multiple diagnoses to include heart disease, stroke, hemiplegia (one side of body affected with paralysis), muscle weakness, depression, and anxiety. In addition, the MDS showed the resident was able to make needs known and received hospice services.
During an interview on 01/22/2024 at 10:12 AM, Resident 49's family member stated that the resident had lost weight and dentures did not fit well and was supposed to receive new dentures but did not know the status.
Review of a document titled, Smile Seattle Dentures, dated 11/03/2022, showed multiple missing teeth, visible decay, and recession. The document showed that the provider had provided treatment for the resident's decay and that a recall was ordered within six months for Resident 49's dental maintenance. A follow-up visit was attempted on 05/26/2023 at the facility; however, the resident was out of the facility.
Review of a progress note dated 12/17/2023 at 8:03 PM showed that an MDS staff documented Resident 49 had a few teeth at the top and bottom that appeared broken and decayed.
During an interview on 01/24/2024 at 9:30 AM, Staff E, Residential Care Manager (RCM), stated that the facility had staff that were supposed to make appointments for the resident's dental schedule; however, one staff left last fall who was doing the dental schedule and that another staff replacement was let go shortly afterwards.
Reference WAC 388-97-1060 (2)(c), (3)(j)(vii)
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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 F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to timely refer a resident to hospice services for 1 of 2 residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to timely refer a resident to hospice services for 1 of 2 residents (Resident 160) reviewed for hospice. This failure placed the resident at risk of not receiving palliative services, unnecessary pain and suffering, and a diminished quality of life.
Findings included .
Review of Resident 160's census showed that the resident admitted on [DATE] and discharged on 09/03/2023.
Review of Resident 160's physician's orders showed a referral for hospice services on 08/28/2023.
Review of a care conference note dated 08/28/2023 showed that family and facility staff agreed that Resident 160 would be referred for hospice services.
During an interview on 01/25/2024 at 9:50 AM, Staff D, Social Services, stated that the social services department would make referrals for hospice services. Staff D further stated that they could not find documentation that Resident 160 was referred for hospice services and this did not meet expectation. Staff D stated that there had recently been a lack of steady social worker in the facility and that this may have contributed to the lack of hospice referral.
During an interview on 01/26/2024 at 10:33 AM, Staff C, Assistant Director of Nursing, stated that referrals for hospice services should occur as soon as possible and could not provide documentation that Resident 160 was referred to hospice.
During an interview on 01/26/2024 at 10:41 AM, Staff B, Director of Nursing Services, stated that hospice referrals would normally be handled by the social services department, but this department had been struggling to maintain a social worker in the facility. Staff B stated this lack socials services may have contributed to the lack of hospice referral for Resident 160. Staff B stated that this did not meet expectation.
No Associated WAC
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
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Based on interview and record review, the facility failed to provide influenza and pneumococcal vaccines for 2 of 5 residents (Residents 93 and 98) when reviewed for vaccinations. This failure place...
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Based on interview and record review, the facility failed to provide influenza and pneumococcal vaccines for 2 of 5 residents (Residents 93 and 98) when reviewed for vaccinations. This failure placed the residents at a higher risk for contracting influenza and pneumococcal infections, related complications, and a decreased quality of life.
Findings included .
Review on 01/24/2024 of Resident 93's electronic health record showed that the resident consented to receive the influenza vaccine on 11/30/2023. Further review showed no vaccine had been ordered or administered.
Review on 01/24/2024 of Resident 98's electronic health record showed that the resident consented to receive the influenza and pneumococcal vaccines on 12/21/2024. Further review showed no influenza and pneumococcal vaccines had been ordered or administered.
During an interview on 01/25/2024 at 12:14 PM, Staff H, Infection Preventionist, stated that if a resident consented to the influenza or pneumococcal vaccines an order should have been entered into the resident's medical record and the vaccines should have been administered to the residents but this did not happen for Residents 93 and 98.
During an interview on 01/25/2024 at 2:27 PM, Staff B, Director of Nursing Services, stated that the vaccines for Residents 93 and 98 were not administered and they should have been.
Reference WAC 388-97-1340 (1), (2), (3).
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
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Based on interview and record review, the facility failed to conduct timely care planning meetings with the resident or responsible party for 2 of 24 residents (Residents 38 and 49) reviewed for car...
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Based on interview and record review, the facility failed to conduct timely care planning meetings with the resident or responsible party for 2 of 24 residents (Residents 38 and 49) reviewed for care planning. This failure placed the residents at risk for unmet needs, not being involved or informed of their plan of care and decreased quality of life.
Findings included .
Resident 38
During an interview on 01/22/2024 at 10:28 AM, Resident 38 stated that they did not have a recent care conference.
Review of the electronic health record (EHR) showed the last care plan meeting was held on 03/02/2023.
Resident 49
During an interview on 01/21/2024 at 11:13 AM, Resident 49 stated that they did not believe they had a care conference.
Review of the EHR showed the last care plan meeting was on 06/05/2023.
During an interview on 01/25/2024 at 11:54 AM, Staff A, Administrator (ADM), stated that the facility had been without Social Services staff and that was why care conferences were not completed. Staff A stated that it was their expectation that care conferences were held every three months or as timely as possible. Staff A further stated the missed care conferences did not meet their expectation.
Reference WAC 388-97-1020(2)(f), (4)(b)
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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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 12
Review of Resident 12's Electronic Health Record (EHR) showed the resident required total assistance for bathing and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 12
Review of Resident 12's Electronic Health Record (EHR) showed the resident required total assistance for bathing and preferred showers during the day.
Observations on 01/21/2024 at 11:26 AM, 01/22/2024 at 10:43 AM and 01/23/2024 at 11:22 AM showed Resident 12 laid in bed wearing a hospital gown. Their hair appeared oily and dried food was noted on the resident's chin.
Review of Resident 12's shower task documentation showed a shower was offered on 01/04 and 01/08/2024. No other showers were documented for the prior 30 days.
Resident 26
Review of Resident 26's EHR showed they required extensive assist with bathing and preferred showers.
Review of Resident 26's shower task showed no showers documented as completed in last 30 days.
During an interview on 01/24/2024 at 10:44 AM, Resident 26 stated that they had one shower in the last month and would like to have one more often.
During an interview on 01/24/2024 at 10:42 AM, Staff M, CNA, stated that residents got showers from the shower aides and that the CNAs did not have time to provide showers when the shower aide was not available.
During an interview on 01/25/2024 at 2:23 PM, Staff B, Director of Nursing Services (DNS), stated that showers should be provided per the resident preference, at least once a week, and a bed bath should be offered and reported to the nurse if a resident refused. Staff B stated that Residents 12 and 26's lack of showers/bathing did not meet their expectations.
Resident 48
During an interview on 01/22/2024 at 9:55 AM, Resident 48 stated that the facility staff rarely had time to assist them to get out of bed, and that they had stopped asking for assistance due to the wait time.
Observation on 01/22/2024 at 10:27 AM, showed Resident 48 laid in bed and asked a CNA for assistance in getting out of bed. The staff stated that they would return later, turned off Resident 48's call light, and moved into a different resident room.
Observation at 01/23/2024 at 11:38 AM showed Resident 48 in bed with their call light on.
Observation on 01/23/2024 at 12:00 PM showed Resident 48 out of bed and in their wheelchair.
During an interview on 01/23/2024 at 12:10 PM, Resident 48 stated that this occurrence of waiting one hour and 33 minutes to receive assistance in getting out of bed was a usual occurrence.
During an interview on 01/24/2024 at 10:09 AM, Resident 48 stated that on 01/23/2024 in the afternoon they had asked for assistance to return to bed to eat lunch, was told to eat in their chair, and was not assisted back to bed until approximately 4:00 PM.
During an interview on 01/25/2024 at 2:00 PM, Staff E stated that the expectation was for staff to only turn off call lights once a resident had been assisted and assistance should be provided timely. Staff E stated that this expectation had not been met for Resident 48.
During an interview on 01/26/2024 at 10:35 AM, Staff C, Assistant Director of Nursing, stated that if a staff turned off a call light before providing assistance the staff should follow-up with the resident to make sure that assistance was provided, and that assistance should be provided timely. Staff C stated that this expectation was not met for Resident 48.
During an interview on 01/26/2024 at 10:45 AM, Staff B stated that the assistance provided to Resident 48 did not meet their expectation.
Reference WAC 388-97-1060 (2)(c)
Based on observation, interview and record review, the facility failed to provide the services to assist residents with activities of daily living (ADL) for 5 of 24 residents (Residents 88, 4, 12, 26, and 48) reviewed for activities of daily living. Failure to provide showers as scheduled (Residents 88, 4, 12, and 26) and assistance to get out of bed (Resident 48) placed the resident at risk for medical complications, unmet needs, and a diminished quality of life.
Findings included .
Review of a document titled, Bath, Shower/Tub [Personal Care], dated February 2018, showed that the purpose of the procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The document showed that the facility staff were to date and time the shower/tub bath was performed, the name and titled of the individual(s) who assisted the resident with the shower/tub bath, conduct an assessment data of any reddened areas, sores, etc, on the residents skin, how the resident tolerated the shower/tub bath, if the resident refused and the reason(s) why and the interventions taken. In addition, the document showed that a signature was needed and title of the person recording the data. The document showed staff were to report to the supervisor if the resident refused the shower/tub bath and to report other information in accordance with facility policy and professional standards of practice.
Resident 88
Review of the admission assessment of minimum data set (MDS), a required assessment, dated 10/12/2023, showed the resident admitted on [DATE] with multiple diagnoses to include paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), neurogenic bladder (a urinary condition due to a lack of bladder control due to brain, spinal cord or nerve problem), osteomyelitis (inflammation of the bone usually due to infection) of vertebra and sacral (bottom of the spine and coccyx [tailbone]) region with pressure ulcer (an injury that break downs the skin and underlying tissue), and depression. The MDS showed the resident was able to make needs known, required a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) and required substantial/maximal assistance with toileting.
During an observation and interview on 01/21/2024 at 1:51 PM, Resident 88 was observed within a wheelchair. The resident appeared disheveled with unshaven face and black substance noted under excessively long fingernails. Resident 88 stated that had only received one shower a month but would like to have more.
Review of a care plan, dated 10/12/2023, showed a focus for staff to engage the resident in opportunities for daily routines that were meaningful relative to their preferences. An intervention within the care plan showed that it was important for the resident to choose how to bathe and that the resident preferred showers. In addition, another focus area was that the resident required assistance for ADL care in bathing, grooming, personal hygiene, and toileting related to the resident's paralysis and weakness. Interventions included extensive assistance with showering.
Review of a task flowsheet for bathing showed that from 12/25/2023 to 01/16/2024, Resident 88 had one shower documented on 01/12/2024.
Resident 4
Review of the quarterly MDS, dated [DATE], showed the resident admitted on [DATE] with multiple diagnoses to include heart and lung disease, stroke, hemiplegia (one side of body affected with paralysis), anxiety, and depression. The MDS showed the resident was able to make needs known and required assistance and was dependent for staff to provide ADL.
Observation and interview on 01/21/2024 at 2:21 PM, showed Resident 4 sat up in their wheelchair. The resident wore a robe with hair uncombed and without wearing their dentures. Resident 4 stated that they would like more showers, but more staffing was needed to assist.
Review of a care plan, dated 02/28/2023, showed Resident 4 required assistance and was dependent on staff for ADL care in bathing, grooming, hygiene, and toileting related to a recent hospitalization. Interventions showed that the resident required extensive assistance with bathing and that staff were to provide opportunity for bathing preference: Resident preferred a shower in the day or evening (before) dinner) and had no preference on the gender providing assistance and preferred receiving showers twice a week.
Review of a bathing record task between 12/26/2023 to 01/18/2024, showed Resident 4 received four documented showers on 12/30/2023, 01/07/2024, 01/08/2024 and 01/17/2024.
During an interview on 01/23/2024 at 2:28 PM, Staff E, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated that the facility had staffing challenges during the months of December 2023 and January 2024 period due to staff call outs (unable to work due to sick calls) and that the shower aide was pulled to work other areas (i.e. restorative care).
During an interview on 01/24/2024 at 8:56 AM, Staff Q, Restorative Nurse Aide (RNA), stated that they gave the residents showers every Tuesday and Thursday and worked as an RNA on Monday, Wednesday, and Friday and when not assigned, the aides (Certified Nursing Assistants (CNA)) were to assist the residents with their showers. Staff Q stated that the aides were to complete a skin assessment sheet and if the resident refused or they (aides) were unable to complete the shower then it was to be documented.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 59
During an interview on 01/22/2024 at 1:27 PM, Resident 59 stated that they had constipation and abdominal discomfort...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 59
During an interview on 01/22/2024 at 1:27 PM, Resident 59 stated that they had constipation and abdominal discomfort off and on.
Review of Resident 59's bowel monitor task showed no BM was documented on the following dates in January 2024: 01/10/2024 to 01/13/2024 (three days) and 01/15/2024 through 01/19/2024 (five days).
Review of Resident 59's MAR for the month of January 2024 showed the resident received MOM on 01/03/2024 and 01/13/2024, but no other as needed laxative medications were administered.
Resident 71
During an interview on 01/21/2024 at 11:28 AM, Resident 71 stated that my constipation is very bad.
Review of Resident 71's bowel monitor task showed their last BM was on 01/12/2024. There was no documented BM in the previous 11 days.
Review of Resident 71's MAR showed the resident received an as needed laxative on 01/08/2024 and 01/13/2024. No other as needed laxatives were administered.
During an interview on 01/24/2024 at 12:10 PM, Staff B, Director of Nursing Services, stated that it was their expectation that staff document resident's BM each shift in the resident's chart and each morning a list was given to the nurses to administer as needed bowel medications. Staff B stated this did not happen for Resident 59 or 71, and this did not meet their expectations.
Side Effect Monitoring
Resident 38
Review of Resident 38's EHR showed that they received a dose of COVID-19 (infectious respiratory virus) vaccine on 01/18/2024 and was tested for COVID-19 on 01/19/2024 which showed a positive result. Resident 38 was started on an experimental antiviral medicine for the treatment of mild-to-moderate COVID-19 on 01/19/2024.
Review of Resident 38's EHR did not show documentation of monitoring for adverse side effects of the COVID-19 vaccine administration or the antiviral medication on 01/18/2024, 01/19/2024 or 01/20/2024 and no documentation of monitoring for symptoms of COVID-19 related to positive COVID-19 results on 01/20/2024, 01/22/2024 or 01/23/2024.
During an interview on 01/24/2024 at 12:44 PM, Staff B stated that Resident 38 should have been placed on alert to monitor for adverse side effects of the COVID-19 vaccine, antiviral medication, and positive COVID-19 result but was not.
Resident 48
Observation on 01/22/2024 at 10:26 AM showed Resident 48 had a bruise approximately the size of a half dollar on their left forearm. Resident 48 could not recall how they received this bruise and was unsure whether staff were aware.
Review of a 01/17/2024 skin assessment showed no documentation of a left forearm bruise.
Review of a 01/24/2024 skin assessment showed no documentation of a left forearm bruise.
During an interview on 01/25/2024 at 1:54 PM, Staff E stated that the facility monitored resident skin conditions by performing skin assessments on admission and weekly and staff filled out additional skin observations during resident showers. Staff E stated that Resident 48 had no skin issues per the EHR but observed that Resident 48 had a bruise on the left forearm. Staff E stated that staff should have noticed Resident 48's bruise and that this did not meet expectation.
During an interview on 01/26/2024 at 10:45 AM, Staff B stated that their expectation was that skin assessments would be accurate, and that Resident 48's skin assessment did not meet this expectation.
Reference WAC 388-97-1060 (1)
Based on observation, interview and record review, the facility failed to provide care which met professional standards for 5 of 24 residents (Residents 14, 38, 71, 59, and 48) when reviewed for quality of care. The facility's failure to consistently monitor and document bowel movements and implement the bowel program when needed (Residents 14, 38, 71, and 59), failure to monitor for adverse side effects (Resident 38), failure to identify and monitor a skin condition (Resident 48) placed the residents at risk for worsening condition, discomfort, and a decreased quality of life.
Bowel Program
Resident 14
Review of the annual minimum data set (MDS), a required assessment tool, dated 10/08/2023, showed resident was able to make needs known and was diagnosed with chronic pain and constipation.
During an interview on 01/22/2024 at 9:18 AM, Resident 14 stated that they had constipation, it was a problem and sometimes would have three days without a bowel movement (BM).
Review of a care plan dated 03/06/2023 showed a focus area that the resident exhibited or was at risk for alterations in comfort related to chronic pain. Interventions included to establish bowel regime, monitor, and report as indicated, any constipation.
Review of the electronic health record (EHR) for Resident 14's report task sheet (30 day look back period) for toileting showed that the resident had multiple episodes of no BM for greater than three days. The following dates showed greater than three days in which Resident 14 had no documentation for a BM: 12/24/2023 to 12/29/2023 (6 days) and 01/08/2024 to 01/19/2024 (11 days).
Review of the providers current order set for Resident 14 showed the provider had ordered multiple medications to be administered as necessary for constipation. The licensed nurse (LNs) were to first administer Milk of Magnesia Suspension (MOM, a medication used for constipation) at bedtime if no BM within 3 days. LNs were then to administer Dulcolax suppository as needed for constipation if no results from the MOM by next shift. The LNs were instructed to administer fleets enema as needed for constipation if no results from the Dulcolax within 2 hours. Finally, if no results from the Fleets enema, the order instructed the LNs to call the provider for further orders.
Review of the December 2023 and January 2024, medication administration record (MAR), showed LNs had not documented the administration of the as needed constipation medication as instructed for the dates 12/24/2023 to 12/29/2023 and 01/08/2024 to 01/19/2024.
Resident 38
Review of the quarterly MDS showed the resident was re-admitted on [DATE] with multiple diagnoses to include gastroesophageal reflux disease (a condition in which stomach contents move up into the esophagus that may damage the esophagus, pharynx and respiratory tract). The MDS showed Resident 38 was able to make their needs known and required assistance with activities of daily living and toileting.
Review of a care plan, dated 10/06/2020, showed a focus area that the resident exhibited or was at risk for gastrointestinal symptoms or complications. Interventions included to establish bowel regimen, utilize pharmacological agents as appropriate (i.e. stool softeners, laxatives, etc.) and document the effectiveness. The interventions directed the LNs to assess for signs and symptoms of constipation, abdominal distension, and cramping. Staff were to monitor and report as indicated any constipation.
Review of the providers order set dated 12/14/2022 for Resident 38 showed the provider had ordered multiple medication to be administered as necessary for constipation. The LNs were to first administer MOM at bedtime if no BM within three days. LNs were then to administer Dulcolax suppository as needed for constipation if no results from the MOM by next shift. LNs were instructed to administer fleets enema as needed for constipation if no results from the Dulcolax within two hours. Finally, if no results from the Fleets enema, the order instructed the LNs to call the provider for further orders.
Review of the EHR for Resident 38's report task sheet (30 day look back period) for toileting showed that the resident had multiple episodes of greater than three days of no BM. The following dates showed greater than three days in which Resident 38 had no documentation for a BM: 01/01/2024 to 01/05/2024 (5 days) and 01/11/2024 to 01/16/2024 (6 days).
Review of the January 2024 MAR showed LNs had not documented the administration of the as needed providers constipation medication as instructed for the dates on 01/01/2024 to 01/05/2024 and 01/11/2024 to 01/16/2024
During an interview on 01/23/2024 at 10:25 AM, Staff O, Certified Nurse Aide (CNA), stated that the facility had an EHR tablet computer that recorded whether the resident has had a bowel BM and directed CNAs to inform the nurses if the residents complained of constipation. Staff O, CNA, stated that the LNs then were to check to see if the resident had or had not had a BM for greater than three days and give any medication.
During an interview on 01/23/2024 at 10:42 AM, Staff E, Residential Care Manager/Licensed Practical Nurse (RCM/LPN), stated that it was their expectations that if the resident did not have a BM, then the CNAs were directed to chart on their EHR tablet every day prior to ending their shifts. Staff E stated that an alert would appear on the EHR for the LNs to administer the as necessary constipation medication if greater than three days without the resident having a BM. The resident would come off the EHR alert status if they had one BM.
During an interview on 01/23/2024 at 10:32 AM, Staff DD, LPN, stated that if the resident did not have a BM for greater than three days an alert would come up on the computer to direct the LNs to administer the as necessary constipation medication. Staff DD stated that they would first assess the resident and administer the constipation medication if necessary.
During an interview on 01/23/2024 at 12:47 PM, Staff C, Assistant Director of Nursing (ADON), stated that it was their expectation that the LNs assess and administer the providers constipation orders as directed whenever the resident was on alert for not having a BM for greater than three days.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to ensure freedom from unnecessary medications for 5 of 9 residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to ensure freedom from unnecessary medications for 5 of 9 residents (Residents 71, 26, 2, 59, and 38) reviewed for unnecessary medications. Failure to provide nonpharmacological interventions prior to as needed pain medications (Residents 38, 26, 2, and 59) and to monitor for anticoagulation (blood thinning) side effects (Resident 71) placed the residents at risk for unintended side-effects related to the medications, medical complications, and a diminished quality of life.
Findings Included .
<Anticoagulation>
Review of a document titled Anticoagulation - Clinical Protocol revised November 2018 showed, The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situations with the physician before giving the next scheduled dose of anticoagulant.
Resident 71
During an interview on 01/21/2024 at 11:20 AM, Resident 71 stated that they had bloody noses on Thursday 01/18/2024 and Friday 01/19/2024 and that they wouldn't stop for a long time.
Review of Resident 71's electronic health record (EHR) showed an order for a anticoagulant two times a day to prevent blood clots. Further review of the EHR showed no plan of care for anticoagulant therapy and no order to monitor for adverse side effects.
During an interview on 01/23/2024 at 9:53 AM, Staff FF, Licensed Practical Nurse (LPN), stated that nurses would document side effect monitoring of an anticoagulant therapy in the medication administration record (MAR). Staff FF stated that Resident 71 had a nosebleed last week that took a long time to stop. When asked if Resident 71 had a place in the MAR to monitor for side effects of the anticoagulant, such as excessive bleeding, Staff FF stated, No, I don't see one.
Review of Resident 71's MAR for the month of January 2024 showed the resident's anticoagulant was not administered on the evening of 01/18/2024 and was administered on the morning of 01/19/2024.
Review of Resident 71's EHR showed a progress note dated 01/18/2024 at 11:02
AM which showed, The resident had a nose bleeding episode. No documentation was found that the provider was notified.
During an interview on 01/24/2024 at 12:31 PM, Staff B, Director of Nursing Services (DNS), stated that it was their expectation that all residents who were receiving anticoagulant therapy would be monitored for adverse side effects with an order in the MAR and a care plan should be in place. Staff B further stated that Resident 71 did not have these things in place and should have.
<Pain Management>
Review of a document titled, Pain Management, dated 08/25/2021 showed that pain management was to be consistent with professional standards of practice and the comprehensive person-centered care plan, and the resident's goals and preferences were to be provided to residents who required such services. The document showed an individualized, interdisciplinary (consisting of professionals from different fields) care plan would be developed and include non-pharmacological (without use of medication, e.g. heat, massage or repositioning) and pharmacological approaches, the care plan would be evaluated until satisfactory pain management was achieved, and the non-pharmacological approaches for effectiveness would be reviewed.
Resident 26
Review of Resident 26's EHR showed orders for as needed (PRN) pain medication and an order to document non-pharmacological interventions (NPI).
Review of Resident 26's January 2024 MAR showed not applicable (NA) was documented for NPI on 01/01/2024, 01/05/2024, 01/06/2024, 01/07/2024, 01/09/2024, 01/10/2024 and 01/11/2024, and no NPI were documented for administrations on 01/04,2024 01/07/2024, 01/11/2024, 01/20/2024 and 01/22/2024.
Resident 2
Review of Resident 2's EHR showed an order for a pain medication when the pain level was five through seven on a one to ten pain scale. The resident received a dose on 01/05/2024 and a dose on 01/09/2024 for a pain level of eight out of ten. There were no corrisponding NPI documented for either dose.
Review of Resident 2's EHR showed an order for a stronger pain medication (10 milligrams) PRN for a pain level of eight through ten. The resident received a dose on 13 occasions in the month of January 2024 without NPI documented in the EHR.
Resident 59
Review of Resident 59's EHR showed an order for a narcotic pain medication PRN and there was an order to attempt NPI. The resident received doses on 01/20/2024, 01/21/2024 and 01/22/2024 with NA documented for NPI.
During an interview on 01/23/2024 at 1:29 PM, Staff E, Resident Care Manager (RCM), stated that residents receiving PRN pain medications should have NPI in their EHR and staff should not mark NA.
During an interview on 01/24/2024 at 12:25 PM, Staff B stated that residents who received PRN pain medications should be offered NPI prior to administration, and this should be documented in the patient's MAR. Staff B stated that staff should not document NA and this did not meet their expectations for Residents 26, 2 and 59.
Resident 38
Review of Resident 38's quarterly Minimum Data Set (MDS), a required assessment, dated 11/02/2023, showed the resident re-admitted on [DATE] with multiple diagnoses to include kyphosis (an excessive outward curvature of the spine which may cause back pain and stiffness) and chondrocalcinosis (a condition in which excessive calcium crystals deposit in the joints potentially causing pain). The MDS showed resident was able to make their needs known.
Review of a provider's order, dated 08/08/2022, showed Resident 38 was to be administered Tylenol Extra strength (a medication used to treat mild to moderate pain) by the licensed nurses (LNs) every eight hours PRN for pain.
Review of a pain care plan intervention for Resident 38, dated 10/02/2020, showed an intervention for the LNs to monitor for pain and to attempt NPI to alleviate pain and document effectiveness.
Review of the December 2023 and January 2024 MAR showed that the resident had been administered Tylenol extra strength on the following dates: 12/29/2023, 01/14/2024 ,01/21/2024 and 01/23/2024; however, no NPI were documented on the dates that the pain medication Tylenol was administered.
During an interview on 01/23/2024 at 11:41 AM, Staff F, RCM, stated that the expectation was for the LNs to assess and attempt NPI first prior to administering any PRN pain medications and document the NPI as to what the nurses did and if the resident refused.
Reference WAC 388-97-1060(3)(k)(i)
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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
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 26
Review of Resident 26's Electronic Health Record (EHR) showed the resident was admitted on [DATE] with a diagnosis o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 26
Review of Resident 26's Electronic Health Record (EHR) showed the resident was admitted on [DATE] with a diagnosis of generalized anxiety disorder.
Review of Residents 26's EHR showed orders for an anti-anxiety medication to be given every four hours as needed (PRN) for anxiety which was renewed every two weeks with start dates of 11/03/2023, 11/18/2023, 12/03/2023, 12/17/2023, 01/05/2024 and 01/19/2024. Further review of Resident 26's EHR showed no documentation that the resident was assessed by a physician to require ongoing therapy.
During an interview on 01/23/2024 at 10:45 AM, Staff F, RCM, stated that PRN antianxiety medications should only be ordered for 14 days, and there should have been an assessment by a physician for ongoing therapy.
During an interview on 01/23/2024 at 12:01 PM, Staff E stated that there should have been a PRN psychotropic form filled out by the provider each time it was renewed but this did not happen for Resident 26.
During an interview on 01/24/2024 at 12:19 PM, Staff B stated that PRN antianxiety medications should only have been given for 14 days without a provider's assessment and documentation for ongoing therapy and that this did not happen for Resident 26 and should have.
Reference WAC 388-97-1060(3)(k)(i)
Resident 12
Review of the quarterly MDS, dated [DATE], showed Resident 12 admitted to the facility on [DATE] with multiple diagnoses to include psychosis (a mental disorder characterized by a disconnection from reality).
Review Resident 12's physician's orders, dated 06/16/2023, was a prescribed an antipsychotic medication once daily and on 08/19/2023, staff were to monitor orthostatic blood pressure (lying/sitting/standing) once a month.
Review of Resident 12's Medication Administration Record (MAR) dated November 2023 showed orthostatic blood pressures of 146/82 lying, sitting, and standing.
Review of Resident 12's MAR dated December 2023 showed orthostatic blood pressures of 126/70 lying, sitting, and standing.
Review of Resident 12's MAR dated January 2024 showed orthostatic blood pressures of 120/59 lying, sitting, and standing.
During an interview on 01/24/2024 at 9:56 AM, Staff F, RCM, stated that it was highly unlikely that Resident 12 had the same blood pressure reading lying, sitting, and standing. Staff F stated that staff should conduct the orthostatic blood pressure as directed and that it did not meet their expectations.
During an interview on 01/24/2024 at 10:24 AM, Staff B, DNS, stated that the expectation was that a resident receiving antipsychotic medication would have orthostatic blood pressures completed correctly (sitting, lying, and standing unless unable) and that it would be accurately documented.
Based on observation, interview, and record review, the facility failed to provide adequate monitoring and assessment of medications for mental health for 4 of 5 residents (Residents 81, 5, 12 and 26) when reviewed for unnecessary medications. Lack of meetings to discuss medications (Residents 81 and 5), lack of blood pressure monitoring (Resident 12) and prolonged use of as needed medications (Resident 26) placed residents at risk of receiving unnecessary medications, avoidable side effects, and a diminished quality of life.
Findings included .
Resident 81
During an interview and observation on 01/22/2024 at 11:05 AM, Resident 81 stated that they were concerned that people were looking into the bathroom window and invading their privacy. Observation showed a fogged window in the bathroom that could not be seen through. Resident 81 stated that they were concerned about the black things crawling in the corners of the room and pointed to a nearby corner. Observation showed that there was nothing in the indicated corner. Resident 81 stated that they were concerned about the mirror over the sink being two-way and that they were being watched. Observation of the indicated mirror showed that it was not a two-way mirror.
Review of Resident 81's diagnosis list on 01/23/2024 showed no diagnosis of depression, anxiety, or psychosis.
Review of Resident 81's physician's orders, on 01/23/2024, showed that the resident received antianxiety, antidepressive and antipsychotic medications.
Review of Resident 81's quarterly Minimum Data Set assessment (MDS), an assessment tool, dated 11/22/2023, showed the resident did not experience delusions or hallucinations, and did not have a diagnosis of anxiety, depression, or psychotic disorder.
Review of Resident 81's 08/22/2023 initiated care plan showed a focus area related to depression and psychosis. Further review did not show a focus area related to anxiety.
Review of Resident 81's assessments showed two interdisciplinary team (IDT, a team of professionals from different fields) psychotropic (medications that affect the mind) meetings dated 09/05/2023 and 01/05/2024. Further review showed that these meeting notes were not completed and showed them as error.
During an interview on 01/25/2024 at 11:17 AM, Staff E, Resident Care Manager (RCM), stated that Resident 81 had delusions/hallucinations. Staff E said Resident 81 should have had an IDT meeting to discuss their mental health needs but did not. Staff E also stated that Resident 81's mental health diagnoses should be documented in the diagnosis list. Staff E stated that the MDS was incorrect relating to mental health.
During an interview on 01/26/2024 at 10:52 AM, Staff B, Director of Nursing Services (DNS), stated that Resident 81's behavioral health services did not meet expectation.
Resident 5
Review of Resident 5's medication list on 01/23/2024 showed that the resident received an antipsychotic, and antidepressant, and an antiepileptic.
Review of Resident 5's IDT psychotropic meeting notes dated 08/08/2023 showed that a follow-up IDT meeting would occur in three months. Further review of the IDT psychotropic meeting notes showed no follow-up meeting occurred.
During an interview on 01/25/2024 at 2:10 PM, Staff E stated that Resident 5 should have had a follow-up IDT psychotropic meeting. Staff E further stated that the facility had previously had a weekly psychotropic meeting with the RCM, DNS, and social services, but that this had stopped happening as the facility had not had a regular social worker in the building for awhile.
During an interview on 01/26/2024 at 10:47 AM, Staff B stated that Resident 5 should have had a follow-up IDT meeting, but had not due to a lack of social worker. Staff B stated that Resident 5's lack of IDT meeting did not meet expectation. Staff B stated that the facility had previously conducted weekly psychotropic meetings, but that this had not been occurring due to a lack of social worker.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
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Based on observation, interview and record review, the facility failed to maintain a safe and sanitary food storage program in 1 of 1 facility kitchen reviewed for food safety. This failure placed r...
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Based on observation, interview and record review, the facility failed to maintain a safe and sanitary food storage program in 1 of 1 facility kitchen reviewed for food safety. This failure placed residents at risk of foodborne illness and a diminished quality of life.
Findings included .
Observation on 01/21/2024 at 10:14 AM showed a small shelf next to the grease hood in the facility kitchen which held a personal cellular phone.
Observation on 01/21/2024 at 11:35 AM showed a facility kitchen staff in the dishwashing area of the kitchen using their personal cellular phone.
Observation of the North resident refrigerator on 01/21/2024 at 12:50 PM showed the following: 1) A half consumed frozen drink without name or date; 2) A box of taquitos opened without seal undated; 3) A bag of cauliflower wings without label; 4) A bag of frozen yellow substance without identifying label, name or date; 5) A bag of fried chicken with the dates 01/17/2024 and 01/20/2024; 6) A bag with a sandwich wrapped in a napkin with dates 01/04/2024 and 01/06/2024; and 7) A paper bag with the dates 01/08/2024 and 01/11/2024. Review of the freezer temperature log showed that the freezer's temperature should be between 0 and -20 degrees and the freezer was recorded at 15 degrees twice daily from 01/01/2024 to 01/21/2024. Review of the refrigerator temperature log showed that the temperature should be between 36 to 46 degrees. Observation of the refrigerator did not show a thermometer.
Review of the South resident refrigerator on 01/21/2024 at 3:30 PM showed the following: 1) A large pizza in the original box without name or date; 2) A bag with a fast-food meal without date; and 3) Three trays of cooked rice without name or date. Review of the freezer temperature logs showed the following: 1) October 2023 was missing 27 of 62 entries; 2) November 2023 was missing 33 of 60 entries; 3) December 2023 was missing 35 of 62 entries; and 4) January 2024 was missing 24 of 41 entries. Review of the refrigerator temperature logs showed that the temperature should be between 36 and 46 degrees and the following entries were made: 1) October 2023 was missing 28 of 62 entries and 33 of 34 entries were below the temperature range; 2) November 2023 was missing 32 of 60 entries and all entries were below the temperature range; 3) December 2023 was missing 35 of 62 entries and 23 of 27 entries were below the temperature range; and 4) January 2024 was missing 25 of 41 entries and all entries were below the temperature range. Observation of the refrigerator did not show a thermometer.
Observation of the kitchen during lunch meal service on 01/25/2024 at 10:48 AM showed a package of frozen meatballs in a plastic bag without date label tied closed on a food preparation area and a bag of tater tots tied closed without date label in the freezer. Further observation showed a personal cellular phone charger under a shelf near the grease hood.
During an interview on 01/26/2024 at 9:45 AM, Staff CC, Dietary Manager, stated that food items should be labeled with the date opened and stored with temperature controls. Staff CC stated that the meatballs and tater tots did not meet expectation for food storage. Staff CC stated that staff personal items should not be used in the kitchen and should be stored in a designated area. Staff CC stated that staff using their personal cellular phone in the kitchen and staff placing a phone or phone charger near the grease hood did not meet expectation. Staff CC stated that food in the resident refrigerators should be labeled with the resident's name and use by date and the temperature should be monitored. Staff CC stated that the temperature monitoring and lack of date/names on food items did not meet expectation.
During an interview on 01/26/2024 at 10:10 AM, Staff A, Administrator, stated that the food storage in the kitchen and resident refrigerators, staff using and storing personal items in the kitchen, and the temperature monitoring in the resident refrigerators did not meet expectation.
Reference WAC 388-97-1100 (3), -2980
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Social Worker
(Tag F0850)
Could have caused harm · This affected multiple residents
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Based on interview, the facility failed to maintain a qualified social worker on a fulltime basis. This placed residents at risk of a lack of medically related social services and a diminished quali...
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Based on interview, the facility failed to maintain a qualified social worker on a fulltime basis. This placed residents at risk of a lack of medically related social services and a diminished quality of life.
Findings included .
During an interview on 01/23/2024 at 9:39 AM, Staff A, Administrator, stated that Staff D, Social Services, was the only social worker that worked in the facility as the facility was between social workers. Staff A stated that the facility had lacked a fulltime social worker for a month and Staff D would come to the facility a couple of days a week.
During an interview on 01/25/2024 at 2:14 PM, Staff D stated that they had been the only social worker for the facility for around a month. Staff D further stated that they did not have enough time to provide all needed social services to the facility's residents.
Reference WAC 388-97-0960 (2)(a)(b)
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were avai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services for all facility residents. The facility had insufficient staff to ensure residents received assistance with Restorative services, Activities of Daily Living (ADL), and call light response in accordance with established clinical standards, care plans, and preferences. These failures placed residents at risk for unmet care needs and a diminished quality of life.
Findings included .
Resident Council
Review of the RC meeting minutes for November 2023 showed residents reported longer than expected wait times during the night shift for their call light to be answered.
Restorative
During an interview on 01/23/2024 at 11:24 AM, Resident 68 stated that it required two staff to get them out of bed but there's never enough help.
During an interview on 01/23/2024 at 9:47 AM, Staff Q, Restorative Nursing Aid, stated that they conducted restorative Mondays, Wednesdays and Fridays and they were the shower aide Tuesday and Thursdays.
Call Light Times
Observation of the call light system at the nurse's station on 01/21/24 at 10:28 AM showed 98 minutes for room [ROOM NUMBER].
Observation of the call light system at the nurse's station on 01/21/2024 at 11:32 AM showed 61 minutes for room [ROOM NUMBER].
Observation of the call light system at the nurse's station on 01/22/2024 at 9:37 AM showed 53 minutes for resident room [ROOM NUMBER].
Observation of the call light system at the nurse's station on 01/23/24 at 9:37 AM showed 41 minutes for resident room [ROOM NUMBER].
Resident Interviews
During an interview on 01/21/2024 at 11:31 AM, Resident 16 stated that the facility was understaffed, and they had to waited two hours for their call light to be answered on evening shift.
During an interview on 01/26/2024 at 9:37 AM, Resident 13 stated that they had gone two to three weeks without a shower or having their sheets changed due to the facility being short staffed.
During an interview on 01/25/2024 at 9:52 AM, Resident 45 stated that the facility was short staffed, especially on weekends. Resident 45 stated that they preferred to get up at 9:30 AM, but due to understaffing they were not able to get up until 11:00 AM. Resident 45 stated they observed a resident call light on at 3:30 AM, but it wasn't answered until shift change at 6:00 AM.
Staff Interviews
During an interview on 01/24/2024 at 10:42 AM, Staff M, Certified Nursing Assistant (CNA), stated that residents got showers from the shower aides and that the CNAs did not have time to provide showers when the shower aide was not available.
During an interview on 01/25/2024 at 12:32 PM, Staff M, CNA, stated that they were currently caring for 20 residents due to short staffing. Staff M stated that the lack of sufficient staffing effected their ability to get residents out of bed, especially when they were a two person assist.
During an interview on 01/25/2024 at 9:33 AM, Staff O, CNA, stated that they were currently caring for 20 residents due to short staffing and weekends were worse. Staff O stated they were asked to work overtime or double shifts on a regular basis.
During an interview on 01/25/2024 at 9:31 AM, Staff GG, Licensed Practical Nurse (LPN), stated that they were currently caring for 22 residents. Staff GG stated that they did not have enough time to complete charting as required and were frequently asked to come in early, stay late or work overtime.
During an interview on 01/25/2024 at 12:46 PM, Staff E, Residential Care Manager (RCM), stated that they were short staffed due to staff calling out or no-showing. Staff E further stated that the facility had been without a staff development coordinator, so hiring was a slower than usual at that time.
During an interview on 01/26/2024 at 11:08 AM, Staff HH, Staff Development Coordinator, stated that they had an issue with staff attendance which led to insufficient staffing. Staff HH stated that staff came to them complaining about staff shortages.
During an interview on 01/25/2024 at 11:54 AM, Staff A, Administrator (ADM), stated that the facility had excessive staff callouts.
REFER FOR ADDITIONAL INFORMATION AT F584, F677, AND F688
Reference WAC 388-97-1080 (1), 1090 (1)
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to control and prevent the transmission of a communicable disease by ensuring the proper application of transmission-based precautions (TBP) for 2 of 2 hallways (North and South) and to ensure the proper use and fit of personal protective equipment (PPE) by staff during an outbreak of a respiratory virus. The facility also failed to provide laundry services in a safe and sanitary manner. These failures placed residents, visitors, and staff at risk for a communicable disease, infections, and a decreased quality of life.
Findings included .
North Hall
Review of the facility's outbreak line list map dated 01/21/2024 showed seven residents (Residents 364 on the north hall and Residents 29, 361, 94, 38, 50 and 97 on the south hall) tested positive for Covid-19 (a highly contagious respiratory virus) on 01/19/2024.
Review of a facility email dated 01/19/2024, which contained recommendations from the [NAME] County Health Department, showed instructions for the facility for outbreak management. It outlined steps to prevent the spread of Covid-19 to include placing all Covid-19 positive residents on isolation precautions which included a gown, gloves, N95 respirator and eye protection when staff entered the room, keep the door closed and have designated equipment.
Observation on 01/21/2024 at 12:39 PM showed Staff W, Certified Nursing Assistant (CNA), entered room [ROOM NUMBER] (Resident 364) without putting on an isolation gown, gloves, or eye protection. When exiting the room, Staff W did not change their N95 respirator.
During an interview on 01/21/2024 at 12:40 AM, Staff W stated that they were not aware that Resident 364 had Covid-19 because there was no precaution sign at the door.
Observation and interview on 01/21/2024 at 1:45 PM showed Staff X, Registered Nurse (RN), exited room [ROOM NUMBER] (Resident 364) with an N95 respirator on. It did not cover the nose and was not sealed on the sides. Staff X stated that the mask was not sealed around their nose and chin and should have been.
During an interview and observation on 01/21/2024 at 1:36 PM, Staff E, Resident Care Manager (RCM), stated that Resident 364 had tested positive for Covid-19 on Friday 01/19/2024. Staff E walked to room [ROOM NUMBER] and stated that the precautions cart was there with no gowns, masks, face shields or wipes and no precaution sign on the door. Staff E also stated that this did not meet the expectations and precautions should have been in place.
South Hall
Observation on 01/21/2024 at 2:08 PM showed an aerosol precaution sign outside of room [ROOM NUMBER] (Resident 38). Staff AA, RN, and Staff BB, CNA, exited the room. They did not wipe down the face shields or change their N95 masks and did not perform hand hygiene.
Review of the Facility's updated outbreak line list dated 01/21/2024 showed five new cases of Covid-19 infection on the south hall (Residents 91, 70, 51, 89 and 54)
Observation on 01/22/2024 at 9:21 AM showed Staff V, Maintenance, entered room [ROOM NUMBER] (Resident 38) without putting on a gown, gloves, or eye protection. Staff V exited the room and did not change N95 respirator and did not perform hand hygiene. There was a sign on the door for aerosol/contact precautions.
Observation on 01/22/2024 at 12:42 PM showed Staff B, Director of Nursing Services (DNS), entered room [ROOM NUMBER] without gown or gloves. There was an aerosol precaution sign at the door. When Staff B exited the room, they did not perform hand hygiene or change their N95 respirator mask.
Observation on 01/25/2024 at 9:22 AM showed Staff U, Central Supply, in the north hall performing Covid-19 rapid test nose swabs on residents. Staff U was wearing a surgical mask and no eye protection. When asked, Staff U stated that they had tested all the residents on south hall yesterday.
Review of the BinaxNOW competency exam form for Staff U, Central Supply, dated 11/15/2023 showed that while performing Covid-19 testing with the BinaxNOW nose swabs, staff should wear a gown, gloves, an N95 respirator and eye protection.
During an interview on 01/25/2024 at 2:40 PM, Staff B, DNS, stated that it was their expectation that a gown, gloves, N95 respirator and eye protection should be used while performing Covid-19 testing and for entering all Covid-19 positive resident rooms.
Review of the facility's outbreak line list dated 01/24/2024 showed 1 new Covid-19 case on 01/23/2024 and ten new cases on 01/24/2024, all on the south hall.
During an interview on 01/24/2024 at 2:19 PM, Staff H, Infection Preventionist, stated that all Covid-19 positive residents should be placed on aerosol/contact precautions with sign on the door and a cart outside the door with gown, gloves, N95 respirators, eye protection and sanitizing wipes. Staff H stated that it was their expectation that staff should put on a gown, gloves and wear a fitted N95 respirator and eye protection when entering a Covid-19 positive resident's room. Staff H stated that when staff exited the room, they should remove their gown and gloves, perform hand hygiene, and then remove the eye protection and respirator, wipe the reusable eye protection with sanitizing wipes, perform hand hygiene again and put on a new well fitted respirator.
Laundry Services
During an observation and interview on 01/24/2024 at 11:03 AM, Staff Y, laundry aide loaded a washing machine with soiled linens. The inner door and gasket were observed to have a white substance covering the surfaces. Staff Y closed the door to the machine and did not sanitize the gasket or door after loading. When asked via a translation service if it was normal practice to sanitize the gaskets and inner door between loading and unloading laundry, Staff Y, Laundry aide, indicated no.
During an interview on 01/24/2024 at 11:11 AM, Staff Z, District Laundry Manager, stated that it was their expectation that the staff sanitize the gasket and door of washing machines after loading to prevent contamination.
Reference WAC 388-97-1320 (2)(a)(b)
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Dec 2023
2 deficiencies
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to address safety risk factors and provide the necessary...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to address safety risk factors and provide the necessary supervision to ensure safety from avoidable accident and injuries for 1 of 3 residents (Resident 1) reviewed for accidents and supervision. This failure resulted in harm when Resident 1 was hit by a moving vehicle while in their wheelchair unsupervised out in the parking lot of the facility. Resident 1 required emergency medical services to transfer to the hospital, sustained a fracture to the left ankle, and experienced severe pain and discomfort.
Findings included .
Review of the admission Minimum Data Set (MDS, a required assessment tool) dated 09/06/2023, showed that Resident 1 admitted on [DATE] with diagnoses to include cerebral infarction (stroke), diabetes, generalized muscle weakness and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). The MDS further showed Resident 1 had moderate cognitive impairment and exhibited inattention (easy distractibility) and episodes of disorganized thinking. According to the MDS, Resident 1 required one-person physical assistance with most activities of daily living including locomotion on and off the unit.
Review of Resident 1's care plan initiated on 09/21/2023, showed that the resident required assistance with activities of daily living (ADL) care due to activity intolerance. The care plan also indicated Resident 1 was at risk for falls due to the resident's impaired mobility and chronic low back pain.
Review of the facility incident log for November 2023, showed that Resident 1 had a fall incident without injury on 11/18/2023 and on 11/20/2023 had the accident in the parking lot with significant injury.
Review of the fall assessment dated [DATE], showed that on 11/18/2023 Resident 1 fell while attempting to self-transfer to the wheelchair in the resident's room. The assessment identified risk safety issues that included impulsive behavior, noncompliance to safety reminders, and the resident engaging in independent activities even though they required supervision and physical assistance.
Review of the facility incident investigation dated 11/20/2023, showed that on 11/20/2023 Resident 1 was in a wheelchair when they entered the parking lot to the left side of the building and was hit by a moving vehicle that was backing out from their parking spot. Further review, showed Resident 1 fell from the wheelchair and hit the ground. The facility called emergency medical services to immediately transfer the resident to the hospital. According to the incident investigation, the hospital performed x-rays of the left ankle and foot, and the results were suspicious for left ankle fracture.
Review of the results of the left ankle and foot x-rays dated 11/20/2023, indicated possible minimally acute displaced fracture of the tip of the lateral malleolus (ankle bone) with overlying soft tissue swelling and adjacent ankle joint effusion (outpouring of fluid).
Observation on 11/27/2023 at 2:03 PM, showed Resident 1 in bed wearing a controlled ankle movement (cam) boot to the left ankle and had bluish discolorations on the left side of the forehead. Resident 1 was awake and responsive to questions asked.
In an interview on 11/27/2023 at 2:06 PM, when asked about the injuries, Resident 1 stated they were hit by a car while in the wheelchair outside the building in the parking lot. The resident further stated they did not remember what happened after falling on the ground. In the middle of the interview, Resident 1 started to get anxious and no longer wanted to be bothered with additional questions and stated, I'm in a bad mood right now.
Observation on 11/27/2023 at 2:09 PM, showed Resident 1 increasingly agitated and screaming for the nurse to hurry up. The resident verbalized, this ankle is killing me. The licensed nurse went in and assessed resident's pain and said they would be back to administer the ordered pain medication. The resident kept insisting for staff to remove the cam boot. Two other nursing staff stayed to reposition the resident and readjusted the resident's cam boot.
In an interview on 11/27/2023 at 2:39 PM, when asked about Resident 1's cognitive function, Staff C, Nurse Practitioner (NP), stated that Resident 1 had been diagnosed with Vascular Dementia (type of dementia caused by conditions such as stroke that disrupt blood flow to the brain and lead to problems with memory, thinking, and behavior) and Pseudobulbar Affect (a neurological condition characterized by uncontrolled crying or outbursts). When questioned about the supervision required by Resident 1 in going outside the facility, the NP stated that the resident was allowed to go out with supervision and often went out with the significant other accompanying the resident. Staff C was further interviewed regarding interventions to address the resident's severe pain. Staff C stated that the nurse administered oxycodone (a narcotic pain medication) a few minutes ago and that a nerve pain medication would be ordered for Resident 1's chronic nerve pain. According to the NP, staff repositioned the resident in bed, and did a skin check around the cam boot.
Review of the orthopedic (branch of medicine concerned with bones and surrounding structures) consult note dated 11/29/2023, indicated that a three-view x-ray of the left ankle was performed, and the result showed a stable nondisplaced left ankle lateral malleolus fracture. Recommendations included for Resident 1 to wear the cam boot while ambulating and when comfortably resting the cam boot may be released.
In an interview on 12/06/2023 at 12:38 PM, Staff B, Registered Nurse/ Assistant Director of Nursing (RN/ADON), stated to allow residents to go out of the facility independently, the facility assessed their cognitive status, and conducted elopement risk assessment and if a smoker then a smoking assessment will be completed. According to Staff B, Resident 1 had never previously left the facility or showed behavior that would put them at elopement risk. Staff B further stated that the facility required the residents to sign the sign-out book before leaving the facility.
In an interview on 12/06/2023 at 1:30 PM, Staff A, Administrator, stated that Resident 1 never had a problem going outside of the facility and often was accompanied by the significant other. Resident 1 usually went straight to the sidewalk instead of turning left to the parking lot. According to the Administrator, what happened in the parking lot was an unfortunate accident.
Reference WAC 388-97-1060(3)(g)
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 F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the bed-hold notice at the time of transfer to the hospital...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the bed-hold notice at the time of transfer to the hospital for 4 of 4 residents (Residents 1, 2, 3 and 4) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their right to hold their beds while admitted in the hospital.
Findings included .
Review of the facility's policy titled, Bed-Holds and Returns, revised October 2022, showed that all residents or resident representatives were to be provided written information regarding the facility and state bed-hold policies which addressed holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). According to the policy, residents regardless of payer source were to be provided written notice about these polices at least twice: well in advance of any transfer; and at the time of transfer (or if the transfer was an emergency, within 24 hours).
Resident 1
Review of Resident 1's discharge Minimum Data Set (MDS, a required assessment tool) dated 12/02/2023, showed that Resident 1 was discharged to the hospital and the facility anticipated the resident's return.
Review of Resident 1's progress note dated 12/02/2023 at 6:46 AM, showed that nursing staff found Resident 1 with their colostomy bag (bag that collects waste from the large intestine) filled with blood. The facility notified the on-call provider who then ordered to send the resident to the emergency room (ER) for evaluation. There was no documentation found that the facility provided a written bed-hold notice to Resident 1 or the resident's representative and whether they accepted or declined the bed-hold.
Resident 2
Review of the discharge MDS dated [DATE] showed that Resident 2 was discharged to the hospital and the facility anticipated the resident's return.
Review of Resident 2's progress note dated 11/03/2023 at 11:00 AM, showed that Resident 2's daughter expressed concern about the resident acting different possibly due to urinary tract infection. Resident 2 was sent to the ER via non-emergent transport. There was no documentation found that the facility provided a written bed-hold notice to Resident 2 or the resident's representative and whether they accepted or declined the bed-hold.
Resident 3
Review of the discharge MDS dated [DATE] showed that Resident 3 was discharged to the hospital and the facility anticipated the resident's return.
Review of Resident 3's progress note dated 11/25/2023 at 8:02AM, showed the licensed nurse found Resident 3 sitting in a chair, difficult to arouse and dry heaving. Resident was sent to the hospital via 911. There was no documentation found that the facility provided a written bed-hold notice to Resident 3's representative and whether they accepted or declined the bed-hold.
Resident 4
Review of the discharge MDS assessment dated [DATE] showed that Resident 4 was discharged to the hospital and the facility anticipated the resident's return.
Review of Resident 4's progress note dated 11/30/2023 at 7:25 PM, showed while working with Resident 4, the physical therapist noticed resident's left side of mouth and face was drooping. The nurse practitioner was notified and ordered to send the resident to the ER for evaluation. There was no documentation found that the facility provided a written bed-hold notice to the resident or resident's representative and whether they accepted or declined the bed-hold.
During an interview on 12/06/2023 at 1:00 PM, Staff B, Registered Nurse/ Assistant Director of Nursing (RN/ADON) stated that the expectation was for the discharging nurse to provide the resident or resident's representative a written bed-hold notice during transfer to the hospital and to document in the progress note whether they accepted or declined the bed-hold.
Reference WAC 388-97-0120(4)
.
Oct 2023
2 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the discharge plan and ensure a safe and orderly discharg...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the discharge plan and ensure a safe and orderly discharge for 1 of 3 residents (Resident 2) reviewed for discharge planning process. This failure placed the resident at risk for unmet needs, medical complications, readmission to the hospital or skilled nursing facility and a diminished quality of life.
Findings included .
Review of the facility's policy and procedure titled, Discharge Summary and Plan, revised December 2016, showed that every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. The discharge plan will include where the individual plans to reside; arrangements that have been made for follow-up care and services; the degree of caregiver/support person availability, capacity, and capability to perform required care; and how the interdisciplinary team will support the resident or representative in the transition to post-discharge care.
Review of Resident 2's admission Minimum Data Set (MDS a required assessment tool) dated 08/15/2023 showed that Resident 2 admitted on [DATE] with diagnoses to include diabetes, hemiplegia (paralysis of one side of the body), use of gastrostomy tube (tube that goes directly to the stomach) for feeding and acquired absence of the right leg below the knee. The MDS further showed Resident 2 required extensive two-person physical assistance with bed mobility, transfers, and toileting. According to the MDS, Resident 2 admitted with moisture-associated skin damage (MASD) to the sacral (base of the spine) area.
Review of Resident 2's discharge plan documentation dated 09/06/2023 showed that the home care services to be provided to Resident 2 included home health aide, physical therapy (PT), occupational therapy (OT), and skilled nursing services with an estimated start date on 09/11/2023. Next visit with the primary care doctor was scheduled on 09/11/2023 at 3:00 PM. The discharge plan documentation showed identified skin issues to Resident 2's bilateral buttocks, 2nd and 3rd toes and unstageable pressure ulcer to resident's coccyx with corresponding treatment orders. There was no documentation that showed the resident or resident's representative received the discharge instructions from the facility.
Review of Resident 2's progress note dated 09/07/2023 at 3:15 PM, showed that Resident 2 discharged with all belongings and medications and was to receive home health, PT, and OT services.
In an interview on 10/09/2023 at 10:33 AM, Collateral Contact A (CCA), stated that the facility did not set up for home health services and no discharge instructions or training to care for Resident 2 had been provided to the resident's caregiver. CCA stated that Resident 2 discharged home and was unable to perform activities of daily living and care for self. Resident 2's pressure ulcer worsened due to no proper treatment at home. According to CCA, after several follow-up calls made to the Social Service Director (SSD) of the facility, CCA talked to the facility's SSD to find out that home health service and follow-up appointment with the resident's primary care doctor were never set up for Resident 2 prior to discharging home.
In an interview on 10/09/2023 at 3:55 PM, Staff D, Licensed Practical Nurse /Resident Care Manager (LPN/RCM), stated that home health services were ordered for Resident 2. According to Staff D, they notified the SSD of the orders and SSD was responsible in setting up home health services, durable medical equipment if needed and arrange follow-up appointments.
In an interview on 10/17/2023 at 4:29 PM Staff B, Director of Nursing Services (DNS) stated that the expectation was for Social Services to make arrangement for home health services and follow-up appointments and to follow through with them. According to the DNS, the SSD involved had been let go and that the facility was in the process of hiring a new SSD.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary care and services in the management of a surg...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary care and services in the management of a surgical wound for 1 of 3 residents (Resident 3) reviewed for wound management. This failure placed the resident at risk for worsening of the wound, infection, medical complications, additional surgery, rehospitalization, and a diminished quality of life.
Findings included .
Review of the facility's policy and procedure titled, Skin Integrity Management, dated 05/26/2021 showed that the facility was to identify the resident's skin integrity status and the need for prevention or treatment modalities through review of all appropriate assessment information. The facility was expected to perform skin inspection on admission and weekly and perform daily monitoring of wounds or dressings for presence of complications or decline and to document if indicated. The policy and procedure indicated that in the management of surgical wounds, specific orders from the surgeon were to be followed.
Review of Resident 3's admission Minimum Data Set (MDS, a required assessment tool) dated 09/25/2023 showed Resident 3 admitted on [DATE] with diagnoses to include acquired absence of the left great toe, diabetes, and stroke. The MDS further showed that Resident 3 had cognitive impairment and required extensive two-person assistance with transfers and toileting. The MDS Skin assessment indicated Resident 3 had a surgical wound.
Review of the hospital discharge orders dated 09/19/2023 indicated Resident 3 needed follow-up appointments with the primary care provider, the podiatric (deals with condition of the foot or lower leg) surgeon, and the infectious disease doctor. There were no specific wound care orders except to apply povidone-iodine (antiseptic solution used for disinfection) as needed.
Review of Resident 3's physician order summary from 09/19/2023 through 10/03/2023, showed an order on 09/19/2023 to apply iodine external solution to the great toe incision topically as needed for skin care. The iodine solution order was not revised until 09/27/2023 which indicated the application of iodine solution every day shift and leaving the incision open to air. The order for follow-up with the podiatric surgeon was not entered until 09/27/2023.There were no orders for follow-up appointment with the primary care doctor or the infectious disease doctor. There was no order for skin checks and monitoring of the surgical wound.
Review of Resident 3's Treatment Administration Record (TAR) dated September 2023 showed no treatment administered to Resident 3's surgical incision from 09/19/2023 to 09/26/2023.
In an interview on 10/09/2023 at 11:22 AM, Collateral Contact B (CCB), stated that the facility failed to follow the surgeon's orders for the care of Resident 3's left foot. According to CCB, Resident 3's left foot was not getting the proper treatment. CCB stated during several visits to Resident 3 at the facility, the resident had their foot dragging on the floor with no proper footrest on the wheelchair. CCB further stated that Resident 3's left foot was unbandaged, swollen, discolored and blood oozed out from the incision. According to CCB, the facility did not make arrangement for a follow-up with the surgeon, and they ended having to make the arrangement for consult themselves. CCB stated that the podiatric surgeon transferred Resident 3 to the hospital due to the resident's severely infected surgical incision.
In an interview on 10/17/2023 at 2:40 PM, Staff E, Licensed Practical Nurse (LPN), stated that initially, Resident 3's left foot was bandaged and later the nurse practitioner ordered to leave the incision open to air to keep it dry. According to Staff E, they followed the treatment order to paint Resident 3's incision with betadine (iodine-povidone solution) daily.
In an interview on 10/17/2023 at 2:46 PM, Staff F, Nurse Practitioner (NP), stated that on 09/27/2023 they observed Resident 3 dragging their foot and the surgical wound bleeding. Staff F stated they cleaned the wound and applied betadine. According to Staff F, they ordered to leave the incision open to air to keep it dry. Staff F stated they ordered a follow-up with the podiatric surgeon on 09/27/2023 after noticing it was not ordered. According to Staff F, last assessment of Resident 3's foot was on 10/03/2023 and there were no concerning issues noted.
Review of Resident 3's History and Physical (H&P) hospital record dated 10/03/2023 showed Resident 3 presented to the emergency department per the instruction of the podiatric surgeon after the resident was seen in the outpatient podiatry clinic earlier that day. The H&P further showed per outpatient clinic notes that there was concern for inadequate wound care at the facility and noted worsening appearance of the left second toe in the past week. According to the podiatric surgeon, appearance of the foot had significantly worsened since the resident was discharged from the hospital, with erythema (redness) and drainage from the incision area.
In an interview on 10/17/2023 at 4:29 PM, Staff B, Director of Nursing Services (DNS), stated that the expectation was for staff to make sure treatment had been ordered and carried out on admission for residents with surgical wounds. There should have been a daily care treatment for Resident 3's surgical wound and not just on as needed basis. According to the DNS, the treatment was not clear and specific and should have been clarified with the surgeon. Staff B further stated that the Resident Care Managers were expected to inform the scheduler of appointments for consults/appointments ordered. Resident 3's follow-up appointments were missed on admission.
Reference WAC 388-97-1060(1)(3)(b)
.
Oct 2023
5 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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**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 care plan that addressed the ...
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**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 care plan that addressed the use of an indwelling urinary catheter for 1 of 3 residents (Resident 1) reviewed for indwelling catheter care. This failure placed the resident at risk for unmet care needs, medical complications, and a diminished quality of life.
Findings included .
Review of Resident 1's admission Minimum Data Set (MDS, a required assessment tool) dated 08/15/2023, showed Resident 1 admitted on [DATE] with diagnosis of Benign Prostatic Hyperplasia (prostate gland enlargement causing difficulty of urination). The MDS further showed that Resident 1 was incontinent of urine.
Review of the Care Area Assessment (CAA) dated 08/15/2023 showed that the care area of urinary incontinence required a comprehensive care plan.
Review of Resident 1's physician order summary from 08/09/2023 through 08/29/2023, showed that on 08/16/2023 Resident 1 received an order for insertion of an indwelling urinary catheter due to urinary retention.
Review of Resident 1's plan of care created on 08/09/2023, showed no care plan that addressed the triggered area of urinary incontinence and no additional care plan for use of an indwelling catheter.
In an interview on 09/28/2023 at 3:42 PM, Staff D, Licensed Practical Nurse/ Resident Care Manager (LPN/RCM) stated that they were not aware Resident 1 did not have a care plan for urinary catheter care. Staff D, LPN/RCM, stated Resident should have been care planned when indwelling catheter was inserted.
In an interview on 10/02/2023 at 3:03 PM Staff C, Registered Nurse/Assistant Director of Nursing (RN/ADON) stated that the expectation was for all residents with indwelling urinary catheter to have a comprehensive care plan addressing use of indwelling catheter.
Reference WAC 388-97-1020
.
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 F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a completed discharge summary that included discharge instr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a completed discharge summary that included discharge instructions regarding indwelling urinary catheter (a catheter inserted and kept in the bladder to drain urine) care and follow-up referrals for 1 of 3 residents (Resident 1) reviewed for discharge planning. This failure placed the resident at risk for complications by not receiving the necessary information to ensure continuity of care when discharged to the community.
Findings included .
Review of Resident 1's electronic health records showed Resident 1 admitted on [DATE] and discharged on 08/29/2023.
Review of Resident 1's progress note dated 08/25/2023 at 11:52 AM, showed that a staff from the senior living facility the resident was discharging to, came in to assess Resident 1's discharge needs. According to the progress note, the senior living facility staff advised that if Resident 1's indwelling catheter removal was successful, the resident could go back to the same level of independent living, and if not successful, recommended for the resident to receive increase in services.
In an interview on 09/11/2023 at 10:57 AM, Collateral Contact stated that Resident 1 was discharged to an independent senior living facility with an indwelling urinary catheter and no discharge instructions provided by the discharging facility.
Review of the nurse practitioner's discharge evaluation note dated 08/29/2023 indicated that Resident 1 diagnosed with urinary retention had failed three voiding trials and needed a follow up with urology (a branch of medicine that focuses on the urinary tract system). The discharge evaluation also indicated that Resident 1 needed to follow up with their primary care provider (PCP) within 30 days.
Review of Resident 1's progress note dated 08/29/2023 at 2:00 PM showed that Staff E, Licensed Practical Nurse (LPN) documented Resident 1 was discharged from the facility with all belongings and medications and a couple of leg bags for Resident 1's indwelling urinary catheter. There was no documentation that discharge instructions were provided to the resident or the resident's representative.
Review of Resident 1's discharge planning documentation dated 08/29/2023, indicated Resident 1 had an indwelling foley catheter. There were no discharge care instructions included that addressed care of the indwelling urinary catheter. The discharge planning documentation indicated that Resident 1's family wanted to find a new PCP and urology provider close to the area the resident was going to be discharged . There was no documentation of follow-up appointments being arranged.
In an interview on 09/28/2023 at 3:42 PM, Staff D, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated that whoever discharged the resident should have provided the discharge instructions. According to Staff D, LPN/RCM, facility staff talked to Resident 1's representative about the indwelling urinary catheter and was told that they will be able to take care of it.
In an interview on 10/02/2023 at 3:03 PM, Staff C, Registered Nurse/ Assistant Director of Nursing, stated that the expectation was for staff to provide a copy of the discharge summary with discharge instructions during the resident's discharge.
Reference WAC 388-97-0080(7)(a-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
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to maintain 8 hours of Registered Nurse (RN) coverage to directly supervise resident care, 24 hours a day, seven days a week for 65 of 91 days...
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Based on interview and record review, the facility failed to maintain 8 hours of Registered Nurse (RN) coverage to directly supervise resident care, 24 hours a day, seven days a week for 65 of 91 days (from April 2023 through June 2023) reviewed for RN coverage. This failure placed all residents at risk to not have immediate access to assessments, care and services provided by an RN, a delay in care and treatment, unmet care needs and medical complications.
Findings included .
Review of the facility's daily staffing posting report for April 2023, showed that the facility did not have RN coverage for a minimum of 8 hours a day for 16 of 30 days reviewed for RN coverage.
Review of the facility's daily staffing posting report for May 2023, showed that the facility did not have RN coverage for a minimum of 8 hours a day for 28 of 31 days reviewed for RN coverage.
Review of the facility's daily staffing posting report for June 2023, showed that the facility did not have RN coverage for a minimum of 8 hours a day for 21 of 30 days reviewed for RN coverage.
In an interview on 10/02/2023 at 3:03 PM, Staff C, RN/Assistant Director of Nursing (RN/ADON), stated that from April 2023 through June 2023 there were two RNs, one worked as Resident Care Manager (RCM) but quit thereafter while Staff C became the interim Director of Nursing Services (DNS). The facility did not employ RN agency staff during that time.
In an interview on 10/02/2023 at 3:10 PM, Staff A, Administrator, stated that the facility was aware of the requirement for RN hours and was in the process of actively recruiting for RN staff.
Reference WAC 388-97-1080 (3)(a)
.
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
Staffing Data
(Tag F0851)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure the direct care data for registered nurse (RN) hours were accurately entered into the Payroll Based Journal (PBJ, a system for track...
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Based on interview and record review, the facility failed to ensure the direct care data for registered nurse (RN) hours were accurately entered into the Payroll Based Journal (PBJ, a system for tracking staffing in nursing homes) for 1 of 1 quarter (Fiscal Year (FY) 2023 3rd quarter, April 2023 through June 2023) reviewed for PBJ reporting. This failure caused the Centers for Medicare and Medicaid Services (CMS) to have inaccurate data related to nursing home staffing levels which had the potential to impact care and services provided to all the residents in the facility.
Findings included .
Review of the Certification and Survey Provider Enhanced Reports (CASPER) Payroll-Based Journal Staffing Data Report dated FY Quarter 3 2023 (April 1 - June 30) showed that result of No RN hour was not triggered. According to the CASPER report, the definition of triggered was Four or More Days Within the Quarter with no RN Hours.
Review of the facility's daily nursing staffing report from April 2023 through June 2023 showed 59 of 91 days had no RN hours.
Review of the RN Punch Detail timesheets from April 2023 through June 2023 did not match the RN hours on the daily nursing staffing report from April 2023 through June 2023.
In an interview on 10/02/2023 at 12:20 PM Staff C, Registered Nurse/Assistant Director of Nursing (RN/ADON), stated that in June 2023, Staff C was told by Staff G, [NAME] President of Operations, to edit their RN hours and put in RN hours worked for dates that according to Staff C they were not in the facility to provide RN oversight.
Review of Staff C's time adjustment slips from April 2023 through June 2023, showed 19 days were edited as missed punches with RN hours entered as hours worked in the facility.
In an interview on 10/02/2023 at 12:50 PM, Staff F, Human Resources Director, stated that they were in-charge of submitting the hours to corporate payroll and corporate payroll gathered the PBJ data and submitted the PBJ report to CMS. According to Staff F, in June 2023, Staff G pointed out that the facility was missing RN hours. That was the time when Staff C submitted edit slips for RN hours worked which were then submitted to corporate payroll.
In an interview on 10/02/2023 at 1:34 PM, Staff H, Chief Operations Officer, stated that the facility conducted their investigation and found inaccuracies in their PBJ report to CMS.
Reference WAC 388-97-1090(1)(2)(3)
.
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
Deficiency F0895
(Tag F0895)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to properly implement the compliance and ethics program, prevent the submission of data know to be inaccurate and unethical practices for 1of ...
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Based on interview and record review, the facility failed to properly implement the compliance and ethics program, prevent the submission of data know to be inaccurate and unethical practices for 1of 1 quarter (Fiscal Year Quarter 3, April 2023 through June 2023) reviewed for Payroll Based Journal (PBJ, a system for tracking staffing in nursing homes) reporting. This failure had the potential to negatively impact the nursing staffing levels and the care and services being provided to all the residents in the facility.
Findings included .
Review of the facility's Compliance Plan revised 10/17/2022, showed that the purpose of the plan was to promote the integrity of the facility's operations, educate staff as to the standards by which they must conduct themselves and to serve as a mechanism for preventing, identifying, and correcting any violation of laws and regulations and/or policy. The guidelines contained in the compliance plan were designed to assist staff in following laws and regulations, to correct violations and to provide guidance in making ethical choices in the work environment.
According to the compliance plan, the facility was expected to strictly comply with all Medicare and Medicaid regulations and related health care fraud and abuse laws. Example of an area of specific concern to the Medicare and Medicaid programs include failing to maintain and retain accurate books or records.
In an interview on 10/02/2023 at 12:20 PM, Staff C, Registered Nurse/Assistant Director of Nursing (RN/ADON) stated that in June 2023, Staff G, [NAME] President of Operations told Staff C to edit their time slips from April 2023 through June 2023 and put in for RN hours worked on dates that Staff C was not working in the facility. According to Staff C, the facility had a compliance hotline number; however, they did not contact the number due to fear of retaliation and after being told not to talk about the situation.
Review of Staff C's time adjustment slips from April 2023 through June 2023, showed 19 days were edited to indicate that Staff C worked and provided RN oversight in the facility.
In an interview on 10/02/2023 at 12:50 PM, Staff F, Human Resources Director, stated that in June 2023, Staff G pointed out that the facility was missing RN hours. According to Staff F, that was the time that Staff C submitted time adjustment slips for missed punches. The edited time slips were then submitted to corporate payroll responsible in submitting the PBJ report to Centers for Medicare and Medicaid Services (CMS).
Review of the Certification and Survey Provider Enhanced Reports (CASPER) Payroll-Based Journal Staffing Data Report dated 04/01/2023 through 06/30/2023, showed inaccurate data of RN hours reported to CMS.
Refer to F851 for additional information.
Reference WAC 388-97-1620 (2)(b)(ii) (c)
Aug 2023
2 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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to ensure resident care plans were reviewed, revised, and accurately...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to ensure resident care plans were reviewed, revised, and accurately reflected resident care needs for 2 of 5 sampled residents (Resident 1 & 2) reviewed for care plan revisions. This failure placed the residents at risk for unidentified, unmet care needs and a diminished quality of life.
Findings included .
<Resident 1>
Resident 1 was admitted to the facility on [DATE]. The Significant Change Minimum Data Set, (MDS-an assessment tool), dated 08/07/2023, documented Resident 1 was severely cognitively impaired.
Review of a delivery ticket dated 08/01/2023 showed the facility received delivery of a scoop mattress for Resident 1. The identified delivery ticket was scanned into the Electronic Health Record (EHR) on 08/01/2023.
Review of a Fall Investigation, dated 08/10/2023, showed Resident 1 was observed on the floor with their leg on the bed.
Review of the Fall Care Plan, created on 07/17/2023, documented Resident 1 was at risk for falls related to brain mass and seizures. On 08/11/2023, the care plan documented the fall prevention intervention of a perimeter mattress to the bed having been developed after Resident 1 experienced a fall from the bed on 08/10/2023.
<Resident 2>
Resident 2 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 2 was cognitively intact.
Review of a Fall Investigation, dated 08/02/2023, documented Resident 2 was observed lying on the floor by their wheelchair. Resident 2 said they tried to lean on the table and lost their balance falling to the floor.
Review of the Fall Care Plan, created on 04/12/2021 and last revised on 02/17/2023, documented Resident 2 was at risk for falls related to impaired mobility, history of falls, status post right tibia fracture. Care plan not updated with new intervention to minimize risk of further falls related to fall on 08/02/2023.
On 08/22/2023 at 1:30 PM, Staff C, Resident Care Manager/Licensed Practical Nurse, stated after a fall the care plan should be updated with an intervention usually by the next day unless it's a Friday then it will be updated on Monday. Staff C said care plans can be updated by any nurse but usually its updated by the Resident Care Mangers, Director of Nursing, or the Assistant Director of Nursing or whoever is doing the investigation of the fall.
On 08/22/2023 at 2:35 PM, Staff C, Nurse Consultant/Registered Nurse, said due to resident safety the updating of care plans and the implementing of interventions should be done by the next day after an event.
WAC 388-97-1020(2)(c)(d)
.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to ensure fall prevention strategies were implemented before a non-i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to ensure fall prevention strategies were implemented before a non-injury fall for 1 of 5 sampled residents (Resident 1) reviewed for accident hazards. This failure place residents at risk for injuries, unmet care needs, and a diminished quality of life.
Findings included .
Facility policy entitled Fall Management with an effective date of 05/26/2021 states, Patients will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury.
Resident 1 was admitted to the facility on [DATE] with diagnoses including unspecified fall and seizures. The Significant Change Minimum Data Set, an assessment tool, dated 08/07/2023, documented Resident 1 was severely cognitively impaired.
Review of the Fall Risk Assessment in the Nursing Documentation Evaluation, dated 07/17/2023, documented Resident 1 had fall risk indicators identified.
A delivery ticket documented the delivery of a scoop mattress to the facility on [DATE]. The identified delivery ticket was scanned into the Electronic Health Record (EHR) on 08/01/2023.
Review of a Fall Investigation, dated 08/10/2023, documented Resident 1 was observed on the floor with their leg on the bed.
Review of the Fall Care Plan, created on 07/17/2023, documented Resident 1 was at risk for falls related to brain mass and seizures. On 08/11/2023, the care plan documented the fall prevention intervention of a perimeter mattress to the bed having been developed after Resident 1 experienced a fall from bed on 08/10/2023.
Review of Resident 1's EHR, documented a provider order, dated 08/11/2023, for a Perimeter mattress to allow resident to recognize edge of bed r/t (related to) NIF (noninjury fall).
On 08/22/2023 at 1:30 PM, Staff C, Resident Care Manager/Licensed Practical Nurse, said they were unaware that a perimeter mattress had been delivered for Resident 1 and placed in the resident's room on 08/01/2023. Staff C stated, prior to Resident 1's fall on 08/10/2023 there wasn't a need for any fall interventions related to the resident not moving very much and not having a history of falls. Staff C said, on 08/11/2023, they were told by Hospice staff there was a scoop mattress in Resident 1's room leaning against the wall. Staff C then initiated the evaluation, consent, and care plan for the perimeter mattress.
On 08/22/2023 at 2:30 PM, Staff B, Director of Nursing Services/Registered Nurse, stated, she was unaware of the perimeter mattress being in Resident 1's room until after the fall on 08/10/2023 when it was applied as a fall intervention.
At 2:35 PM, Staff D, Nurse Consultant/Registered Nurse, said that any outside agencies should be collaborating with the nursing staff at facility. Staff D said any recommendations should be discussed, orders received, implemented, and the care plan updated.
Refer to F 657 for additional information.
Reference WAC 388-97-1060 (3)(g)
.
Jul 2023
2 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 F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to ensure informed consents were completed with reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to ensure informed consents were completed with residents and/or resident representatives regarding non-adherence to recommended interventions to prevent increased worsening of lower extremity wounds for 1 of 3 sampled residents (Resident 1) reviewed for resident rights. This failure places residents and resident representatives at risk for not understanding the potential for medical complications and a decreased quality of life.
Findings included .
The facility policy entitled Requesting, Refusing and/or Discontinuing Care or Treatment, dated February 2021, documented residents had the right to refuse treatment, defined in the policy as medical care, nursing care, or interventions provided to maintain or restore health and well-being. In the event the resident refused treatment a member of the interdisciplinary team would meet with the resident or resident representative to discuss the potential negative outcomes of the resident's refusal, and this should be documented in the medical record.
Resident 1 was admitted to the facility on [DATE] with diagnoses including previous amputation of the right leg above the knee, amputation of multiple toes on the left foot, diabetes (a chronic disease that effects how your body processes glucose) with left foot ulcer (wound) and peripheral vascular disease (reduced blood flow to the extremities).
The quarterly Minimum Data Set (MDS), an assessment tool, dated 06/19/2023, documented the resident was cognitively intact, and did not reject care that was medically necessary to achieve resident goals for health and well being. The MDS documented Resident 1 was medically complex, required extensive assistance of two staff members for bed mobility and toileting, and had diabetic foot ulcers.
The care plan, initiated 10/15/2022, documented interventions, initiated 10/20/2022, to provide patient or healthcare decision maker education regarding risk factors and interventions.
A wound care provider note, dated 05/26/2023 at 11:43 AM, documented the resident was being seen for follow up with chronic reoccurring wounds and did not wear protective footwear, which was a large barrier to healing.
A wound care provider note, dated 06/02/2023 at 10:11 AM, documented the resident was being seen for follow up chronic wounds. The note showed the resident had left hip and knee contractures providing pressure to her left lower extremity and foot, and noted the resident refuses to wear proper offloading footwear.
A wound care provider note, dated 06/09/2023 at 10:50 AM, documented the resident continues to be non-compliant with offloading .
A wound care provider note, dated 06/23/2023 at 11:05 AM, documented the resident does not participate in offloading . nursing continues to attempt to offload but patient refuses to offload.
A wound care provider note, dated 07/07/2023 at 11:16 AM, documented the resident was being referred to a surgeon for potential amputation and the wounds are unchanged due to patient refusing to offload.
On 07/26/2023 at 12:36 PM, Resident 1 was observed sitting in her wheelchair. The resident's left foot was notably bent inward and touching the floor. The foot was covered by a gray sock and appeared to have a dressing underneath. A wedge cushion was on Resident 1's bed. Resident 1 said she was admitted with left foot wounds. The resident said she was not aware of any special footwear she was to use, and stated, What is that? I want to do anything I can to save this foot or else I will face another amputation. Resident 1 said she preferred to lay on her left side and that naturally caused her foot to touch the bed.
On 07/27/2023 at 10:01 AM, Resident 1's family member (FM) said she was never contacted regarding the need for an offloading shoe. The FM said she visited weekly and had never seen an offloading shoe in the room. The FM said she had seen a wedge cushion, but had not seen the resident use it.
A wound care provider note, dated 07/28/2023 at 1:35 PM, documented Resident 1's wounds had greatly deteriorated to the left foot and ankle and noted the resident does not offload, only lays on her side with constant pressure to her foot.
On 07/31/2023 at 11:15 AM, Staff D, Licensed Practical Nurse (LPN), said Resident 1 preferred to lay on her left side, and had a contractured leg that makes it hard for her to straighten it out. Staff D said they try to encourage the resident to use pillows to offload pressure and to get up in her chair, but she often refuses. Staff D said the resident had been told about the risks of not getting up.
At 11:33 AM, Staff C, LPN and Resident Care Manager, said she was not sure if risks of non-compliance had been discussed with the resident, as she had just arrived on the unit about a month ago. Staff C said she believed the wound care provider had discussed it with the resident. Staff C said they continued to educate the resident and encourage to get out of bed more.
At 1:30 PM, Resident 1 said staff did not inform her of the need for an offloading boot, about the need to relieve pressure with pillows, or the negative impact not adhering to those recommendations. Resident 1 said she was able to use a pillow to offload pressure to her left leg but did not do it because it was uncomfortable.
At 2:27 PM, Staff B, Registered Nurse and Director of Nursing Services, said if a resident was consistently refusing recommended interventions, she would expect the resident and/or decision maker to be notified and a signed risks and benefits form to be in the record.
At 3:39 PM, Staff E, Nursing Assistant (NA), said when caring for Resident 1, she encouraged the resident to use pillows to offset pressure, but the resident often refused. Staff E said Resident 1 often refused care, because she wanted to do it herself. Staff E said when this happened, she notified the nurse.
Review of the electronic medical record did not show the risks and benefits, including the potential negative outcome for refusals of offloading pressure, were discussed with the resident by facility staff.
On 08/03/2023 at 9:45 AM, Collateral Contact (CC), Wound Care Provider, said Resident 1 was medically complex with other factors impairing wound healing, but if she would have been more complaint with offloading it may have helped. CC said he recalled the resident refusing to wear an offloading shoe. CC said he had many conversations regarding risks and benefits of offloading pressure, but she was not consistently complaint due to contractures of the limb and discomfort of the necessary offloading position. CC said he was not aware if the facility had discussed risks of non-adherence to recommendations, but he would expect that they had.
Reference WAC 388-97-0260
.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to ensure bathing/showers were provided for dependent ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to ensure bathing/showers were provided for dependent residents for 2 of 3 sampled residents (1 & 2) reviewed for activities of daily living (ADLS). This failure placed residents at risk of not receiving assistance with ADLS, poor hygiene, and a diminished quality of life.
Findings included .
1) Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 06/19/2023, documented Resident 1 was medically complex, cognitively intact, required extensive assistance of two staff members for bed mobility and toileting, and that bathing had not occurred during the previous 7 days.
On 07/26/2023 at 12:38 PM, Resident 1 was observed sitting in her wheelchair in her room. Resident 1 said she had just received a shower, but the last one received was about two weeks ago. Resident 1 said they do give her bed baths but then they do not clean her whole body and do not wash her hair. Resident 1 said it was not a head-to-toe bath. They only clean the area down here pointing to her brief area. Resident 1 said she had not had her hair washed since the last shower. Resident 1 stated, I felt so icky, like there are bugs crawling in my hair. Resident 1 said she always prefers a shower.
Review of the Electronic Health Record (EHR) bathing task documentation, dated 06/27/2023 to 07/26/2023, showed Resident 1 last received a shower on 07/12/2023. That was the only shower documented during the 30 days. There was only one bed bath documented between 07/14/2023 and 07/26/2023.
2) Resident 2 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented the resident was cognitively intact, medically complex, required extensive assistance of two staff members for bed mobility and transfers and that bathing had not occurred during the past 6 days (06/20/2023 to 06/26/2023).
Review of the Resident 2's EHR bathing task, dated 06/27/2023 to 07/26/2023, documented only one shower was given.
On 07/31/2023 at 11:15 AM, Staff D, Licensed Practical Nurse (LPN), said most residents usually received two showers a week, and bed baths were for residents that were primarily bed bound. Staff D said a bed bath would include washing hair as well as changing linens.
At 12:02 PM, Resident 2 was observed in bed with a gown on. Resident 2 said it was days and days between showers. Resident 2 said the facility told her she was supposed to receive a shower weekly, but her last shower was 8 days ago. Resident 2 said once a week just wasn't enough, and the lack of bathing had left her skin very dry. The resident said she had to ask her daughter to bring in moisturizing wipes.
At 1:07 PM, Staff F, Nursing Assistant (NA) and Shower Aid, said she was usually assigned 10-13 resident showers a day, and it is hard to get to all of the residents because they have to help with meals and trays. Staff F said most days she can only get to 7-8 resident showers completed. Staff F said currently residents were supposed to get one shower a week. They were working on increasing it to twice a week, but frequently the shower aids got pulled to the floor. Staff F said they asked residents if they wanted a shower or bed bath and bed baths included washing hair.
At 2:31 PM, Staff B, Registered Nurse and Director of Nursing Services, said the facility provided residents with one shower per week,. If the resident requested more, they would accommodate that. Staff B said she was hopeful they would be able to provide showers twice a week in the future. Staff B said sometimes staffing could be a challenge but if there were call ins or the shower aide was pulled to the floor, she felt if NAs had 10-12 residents assigned, they should still be able to do one or two showers during their shift.
On 08/01/2023 at 4:15 PM, additional information was provided by the facility. The documentation showed two additional showers were given for Resident 2, however, Resident 2 had no documented shower from 06/27/2023 to 07/05/2023 (8 days), and from 07/18/2023 to 07/26/2023 (8 days).
Reference WAC 388-97-1060 (2)(c)
.
Jun 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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to report to the state agency allegation of abuse for 1 of 3 residents (Resident 1) reviewed for abuse and neglect. This failure placed reside...
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Based on interview and record review, the facility failed to report to the state agency allegation of abuse for 1 of 3 residents (Resident 1) reviewed for abuse and neglect. This failure placed residents at risk for unidentified abuse, continuous abuse, psychosocial harm, and a diminished quality of life.
Findings included .
Review of the facility's policy and procedure titled, Abuse Prohibition Policy and Procedure, dated 02/23/2021, showed the facility upon receiving information concerning a report of suspected or alleged abuse was expected to report the allegation involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation was made.
In an interview on 05/30/2023 at 4:00 PM, Resident 1 stated a Certified Nursing Assistant (CNA) placed a pillowcase over their face and had done it twice to them. Resident 1 verbalized fearing the named CNA. According to Resident 1, other staff came running inside the resident's room upon hearing them scream and were informed of the alleged incident.
Review of the facility's incident reporting log for May 2023, showed an entry of an incident that involved Resident 1 on 05/08/2023. The facility failed to completely fill out the incident entry log leaving several sections (nature of occurrence, incident location, type of injury, findings, actions) blank. The incident reporting log indicated the facility did not notify the state hotline of the incident.
Review of the facility investigation, dated 05/08/2023, showed Resident 1 alleged a CNA placed a piece of linen over their face. In the investigation, Resident 1 identified and named the CNA.
In an interview on 06/07/2023 at 2:00 PM, Staff B, Director of Nursing Services (DNS), stated the facility investigated the incident; however, did not report the allegation to the state agency.
In an interview on 06/07/2023 at 2:25 PM, Staff A, Interim Administrator, stated the expectation was for staff to report to the state any allegation of abuse, neglect, mistreatment and exploitation.
Reference WAC 388-97-0640 (5)(a)
.
Mar 2023
2 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 F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a completed Notice of Medicare Non-Coverage (NOMNC, a notif...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a completed Notice of Medicare Non-Coverage (NOMNC, a notification that Medicare benefits were ending) and a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN, a required form that provides an estimated cost of continuing services which may no longer be covered by Medicare) for 1 of 3 residents (Resident 2) reviewed for liability notices. This failure placed the resident at risk for not having adequate information to make care and financial decisions during their continued stay.
Findings included .
Review of the admission Minimum Data Set assessment, dated 10/21/2022, showed Resident 2 was admitted to the facility on [DATE] with Medicare Part A as the payment source.
Review of Resident 2's progress notes dated 12/29/2022 showed the staff spoke with Resident 2 regarding the NOMNC, and Resident 2 indicated they were not ready to return to the community at that time.
Review of Resident 2's NOMNC, signed on 12/29/2022, showed no documented date when Medicare services would end.
On 03/28/2023 at 1:24 PM, Staff C, Business Office Manager, stated that [Resident 2's] NOMNC did not have a date listed when Medicare services would end, and the resident had not received an ABN. Staff C stated the NOMNC was not completed correctly, and [Resident 2] should have been issued an ABN because they continued to receive services at the facility, and it was missed.
On 03/30/2023 at 4:33 PM, Staff A, [NAME] President of Operations, stated that the facility failed to provide a completed NOMNC and an ABN to Resident 2.
Reference WAC 388-97-0300(1)(e)
.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to ensure sufficient staff were available to provide ti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview and record review, the facility failed to ensure sufficient staff were available to provide timely care and services for 6 of 10 residents (Residents 1, 4, 6, 9,10, & 11). The failure to provide sufficient nursing staff resulted in untimely response to resident call lights, showers not being provided, residents being left for extended times in wet/soiled briefs, residents not turned and repositioned, and potentially contributed to the re-opening of a healed pressure injury (bed sore).
Findings included .
< STAFF INTERVIEWS >
On 03/28/23 at 5:26 AM, Staff D, Licensed Practical Nurse (LPN) stated that on the night shift they were understaffed a lot. Staff D stated that they could manage with two aides and two nurses on each side. Staff D stated that many times they had one nurse on each side with one aide. Staff D indicated that when they were understaffed, it took longer to answer the call lights and they couldn't provide the care the residents needed. Staff D indicated residents only received one round at night and medications were not administered timely when they were understaffed. Staff D stated that they had a resident whose behavior included disrobing in the halls and when there was not enough staff they might not see it right away. Staff D stated that they talked with management when they didn't have enough staff.
At 5:45 AM, Staff E, Certified Nursing Assistant (NAC), indicated staffing had been a problem. Staff E stated that when working alone a recent night shift, a call light went unanswered for three hours. Staff E indicated that when they did not have enough staff they were not able to take care of resident needs or answer call lights promptly. Staff E indicated that staffing worsened when the facility stopped using temporary nursing aides from an agency before ensuring they had enough staff hired to replace temporary workers.
On 03/30/2023 at 10:45 AM, Staff I, LPN, Staff Development Coordinator, stated that the term check and change on the Care Plan meant the resident needed to be checked every two hours because they were dependent and/or a fall risk and they were not going to notify staff they needed assistance. Staff I indicated that staff were to go into the room every two hours and ask resident if they needed anything and/or if the resident was not able to tell the staff, the staff needed to check the resident to determine if they needed to be changed.
On 03/30/2023 at 10:59 AM, Staff F, NAC, stated that check and change on the [NAME] (instructions for care for each resident) meant they were to check the resident every two hours to determine if their brief needed to be changed. Staff F stated that when they had 16 or 17 residents assigned to them on the day shift they were not able to complete the care according to the [NAME]. Staff F indicated residents were turned, repositioned and changed once per shift. Staff F stated that the management knew about it and were very understanding and would tell the staff to inform the aide on the next shift regarding care that was not done.
< RESIDENT 1 >
Resident 1 was admitted [DATE] with diagnoses including paralysis of the right side of body after a stroke and a Stage III pressure injury (bed sore with exposed damage to tissue) at the sacral region (a region of the body where the tail bone is located).
Wound Care Provider's note, dated 03/24/2023, documented Resident 1's wound care for the sacral wound had reached its goal and the resident no longer needed treatment.
Nursing Note, dated 03/27/2023, documented Resident 1 did not have a wound.
On 03/28/2023 at 5:55 AM, Resident 1 was observed in bed, lying on the right side, trying to pull off a wet brief. The wet brief was removed by staff and an open wound at the coccyx (tail bone) was observed.
At 6:00 AM, Staff J, LPN, stated they had two aides for over 50 residents and sometimes it was one nurse and one aide on night shift. When asked if incontinent residents were checked and changed every two hours, Staff J stated that they were not always able to do it that frequently. When asked how the care would be prioritized on the night shift if there were not enough nursing assistants, Staff J indicated priority was sometimes those who asked to be changed. When asked about residents who cannot ask for help, Staff J stated it was sad because these were the ones that suffer the most.
At 6:30 AM, Staff G, NAC, stated that staffing was difficult on night shift. Staff G explained that without adequate staff the residents who were dependent on staff didn't get checked and changed enough. Staff G stated that if the residents don't get changed every two hours they would be at risk for getting pressure injury. Staff G stated that if there was no shower aide scheduled then showers were not done. Staff G stated, I feel for these people, I've been left alone too many times.
Point of Care (POC) documentation, reviewed 03/28/2023, showed that it had been 11 days since Resident 1 was bathed.
At 2:13 PM, Collateral Contact (CC) A stated they visit Resident 1 at least three times weekly and the resident's brief was always soiled and smelly. CC A stated it could take a half hour to get Resident 1's staff to change the brief.
Resident 1 was observed lying on the right side, facing the wall at the following times: 5:30 AM, 5:55 AM, 6:10 AM, 9:03 AM, 9:24 AM,10:45 AM, 11:45 AM, 12:36 PM, 12:57 PM, 1:02 PM and 3:45 PM.
On 03/30/2023 at 10:42 AM, Staff H, LPN and Resident Care Manager, stated Resident 1 should be turned/repositioned and checked/changed every two hours. When asked about the lack of shower or bath documentation for Resident 1, Staff H stated it could be that the shower aide was pulled to work the floor and it was hard for the aides to do showers if there wasn't enough staff. Staff H stated she had been working on a priority project to ensure showers were provided as scheduled.
< RESIDENT 4 >
Resident 4 was admitted [DATE] with diagnoses including arthritis and depression. Resident 4's Minimum Data Set (MDS), an assessment, dated 03/06/2023, documented the resident needed extensive assistance of two people for bed mobility and toileting. The MDS documented Resident 4 was always incontinent of bowel and bladder.
On 03/30/2023 at 12:45 CC 2 was observed attempting without success to pull Resident 4 up in bed. CC 2 stated that the CC had to help as there was no help. CC 2 stated the repositioning had to be done because Resident 4 was hurting due to arthritis in shoulders. Resident 4 stated I'm wet I haven't been changed since middle of the night .not enough staff. When asked if the call light was used to summon staff for help, Resident 4 stated, I don't want to bother them, I wait my turn. Resident 4 indicated knowledge that lying in wet or soiled briefs could increase the risk for bed sores and stated, I had that in the hospital.
Review of Resident 4's POC documentation, by nursing assistants, reviewed 03/30/2023, showed the resident was incontinent of urine the past 23 of 24 days. The POC documentation showed that Resident 4 received no showers or bed baths in the first 15 days of admission.
< CALL LIGHT RESPONSE >
Resident 10 was admitted [DATE] with diagnoses including heart failure. On 03/28/2023 at 6:06 AM, Resident 10 stated that it takes a while for the call light to be answered, it could be up to an hour.
Resident 6 was admitted [DATE] with diagnoses including heart disease and insomnia. On 03/28/2023 at 8:16 AM, Resident 6 indicated there was not enough staff and residents with calling out behaviors at night kept him awake and the staff didn't stop the noise.
Resident 9 was admitted [DATE] with diagnosis of right sided paralysis related to a stroke. On 03/28/2023 at 11:03 AM, Resident 9 stated, I've had to hold it .needing to go to the bathroom I'm holding and shaking because I'm going to lose it .I barely make it .
Resident 11 was admitted [DATE] with diagnosis of right sided paralysis related to a stroke. On 03/28/2023 at 11:15 AM, Resident 11 indicated discouragement and stated that it was difficult to get help, especially at night.
On 03/30/2023 at 3:34 PM, Staff A, Acting Administrator and Regional [NAME] President of Operations, indicated there was a recent turnover of the leadership team and the priority now was to build a cohesive team that could focus on hiring, retaining, educating, mentoring, supervising and supporting staff to improve the overall quality of care. Staff A stated that it was not the policy to admit residents to the facility when they did not have the staff to provide care. Staff A indicated the COVID-19 pandemic exacerbated an already strained staffing problem and that retention of staff was a critical focus.
Refer to F656
Reference WAC 388-97-1080 (1), 1090 (1)
.
Mar 2023
2 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the required assistance for activities of dail...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the required assistance for activities of daily living (ADLs) care for 2 of 6 dependent residents (Residents 1 and 2) reviewed for ADL care. This failure placed the residents at risk for poor nutrition, poor hygiene, medical complications, and a diminished quality of life.
Findings included .
Review of the facility policy and procedures titled, Activities of Daily Living (ADLs). Revised March 2018 showed that appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene, mobility, elimination, dining, and communication.
<Resident 1>
Review of Resident 1's admission Minimum Data Set (MDS, a required assessment tool) dated 01/12/2023 showed that Resident 1 admitted on [DATE] with diagnoses to include stroke, encephalopathy (disease or damage of the brain that alters brain function), diabetes, kidney disease, and depression. The MDS further showed that Resident 1 had severe cognitive impairment and required extensive one-person physical assist with activities of daily living (ADLs). The MDS indicated that Resident 1 had no pressure ulcer at the time of assessment; however, identified the resident as at risk of developing pressure injuries.
Review of Resident 1's care plan initiated 01/08/2023, showed that Resident 1 required assistance for ADL care in bathing, grooming, personal hygiene, eating, bed mobility, transfers, locomotion, and toileting.
In an interview on 03/01/2023 at 1:13 PM, Collateral Contact (CC), stated that the facility did not feed or offer fluids to Resident 1. According to CC, on multiple occasions CC walked in the resident's room with the resident's meal tray left untouched with plate of food and drink still covered with plastic wrap. CC also stated that several times Resident 1 was seen in bed with sheets saturated in urine and dried up ring marks on the sheets along resident's torso area indicating the resident had not been changed for a long period of time.
Review of Resident 1's electronic health records (EHR) Tasks tab from 01/31/2023 through 02/07/2023, showed that the nursing aides documented Resident 1 was independent of eating and required no assistance or staff oversight at any time.
In an interview on 02/27/2023 at 2:37 PM, Staff D, Licensed Practical Nurse (LPN), stated that Resident 1's condition declined and that the resident needed to be fed during mealtime.
In an interview on 03/15/2023 at 12:55 PM, Staff C, Nurse Practitioner (NP) stated that they ordered one on one feed for Resident 1 due to the decline in resident's condition.
Review of Resident 1's progress note dated 02/14/2023 showed that the facility transferred Resident 1 to the hospital due to altered mental status.
<Resident 2>
Review of the quarterly Minimum Data Set (MDS, a required assessment tool) dated 12/30/2022 showed that Resident 2 admitted on [DATE] with diagnoses to include dementia, malnutrition, adult failure to thrive, stroke, and generalized muscle weakness. The MDS further showed Resident 2 had severe cognitive impairment and required extensive one to two-person assistance with ADLs.
Review of Resident 2's care plan revised 01/04/2023, showed that Resident 2 required assistance and was dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, locomotion, and toileting.
In an observation on 02/27/2023 at 3:36 PM, Resident 2 laid in bed, with no shirt or gown, covered halfway with a bedsheet. Resident 2 was awake but confused. At the bedside, facility staff left Resident 2's lunch tray sitting on top of the overbed table untouched and covered. Further observation showed when Resident 2 slightly turned to the side, the bedsheet underneath was soaked in urine with dark brown stain that had dried up noted along the midback area of the resident. Resident 2's briefs were heavily soiled in urine and stool. This investigator called the attention of the nurse who immediately got one of the aides to help clean and change the resident.
In an interview on 02/27/2023 at 3:59 PM, Resident 3, the roommate of Resident 2, stated they would normally leave the room whenever Resident 2 got changed to provide privacy. According to Resident 3 nobody came to change Resident 2 since 7:00 AM. Resident 3 stated that it happened not just one time but several times wherein facility staff left Resident 2 soiled for an extended period.
In an interview on 02/27/2023 at 4:16 PM Staff E, Nursing Assistant Certified (NAC), stated that that the outgoing NAC did not provide report regarding the residents. Staff E, NAC stated that the nurse provided the report. According to Staff E, they did not know Resident 2 was soiled and needed to be changed.
In an interview on 02/27/2023 at 4:39 PM, Staff B, Director of Nursing Services (DNS) stated that the expectation was for staff to assist residents with their activities of daily living according to resident care plan and to document the care provided to the residents in the computer.
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 F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to reassess and monitor the nutritional status and modify intervention...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to reassess and monitor the nutritional status and modify interventions to address the nutritional needs of 1 of 3 residents (Resident 1) reviewed for nutrition management. These failures placed the resident at risk for unmet needs, further functional decline, medical complications, hospitalization, and death.
Findings included .
Review of the facility policy and procedures titled, Nutritional Assessment, revised October 2017, showed that as part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, should be conducted for each resident. The policy and procedures further showed that the dietician, in conjunction with the nursing staff and healthcare practitioners would conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that placed the resident at risk for impaired nutrition.
Review of Resident 1's plan of care initiated on 01/08/2023, showed that Resident 1 required assistance with ADLs including eating. The care plan indicated Resident 1 was a nutritional risk due to poor oral intake. Care plan interventions included were to monitor the resident's intake at all meals, offer alternate choices and to notify the dietician and physician to any decline in intake.
In an interview on 02/27/2023 at 3:05 PM, Staff D, Licensed Practical Nurse (LPN), stated that the assistance provided would be based on the resident's care plan. According to Staff D, LPN, nursing assistants documented in the computer the tasks performed such as the assistance provided during meals, and were supposed to document the percentage of food intake during meals.
Review of Resident 1's electronic health records (EHR) under the tasks tab from 01/31/2023 through 02/13/2023, showed that from 01/31/2023 through 02/07/2023, nursing assistants documented Resident 1's eating performance as independent requiring no assistance or staff oversight at any time. The EHR showed the lack of documentation of the amount of food and fluid intake by the resident.
Review of the Change in Condition (CIC) Evaluation dated 02/06/2023, showed that Resident 1 had decreased food and fluid intake.
Review of Resident 1's progress note dated 02/06/2023 at 6:22 AM, showed that Resident 1 had no urine output for 12 hours and the physician ordered to send the resident to the hospital for evaluation.
Review of the document titled, After Visit Summary, dated 02/06/2023, showed instructions from the hospital to infuse normal saline IV fluids for the next 24 hours to provide hydration while Resident 1 was not drinking adequate fluids and to encourage Resident 1 oral hydration to stay better hydrated.
In an interview on 03/01/2023 at 1:13 PM, Collateral Contact (CC) stated that the resident returned to the facility from the hospital in less than 24 hours with an order for intravenous (IV) fluids due to dehydration and an indwelling catheter due to urinary retention. CC further stated that the facility staff did not provide Resident 1 the assistance needed during meals. According to CC, on multiple occasions, Resident 1's plate of food and glass of drink remained covered with plastic wrap, untouched, and left sitting on top of the overbed table.
Review of Resident 1's EHR for February 2023 showed no nutrition assessment from the dietician or the dietician's recommendations to address Resident 1's nutritional needs after the resident returned from the hospital for dehydration and after facility identified development of pressure injury. The EHR indicated that the last nutritional assessment was conducted on 01/18/2023 as part of the admission assessment. Also, there was no documentation found that care plan interventions were reviewed and modified to meet Resident 1's nutritional needs.
In an interview on 03/06/2023 at 1:20 PM, Staff F, Regional Dietary Consultant, stated that the facility just hired a new dietician to the position. The expectation was for the dietician to conduct assessment on admission, quarterly and when there was change of condition requiring nutritional reassessment.
In an interview on 03/06/2023 at 2:00 PM, Staff A, Administrator, stated that the nurse practitioner was notified of Resident 1's poor oral intake and a referral was made to dietary services for consult. A nutritional reassessment should have been done and interventions reviewed and revised to meet Resident 1's needs.
In an interview on 03/15/2023 at 12:25 PM Staff C, Nurse Practitioner (NP), stated that there was an active standing order for nutrition consult for Resident 1 and that she ordered for nursing staff to provide one on one feeding assistance to Resident 1 during meals. A family care conference was set up for 02/14/2023 to further discuss care and treatment due to the decline in resident's condition and options to address the resident's nutritional needs. According to Staff C, NP, Resident 1 transferred to the hospital on [DATE] due to altered mental status before the care conference could happen.
Refer to F677 for additional resident information.
Reference WAC 388-97-1060(3)(h)(i)
Feb 2023
3 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 F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to track the influenza and pneumonia vaccination status and offer need...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to track the influenza and pneumonia vaccination status and offer needed immunizations for 3 of 10 residents (Residents 6, 7, and 8) reviewed for influenza and pneumonia immunizations. This failure placed the residents at risk for unmet vaccination needs and contracting infectious diseases.
Findings included .
Review of the facility's policy and procedures titled, Vaccination of Residents, dated October 2019, showed that all residents would be offered vaccines that aid in preventing infectious diseases unless the vaccine was medically contraindicated, or the resident had already been vaccinated. According to the policy and procedures, prior to receiving vaccinations, the resident or the legal representative would be provided information and education regarding the benefits and potential side effects of the vaccinations. Provision of such education should be documented in the resident's medical record. The policy and procedures further showed that all new residents should be assessed for current vaccination status upon admission.
<Resident 6>
Review of Resident 6's admission Minimum Data Set (MDS, a required assessment tool) dated 01/03/2023 showed that Resident 6 admitted on [DATE] with diagnoses to include hypertension (high blood pressure), diabetes and chronic lung disease. According to the MDS, Resident 6 was cognitively intact and able to make needs known. The MDS vaccine section indicated that Resident 6 did not receive the influenza and pneumonia vaccines and that the vaccines were not offered to the resident.
Review of Resident 6's immunization record, undated, showed no documentation of the pneumonia and influenza vaccinations.
Review of Resident 6's consent for vaccination, showed Resident 6 declined the pneumonia vaccine on 12/28/2022. There was no documentation that the facility provided education of the risks and benefits of the influenza vaccine or that the resident was offered and declined the influenza vaccine.
<Resident 7>
Review of Resident 7's admission MDS dated [DATE] showed that Resident 7 admitted on [DATE] with diagnoses to include hypertension and dementia. According to the MDS, the resident had severe cognitive impairment. The MDS vaccine section indicated that Resident 7 did not receive the influenza vaccine in the facility during the influenza season and that the vaccine was not offered.
Review of Resident 7's immunization record, undated, showed no documentation of the influenza and pneumonia vaccinations.
Review of Resident 7's consent for pneumonia vaccination dated 12/08/2022, showed that the resident's representative was offered and declined the pneumonia immunization for Resident 7. There was no documentation that the resident's representative was provided education about the risks and benefits of the influenza vaccine or that the representative was offered and declined the vaccine for Resident 7.
<Resident 8>
Review of Resident 8's admission MDS dated [DATE] showed Resident 8 admitted on [DATE] with diagnoses to include hypertension. The MDS showed Resident 8 had moderate cognitive impairment and able to make needs known. The MDS vaccine section indicated that Resident 8 did not receive the influenza vaccine in the facility during the influenza season and that the vaccine was not offered.
Review of Resident 8's immunization record, undated, showed no documentation of the influenza vaccination.
Review of Resident 8's consent for pneumonia vaccination dated 01/09/2023 showed Resident 8 was offered and declined the pneumonia vaccine. There was no documentation that Resident 8 was provided education about the risks and benefits of the influenza vaccination or that Resident 8 was offered and declined the influenza vaccine.
In an interview on 02/16/2023 at 12:42 PM, Staff C, IP, stated that the facility's process was for the admitting nurse to find out the resident's vaccination status for influenza and pneumonia, provide information of the risks and benefits of the vaccines and have the resident or the resident's representative sign the vaccination consent forms whether they consented to receive the vaccines or not.
In an interview on 02/16/2023 at 3:01 PM, Staff B, Director of Nursing Services stated that the expectation was for the admission nurse to verify if the resident being admitted had the vaccinations for influenza and pneumonia. According to the DNS, the IP or staff nurses were responsible in administering the vaccines.
In an interview on 02/16/2023 at 4:15 PM, Staff A, Administrator, stated that during admission, the facility provided the resident the admission packet that included vaccination information and consent forms for the influenza and pneumonia vaccines. According to Staff A, the expectation was for the admitting nurse to go over the vaccination consent forms with the resident or the resident's representative.
Reference WAC-388-97-1340(1)(2)
.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to conduct ongoing analysis and interpretation of surveillance data for 3 of 3 infection control surveillance logs (Surveillance logs in Decem...
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Based on interview and record review, the facility failed to conduct ongoing analysis and interpretation of surveillance data for 3 of 3 infection control surveillance logs (Surveillance logs in December 2022, January 2023, February 2023), reviewed for infection control and prevention. This failure placed the residents at risk for spread of infections and contracting communicable diseases.
Findings included .
Review of the facility's policy and procedures titled, Surveillance for Infections, dated September 2017, showed that the Infection Preventionist (IP) was expected to conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other significant infections that had substantial impact on potential resident outcome and that may require transmission-based precautions and preventive interventions. According to the policy and procedures, the purpose of the surveillance of infections was to identify individual cases or trends of significant infections and HAIs, to guide appropriate interventions and to prevent future infections.
Review of the infection control surveillance log for December 2022, showed an infection control line listing (infection database) and infection control surveillance mapping (location of infections). There was no documentation of the analysis and interpretation of the surveillance data from the December 2022 infection control surveillance log.
Review of the infection control surveillance log for January 2023, showed an infection control line listing and infection control surveillance mapping. There was no documentation of the analysis and interpretation of the surveillance data from the January 2023 infection control surveillance log.
Review of the infection control surveillance log for February 2023, showed an infection control line listing with no infection control surveillance mapping documented from 02/01/2023 through 02/16/2023.
In an interview on 02/16/2023 at 4:00 PM, Staff C, IP, stated that they did not do the infection control surveillance mapping for February 2023.
During the onsite visit on 02/16/2023, this investigator requested for the documentation of analysis, interpretation, and plan of actions to address infection control findings from the December and January Surveillance logs. The facility was unable to provide the requested documentation.
In an interview on 02/16/2023 at 4:15 PM, Staff A, Administrator, stated that the facility's expectation was for IP to conduct ongoing surveillance of infections that included data collection, mapping, analysis, conclusion and interventions and the infection control report presented to the Quality Assurance Performance Improvement committee.
Reference WAC 388-97-1320(1)(a)(2)(a)(c)
.
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 F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to track the Coronavirus (COVID-19) vaccination status an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to track the Coronavirus (COVID-19) vaccination status and offer the COVID-19 vaccine for 4 of 10 residents (Residents 6,7,8, and 9) reviewed for COVID-19 immunization. This failure placed the residents at risk for unmet vaccination needs, and the potential for contracting the COVID-19 infection that could result in severe illness or death.
Findings included .
Review of the facility's policy and procedures titled, Coronavirus Disease (COVID-19)-Vaccination of Residents, dated November 2021, showed that each resident would be offered the COVID-19 vaccine unless the immunization was medically contraindicated or the resident had already been immunized. The policy and procedures further showed that the resident or the resident representative would be given the opportunity to accept or refuse a COVID-19 vaccine and to change their decision.
Refer to F883 for additional resident information
<Resident 6>
Review of Resident 6's immunization record, undated, showed that COVID-19 vaccination dose 1 required consent.
Review of Resident 6's consent for vaccination, showed no documentation that the facility provided education of the risks and benefits of COVID-19 vaccine or that the resident was offered and declined the COVID-19 vaccine.
Review of Resident 6's progress note dated 01/28/2023, showed that the facility tested Resident 6 for COVID-19 due to potential exposure and the result came back positive for COVID-19.
Review of the progress note dated 02/01/2023, showed that Resident 6 discharged from the facility per resident's wish despite positive COVID-19 result and discharged in stable condition.
<Resident 7>
Review of Resident 7's immunization record, undated, showed that COVID-19 vaccination dose 1 required consent.
Review of Resident 7's consent for vaccination showed no documentation that the resident's representative was provided education about the risks and benefits of the COVID-19 vaccination or that the representative was offered and declined the COVID-19 vaccine for Resident 7.
Review of Resident 7's progress note dated 01/28/2023, showed that Resident 7 frequently wandered the halls without a mask while the facility was on a COVID-19 outbreak. According to the progress note the facility tested the resident due to potential exposure and result of the COVID-19 test came back positive. The progress note indicated Resident 7 was asymptomatic.
Observation and interview on 02/16/2023 at 2:34 PM showed Resident 7 in the room no longer on transmission-based precaution, comfortably sitting in the chair with no signs or symptoms of respiratory distress. Resident 7 was unable to respond when asked if they had received the COVID-19 vaccine. Resident 7 stated feeling ok and denied being sick recently.
<Resident 8>
Review of Resident 8's immunization record, undated, showed no documentation of the COVID-19 vaccination.
Review of Resident 8's consent for vaccination showed no documentation that Resident 8 was provided education about the risks and benefits of the COVID-19 vaccination or that Resident 8 was offered and declined the COVID-19 vaccine.
Review of Resident 8's progress note dated 01/31/2023, showed that the facility tested Resident 8 for COVID-19 due to facility outbreak and potential exposure. The progress note indicated that the result came back positive for COVID-19. Resident denied being symptomatic.
Observation on 02/16/2023 showed Resident 8 in the room on aerosol contact precaution due to COVID-19.
<Resident 9>
Review of Resident 9's quarterly MDS dated [DATE] showed that Resident 9 readmitted on [DATE] with diagnoses to include heart disease, hypertension, and diabetes. The MDS indicated resident was cognitively intact and able to make decisions.
Review of Resident 9's immunization record from the electronic health records, showed that Resident 9 refused the COVID-19 vaccination.
Review of Resident 9's COVID-19 immunization consent form dated 11/14/2022, showed that Resident 9 consented to receive the COVID-19 vaccine.
Review of Resident 9's progress note dated 02/03/2023 showed that the resident tested positive for COVID-19; however, was asymptomatic.
In an interview on 02/16/2023 at 12:42 PM, Staff C, IP, stated that the facility's process was for the admitting nurse to find out the resident's COVID-19 vaccination status, provide information of the risks and benefits and have the resident or the resident's representative sign the vaccination consent form whether they consented to receive the vaccine or not.
In an interview on 02/16/2023 at 3:01 PM, Staff B, Director of Nursing Services stated that the expectation was for the admitting nurse to verify if the resident being admitted required the COVID-19 vaccine. According to the DNS, the IP or staff nurses could administer the vaccine.
In an interview on 02/16/2023 at 4:15 PM, Staff A, Administrator, stated that during admission, the facility provided the resident the admission packet that included vaccination information and consent form for COVID-19 vaccination. According to Staff A, the expectation was for the admitting nurse to go over the vaccination consent form with the resident or the resident's representative.
Reference WAC 388-97-1780 (1)(2)(d)
.
Feb 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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary care and services to promote the healing of a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary care and services to promote the healing of an existing pressure injury and prevent new pressure injuries from developing for 1 of 3 residents (Resident 5) reviewed for management of pressure injuries. This failure placed the resident at risk for unmet needs, worsening of an existing pressure injury, development of new skin breakdown, medical complications, and a diminished quality of life.
Findings included .
Review of the facility's policy and procedure titled, Skin Integrity Management, dated 05/26/2021 showed that the facility was expected to complete a comprehensive evaluation on admission that included the completion of risk evaluation; identify the resident's skin integrity status and the need for prevention intervention or treatment modalities; perform skin inspection on admission and weekly and document on the treatment administration record or in Point Click Care (PCC, an electronic health record system); perform wound observations and measurements upon initial identification of altered skin integrity; develop a comprehensive, interdisciplinary plan of care including prevention and wound treatments as indicated; and implement pressure ulcer (pressure injury) prevention for identified risk factors.
Review of Resident 5's admission Minimum Data Set (MDS, a required assessment tool) dated 01/13/2023 showed that Resident 5 admitted on [DATE] with diagnoses to include stroke, hemiplegia (weakness of one side of the body), aphasia (loss of ability to understand or express speech), diabetes, and abnormalities in gait and mobility. The MDS further showed Resident 5 had severe cognitive impairment and required one to two-person physical assistance with activities of daily living. The MDS indicated Resident 5 had one Stage 3 pressure ulcer (pressure injury involving the full thickness of the skin that may extend to the subcutaneous tissue layer) present during admission.
In an interview on 01/24/2023 at 1:17 PM, Collateral Contact (CC) stated that Resident 5 admitted with a Stage 3 pressure injury on the buttocks. CC further stated that the facility provided no preventive measures for an existing pressure injury. According to CC, the facility did not prop up resident with pillows to offload affected area and did not provide a specialty air mattress for the resident's bed.
Review of Resident 5's admission skin assessment dated [DATE], showed documentation of redness to Resident 5's bilateral buttocks, left elbow, left inner and outer ankle and scrotal area. The admission skin assessment did not indicate that Resident 5 had a Stage 3 pressure injury on the buttocks on admission.
Review of the Nursing Documentation Evaluation dated 01/06/2023, showed Resident 5 with two open areas to bilateral buttocks, redness to the left elbow, left inner and outer ankle, and scrotal area. There was no documentation of measurements and description of the two open areas on Resident 5's buttocks.
Review of Resident 5's Care Area Assessment (CAA) dated 01/13/2023, showed that Resident 5 required a comprehensive care plan for the Stage 3 pressure injury on the buttocks. The CAA identified Resident 5 with an actual skin integrity problem and identified pressure as one of the extrinsic risk factors that required the need for a specialty bed for Resident 5 or the need for pillows and wedges to offload the affected area.
Review of Resident 5's care plan initiated on 01/06/2023, identified the resident as a risk for skin breakdown; however, the care plan did not address the actual skin integrity problem and the interventions being implemented.
In an interview on 02/01/2023 at 12:57 PM, Staff C, Registered Nurse/ Resident Care Manager (RN/RCM), stated that the RCMs were the ones assigned to complete the admission assessment and document in PCC the assessment of the resident's skin integrity, measurements, and description of pressure ulcers on the day of admission. Staff C, RN/RCM further stated that care plan was then initiated that addressed identified existing issues and risk factors. In addition, Staff C, stated that the interventions implemented should be reflected in the resident's care plan.
In an interview on 02/01/2023 at 2:05 PM, Staff B, Director of Nursing Services (DNS) stated that nurses were expected to complete the skin assessment on admission including wound measurements, wound description and staging if stageable and document in PCC. The DNS further stated that the actual pressure injury and the risk for further skin breakdown should have been addressed in Resident 5's comprehensive care plan.
In an interview on 02/01/2023 at 3:00 PM, Staff A, Administrator, stated that the expectation was for staff to complete a comprehensive admission assessment timely, initiate a comprehensive plan of care that addressed the risk factors identified, document actual skin impairment measurements and make the necessary referrals for consult.
Reference WAC 388-97-1060(3)(b)
Jan 2023
2 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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to thoroughly investigate incidents with the potential for abuse or neglect for 3 of 6 residents (Residents 1, 2, and 3) reviewed for abuse, a...
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Based on interview and record review, the facility failed to thoroughly investigate incidents with the potential for abuse or neglect for 3 of 6 residents (Residents 1, 2, and 3) reviewed for abuse, and neglect. This failure placed the residents at risk for unidentified and continuous abuse or neglect, continuous psychosocial harm, and a diminished quality of life.
Findings included .
Review of the Complaint Resolution Unit's (CRU) intake dated 12/20/2022 showed that the facility reported care concern regarding three residents (Resident 1, 2 and 3) found unchanged in their briefs and left in wet briefs for an extended period by the night shift aides. According to the intake report, the facility identified the alleged perpetrator (AP) and terminated AP's employment with the facility.
Review of the facility incident reporting log dated 12/20/2022, showed that the facility logged an incident reported on 12/19/2022 at 6:34 PM involving Resident 1 for an allegation of neglect. The facility incident reporting log showed no documentation of similar allegation being logged for Resident 2 and 3.
Review of Resident 1's facility incident investigation report dated 12/19/2022 at 6:34 PM showed that Resident 1 was found in bed with soaked bedsheets and briefs. The facility incident investigation showed no documentation of the alleged perpetrator being identified and investigated. The facility had no statements obtained from nursing staff assigned to Resident 1 and other staff working the shift when the alleged incident happened. The facility did not conduct extended interviews with other residents if they had similar care concerns. There was no documentation of a conclusion to the investigation, whether abuse or neglect was substantiated or not.
On 01/06/2023 during onsite visit, complaint investigator requested from the facility for their facility investigation report on Resident 2 and Resident 3 with similar allegations as Resident 1 on 12/19/2022. The facility was unable to provide requested documentation that showed a thorough investigation had been completed for Resident 2 and 3.
In an interview on 01/18/2023 at 2:38 PM, Staff C, Licensed Practical Nurse/Staff Development Coordinator (LPN/SDC), stated that the resident care managers (RCMs), Assistant Director of Nursing (ADON)and the Director of Nursing Services (DNS) conducted the investigations but would also depend upon what the event was about. According to Staff C, LPN/SDC during investigation, the staff assigned to investigate gathered information about the incident, obtained statements from individuals involved and followed-up with the resident(s).
In an interview on 01/18/2023 at 2:49 PM, Staff D, ADON, stated that allegations/ incidents were reported to the supervisor, staff then initiated risk management in the computer. According to Staff D, ADON, the risk management system contained the investigations compiled together. Staff D, ADON, was not able to locate investigations conducted for Resident 2 and 3 for the allegations on 12/19/2022.
Reference WAC 388-97-0640(6)(a)(b).
.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to reevaluate risk factors and effectiveness of intervent...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to reevaluate risk factors and effectiveness of interventons to minimize the potential for falls and injuries for 1 of 3 residents (Resident 4) reviewed for falls. This failure placed the resident at risk for repeated falls, injuries, and a diminished quality of life.
Findings included .
Review of Resident 4's admission Minimum Data Set (MDS, a required assessment tool) dated 12/25/2022, showed Resident 4 admitted on [DATE] with diagnoses to include metabolic encephalopathy (loss of brain function that is caused by illness), cognitive communication deficit, open wound to the lower leg, lymphedema (swelling due to accumulation of lymph fluids in tissues) obesity and abnormalities in gait and mobility. The MDS indicated that Resident 4 had cognitive impairment and required two-person extensive assistance to total dependence with activities of daily living.
Review of Resident 4's Care Area assessment dated [DATE], showed Fall care area was triggered due to Resident 4's high risk for falls.
Review of the facility incident reporting log dated 12/31/2022 showed that Resident 4 had a fall incident with no injury.
Review of the facility incident investigation dated 12/31/2022 showed that facility staff heard Resident 4 yelling for help from his room and staff found the resident sitting on the floor with his back leaning against the bed and legs out in front. According to the incident investigation, Resident 4 was at his baseline confused state.
Review of Resident 4's plan of care initiated 12/18/2022, showed that the facility did not reevaluate fall risk factors and effectiveness of fall interventions, or implement additional appropriate fall precautions after the 12/31/2022 fall incident.
An observation on 01/06/2023 at 1:23 PM, showed Resident 4 drowsily sitting in a regular wheelchair in his room. The resident's room was located at the far end of the hall, far from the nurse's station. Resident 4 wore a gown and had briefs on. The resident adjusted his bottom that kept slipping at the edge of the seat. Resident 4 had severe lymphedema and both legs were wrapped with compression bandages which provided no traction for his feet. Observation showed the resident with no non-skid socks on. Resident 4 had to be prompted to use the call light that was clipped to his bed. Two nursing aides came to answer the call light and were informed that Resident 4 kept slipping to the edge of the wheelchair.
In an interview on 01/06/2023 at 1:30 PM, Staff E, Licensed Practical Nurse (LPN), was asked about the assistance needed by Resident 4 and the resident's risk for falls. Staff E, LPN stated she was not that familiar with the resident and had to review Resident 4's records.
In an interview on 01/06/2023 at 2:00 PM, Staff B, DNS, stated that she expected nursing staff to review the residents' care plan and be aware of residents at high fall risk. Staff B, DNS, further stated she would make sure that Resident 4 was provided nonskid socks and would consider transferring the resident to a room close to the nurse's station for closer monitoring as soon as one became available.
Reference WAC 388-97-1060(3)(g).
Oct 2022
17 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
Based on interview and record review, the facility failed to provide information on the risks and benefits of a psychotropic medication (a drug that affects behavior, mood, thoughts, or perception) fo...
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Based on interview and record review, the facility failed to provide information on the risks and benefits of a psychotropic medication (a drug that affects behavior, mood, thoughts, or perception) for two of five residents (Residents 96 and 3) reviewed for Unnecessary Medications. Failure to obtain an informed consent prior to use of a psychotropic medication had the potential for the resident and/or the resident's legal representative to have a lack of knowledge to make an informed decision regarding the use of the medication for the resident.
Findings included .
RESIDENT 96
Review of Resident 96's Medication Administration Record (MAR) showed an order for bupropion (an antidepressant) 100 milligram (mg) two times daily for depression, with a start date of 04/13/2022.
Review of Resident 96's MAR showed an order for mirtazapine (an antidepressant) 15 mg every day for depression, with a start date of 08/23/2022.
Review of Resident 96's electronic health record on 10/25/2022 showed no consent for mirtazapine and an outdated consent for bupropion at a lower dosage.
During an interview on 10/26/2022 at 8:51 AM, Resident 96 stated they did not remember signing consents for any medications.
RESIDENT 3
Review of the current physician orders in Resident 3's electronic health records (EHR) on 10/21/2022 showed that Resident 3 had an order dated 10/03/2022 for amitriptyline HCI (an antidepressant/psychotropic medication) to be given at bedtime for chronic pain and depression.
Review of the October 2022 MAR on 10/21/2022 showed that Resident 3 was provided/received amitriptyline HCI per physician orders.
Review of Resident 3's EHR on 10/21/2022 showed no documentation of a completed informed consent to include risks and benefits for the use of amitriptyline HCI.
During an interview on 10/24/2022 Staff C, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated that prior to giving a psychotropic medication to a resident, it required a provider order and an informed consent with risks and benefits to be obtained and in place. Additionally, Staff C, stated that she was unable to locate an informed consent in Resident 3's EHR.
During an interview on 10/24/2022 at 11:57 AM, Staff B, Director of Nursing Services (DNS), stated that Resident 3 was administered amitriptyline HCI; however, there was an informed consent initiated on 10/19/2022 that was not completed, signed, or dated and it should have been. Staff B stated that this did not meet expectations.
Reference WAC 388-97-0260
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 26
Review of Resident 26's admission Minimum Data Set assessment dated [DATE] showed the resident admitted with a histo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 26
Review of Resident 26's admission Minimum Data Set assessment dated [DATE] showed the resident admitted with a history of stroke with hemiplegia (partial paralysis), traumatic brain injury, and falls.
During an interview and observation on 10/19/2022 at 2:23 PM Resident 26 stated that they had multiple falls, most recently a couple days ago. Resident 26 further stated that the resident thought they fell because they had bare feet, and the floor was wet and every time they had fallen recently was because they did not have shoes on. Resident 26 lifted their shirt sleeve and showed a swollen bruised left elbow and stated they hurt it during the most recent fall.
Review of the document titled Fall Management dated 05/26/2021 showed the purpose was to address injury and provide care after a fall. This policy included that patients experiencing a fall will receive appropriate care and investigation of the cause.
Review of Resident 26's progress note dated 10/17/2022 at 4:56 AM which stated that Resident 26 was observed laying on the resident's back near the foot of their bed, laying in puddle of urine and that the resident complained of pain to both elbows and buttock with a red mark noted to buttocks and left elbow and small superficial abrasion to the right lower leg.
During an interview on 10/24/2022 at 11:14 AM Staff H, Registered Nurse (RN), stated that if a resident fall was unwitnessed the nurse would complete a head-to-toe assessment, start neurological assessments in case they hit their head, interview any witnesses, and notify the family, director of nursing, resident care manager and the provider.
Review of an incident report dated 10/17/2022 showed Resident 26 had a fall in their room and was found lying on their back near the foot of the bed in a puddle of liquid. Resident 26 stated they had to use the restroom urgently and slipped on the wet floor. No staff interviews were included in the incident report.
During an interview on 10/25/2022 at 9:12 AM Staff B, DNS, stated that after a fall, interviews should be conducted with staff and copies of those would be attached to the incident report or in a soft file in her office.
Refer to F658 for additional information.
Reference WAC 388-97-0640 (6)(a)(b)
Based on observation, interview, and record review, the facility failed to identify an allegation of abuse and initiate an investigation when reported to staff for one of three residents (Resident 105) reviewed for Abuse and failed to conduct a thorough investigation for the cause of a fall for two of three residents (Residents 262 and 26) reviewed for Falls. These failures placed residents at risk for continued verbal abuse, emotional injury, continued falls, injury from additional falls, and a diminished quality of life.
Findings included .
RESIDENT 105
During an interview on 10/19/2022 at 3:29 PM, Resident 105 stated that six months prior a staff member had called the resident boy three times, which the resident felt was racially motivated. Resident 105 further stated that the resident completed a grievance form and was told an investigation was completed. Resident 105 also stated that that the resident felt like staff didn't care about the incident and the resident was pissed. Resident 105 stated that the resident had a scheduled meeting with Staff A, Administrator (ADM), to discuss these issues.
Review of the Grievance Log from April to October 2022 showed no grievance logged for this incident.
Review of the Accident/Incident Log from April to October 2022 showed no allegation of verbal abuse logged for this incident.
During an interview on 10/25/2022 at 11:03 AM, Staff A, ADM, stated that when an allegation of verbal abuse was reported the facility would immediately suspend the staff who the allegation was against, investigate, log the incident in the Accident/Incident Log, notify state hotline, and determine whether the allegation of verbal abuse was substantiated. Staff A further stated that any remark directed toward a resident which was construed as demeaning or harmful would be considered verbal abuse and investigated.
During continued interview on 10/25/2022 at 11:03 AM, Staff A stated that Resident 105 had met with her to discuss the resident's concerns. Staff A further stated that Resident 105 had informed her of the incident of being called boy by a staff member, but that she believed it had been investigated. Staff A also stated that the incident had not been investigated, had not been reported to the state hotline, and Resident 105 had not been protected from further abuse. Staff A stated that this did not meet her expectations.
During an interview on 10/25/2022 at 1:12 PM, Resident 105 stated that the resident had felt discriminated against.
RESIDENT 262
Observation on 10/25/2022 at 11:51 AM showed Resident 262 lying in bed with eyes closed, neck brace in place, and with a greenish/purplish fading discoloration over the left eyebrow about the size of a quarter.
Review of the admission Record undated on 10/20/2022 showed that Resident 292 admitted on [DATE] with diagnoses to include displaced fracture [bone breaks into two or more pieces and moves out of alignment] of second cervical vertebra [upper neck bone], and dementia (a group of thinking and social symptoms that interferes with daily functioning) with other behavioral disturbance.
Review of the Nursing Documentation Evaluation form dated 10/18/2022 showed that Resident 262 did not follow directions, had a high fall risk, poor safety awareness, and fell 30 minutes post admission. It further showed that Resident 262 used a wheelchair and walker for mobility, and had on a C collar, (neck brace) from a previous fall while at home.
Review of the active/current care plan on 10/25/2022 showed that Resident 262's care plan did not show that the resident had actual falls but rather was at risk for falls.
Review of Resident 262's incident report dated 10/18/2022 showed, Resident [262] had 2 falls throughout shift. Was sitting on edge of bed both times. Slipped onto [Resident 262's] bottom with no injuries. Was able to get into bed after first fall, after second fall staff placed resident in wheelchair by nurse station to monitor closely. It showed, Resident unable to give description. Additionally, it showed that falls occurred while Resident 262 was alone in the room, first aid was provided to left eyebrow abrasion [damaged by scraping], and it showed that the resident's representative was notified on 10/19/2022 at 2:30 PM (the day after the incidents occurred).
In continued review, Resident 262's incident report, did not show documentation of the exact times both falls had occurred, if the injury over the left eyebrow occurred after the first fall or the second fall, if staff interviews and/or witness statements were obtained, or documentation to show the provider was notified of both falls or alert charting was completed to monitor for latent injuries.
During an interview on 10/25/2022 at 8:44 AM, after reviewing Resident 262's electronic health record (EHR) and 10/18/2022 incident report investigation regarding unwitnessed falls, Staff C, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated that documentation should have included notification of the physician/provider, timely notification to family, and alert charting documented each shift to monitor for latent injuries. Additionally, Staff C stated, there should have been staff interviews/statements conducted/obtained, care plan revised to show actual falls occurred, a more thorough investigation of both falls, and this did not meet expectations.
During an interview on 10/25/2022 at 9:12 AM, after reviewing Resident 262's 10/18/2022 unwitnessed falls incident report investigation and EHR, Staff B, Director of Nursing Services (DNS), stated that Resident 262's first fall happened at 5:30 PM and that she had interviewed Resident 262 on 10/18/2022 at 7:00 PM; however, Staff B was not able to say when the second fall happened. Staff B stated that she was unable to locate post fall monitoring and documentation for latent injury. Staff B stated that Resident 262's responsible party was not notified timely, there was no documentation that the provider was notified, and no staff interviews/staff statements conducted/obtained. Staff B further stated that Resident 262's care plan should have been revised to show the resident had two actual falls, and both falls should have been thoroughly investigated and this did not meet expectations.
Refer to F658 for additional information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 96
Review of Resident 96's progress note, dated 05/07/2020, showed a PASRR level II evaluation with recommendations for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 96
Review of Resident 96's progress note, dated 05/07/2020, showed a PASRR level II evaluation with recommendations for psychiatrist consult for medication changes.
Review of Resident 96's electronic health record showed a PASRR Level II dated 06/09/2020.
Review of Resident 96's MDS, dated [DATE], showed PASRR Level II was not completed.
During an interview on 10/25/2022 at 11:56 AM, Staff G, LPN/MDS-RAI, stated they had reviewed Resident 96's progress notes to find the most current PASRR and entered the level into the MDS for coding purposes. Staff G stated they misread the progress notes and did not see the Level II PASRR. Staff G further stated that, ideally, they should have seen the most recent PASRR and updated the MDS appropriately. Staff G stated Resident 96's MDS was coded inaccurately as a No PASRR II with diagnosis.
Reference WAC 388-97-1000 (1)(b)
RESIDENT 35
Review of Resident 35's level 2 PASRR showed it was completed on 04/20/2020.
Review of Resident 35's quarterly MDS dated [DATE] showed no level 2 PASRR was completed.
RESIDENT 42
Review of Resident 42's electronic health record on 10/25/2022 at 11:07 AM showed an order for insulin injection of 22 units subcutaneously (under the skin) every day at bedtime for diabetes with a start date of 08/13/2022, and an order for insulin injection of 26 units every day in the morning for diabetes with a start Date of 08/13/2022.
Review of the September 2022 Medication Administration Record showed Resident 42 received an insulin injection two times a day between the dates of 09/01/2022 and 09/07/2022.
Review of the quarterly MDS dated [DATE] showed 0 injections, and no insulin
During an interview on 10/25/2022 at 1:34 PM, Staff G, LPN/MDS-RAI, stated that Residents 35 and 42 were not coded accurately on the MDS and should have been.
RESIDENT 40
Review of Resident 40's 12/07/2021 annual MDS showed that the resident had not completed a level two PASRR.
Review of Resident 40's electronic health record (EHR) showed a PASRR level two completed on 03/23/2016.
During an interview on 10/25/2022 at 11:42 AM, Staff G, LPN/MDS-RAI, stated that Resident 40's 12/07/2021 MDS showed that the resident had not completed a PASRR level two. Staff G further stated that Resident 40 had completed a level two PASRR on 03/24/2016 and the 12/07/2021 annual MDS was not accurate.
During an interview on 10/25/2022 at 2:07 PM, Staff B, DNS, stated that her expectation was that the MDS be accurate and Resident 40's 12/07/2022 annual MDS did not meet this expectation.
RESIDENT 54
Review of the significant change in condition MDS dated [DATE] showed that Resident 54 admitted on [DATE] and was able to make needs known. It further showed that the resident received nutrition through a feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation); however, it also showed that the resident required supervision with set up only when eating.
Review of the physician order dated 08/22/2022 showed, NPO (nothing by mouth) diet NPO texture, related to malignant neoplasm of oropharynx [throat cancer].
During an interview on 10/26/2022 at 11:38 AM Staff G, LPN/MDS-RAI, stated that Resident 54's significant change in condition MDS dated [DATE] was coded inaccurately and should have been coded that Resident 54 was total dependent of one person for feeding because of the need for a nurse to connect the feeding tube.
During an interview on 10/26/2022 at 12:15 PM Staff B, Director of Nursing Services, stated that Resident 54's significant change in condition MDS dated [DATE] was not accurate. Staff B stated that Resident 54 was fed via a tube and should have been coded total dependent with one assist.
Based on interview and record review, the facility failed to accurately assess the status for three of six residents (Residents 40, 96 and 35) reviewed for Pre-admission Screening Assessment (PASRR, a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility). In addition, the facility failed to accurately assess one of five residents (Resident 54) related to nutrition and two of six residents (Residents 107 and 42) assessed for medication. These failures had the potential to place the residents at risk for not receiving the care and services required to meet their needs.
Findings included .
RESIDENT 107
Review of the quarterly Minimum Data Set (MDS, a required assessment tool) dated 10/06/2022, showed that Resident 107 was admitted on [DATE] with multiple diagnoses to include heart disease, diabetes, hemiplegia (paralysis of one side of the body), and depression. Resident 107 was able to make needs known. In addition, the MDS showed that the resident was coded as had been administered insulin during the seven day look back period.
Review of a Medication Administration Record (MAR) dated October 2022, showed that Resident 107 had no documentation that recorded that the resident had been administered an insulin medication, but rather a medication that was an antidiabetic medication and not an insulin medication.
During an interview on 10/27/2022 at 1:04 PM, Staff G, Licensed Practical Nurse/Minimum Data Set Resident Assessment Instrument (LPN/MDS-RAI), stated that Resident 107's MDS had been inaccurately coded and that the medication that was currently being administered to the resident was an antidiabetic medication and not an insulin medication. In addition, Staff G stated that MDS would be corrected to indicate that the resident was not being administered any insulin.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 9
Observation and interview on 10/20/2022 at 10:13 AM showed Resident 9 sat in bed with the TV on and the volume turned...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 9
Observation and interview on 10/20/2022 at 10:13 AM showed Resident 9 sat in bed with the TV on and the volume turned down staring at the ceiling. Resident 9 stated they were blind and can only see shadows.
Review of Resident 9's admission MDS dated [DATE] showed the resident had highly impaired vision with no corrective lenses.
Review on 10/20/2022 at 12:42 PM of Resident 9's electronic health record showed no care plan related to decreased vision/blindness.
Observation on 10/24/2022 at 9:01 AM showed Resident 9 in bed eating a meal. Resident 9 was using their hands to touch the food on the plate. Resident 9 asked what was on the plate.
During an interview on 10/24/2022 at 11:48 AM Staff C, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated she was not aware that Resident 9 was blind. Staff C further stated that any resident who was admitted with vision impairment, such as Resident 9, should have a care plan in place and Resident 9 did not.
During an interview on 10/24/2022 at 1:41 PM, Staff B, DNS stated it was her expectation that Resident 9 had a care plan in place for visual impairment but did not.
RESIDENT 99
During an interview on 10/20/2022 at 10:50 AM, Resident 99 stated that it burned and stung when they urinated, and believed they were on an antibiotic for something.
Review of Resident 99's admission MDS showed an admission date of 09/15/2022 with diagnosis to include urinary tract infection (UTI).
Review of Resident 99's electronic health record showed a urinalysis completed on 10/12/2022 for symptoms of UTI.
Review on 10/22/2022 at 7:53 AM of Resident 99's EHR showed no infection/UTI care plan.
During an interview on 10/24/2022 at 11:31 AM Staff C, LPN/RCM, stated that any resident admitted with UTI should have a care plan in place and Resident 99 did not.
Reference WAC 388-97-1020(1), (2)(a)(b)
Based on observation, interview and record review, the facility failed to develop and/or implement comprehensive care plans for one of four residents (Resident 31) reviewed for nutrition; one of three residents (Resident 9) reviewed for communication-sensory; and one of two residents (Resident 99) reviewed for urinary tract infections. Failure to develop a comprehensive care plan for Resident 31's fluid restrictions, Resident 9's vision status, and Resident 99's urinary tract infection placed residents at risk for unmet needs and a diminished quality of life.
Findings included .
RESIDENT 31
During an interview on 10/20/2022 at 1:32 PM Resident 31 stated, I think I am on fluid restriction. However, Resident 31 was not sure of the amount the resident was able to consume.
Review of the current/active physician orders on 10/21/2022 showed Resident 31 had an order dated 08/16/2022 for, two-gram (gm, a measurement of mass) Sodium (salt) diet, regular texture, 2000 milliliters (ml, a measurement of volume) fluid restriction (a diet which limits the amount of daily fluid consumption). Additionally, there was an order dated 08/17/2022 that showed, Monitor Daily Fluid Restriction Total 2000 ml (must match diet order); Breakfast tray 240 ml; Fluids day shift 580 ml; Lunch tray 240 ml; Fluids Evening Shift 580 ml; Dinner tray 240 ml; Fluids Night Shift 120 ml. every shift for CHF [congestive heart failure].
Review of Resident 31's care plan on 10/26/2022 included a focus area initiated on 08/17/2022 that showed, Resident exhibits or is at risk for dehydration as evidence by fluid restriction/insufficient intake, mediations diuretics [used to help rid body of salt and water]. However, it did not show documentation of what the fluid restrictions were and did not show how much fluid nursing was to provide each shift and how much dietary was to provide during meals.
During an interview on 10/26/2022 at 9:02 AM, Staff V, Nursing Assistant Noncertified, stated that Resident 31 was on fluid restrictions that included two drinks with every meal and that a water pitcher could be provided twice a day. Staff V stated that she was not sure of the exact amount of fluid that Resident 31 was to be provided during the shift. Additionally, Staff V stated that the amount of the fluid to be provided for Resident 31 was not documented in the resident's [NAME] (directions to care for the resident) and it should have been.
During an interview on 10/26/2022 at 12:23 PM, Staff B, Director of Nursing Services (DNS), stated that Resident 31 should have had fluid restrictions care planned and documentation for both nursing and dietary intake and this did not meet expectations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure services provided
following incidents of a fall met the prof...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure services provided
following incidents of a fall met the professional standards of practice for two of three residents (Residents 26 and 262) reviewed for falls. In addition, the facility failed to address/assess the need for a neck brace for one of four residents (Resident 262) reviewed for limited range of motion. These failures placed the residents at risk for unidentified latent injury, repeated falls, unmet needs, and a diminished quality of life.
Findings included .
According to the Agency for Healthcare Research and Quality's (AHRQ) clinical guidelines titled, Fall Management Program: A Quality Initiative for Nursing Facilities, dated December 2017, Immediate evaluation by the nurse after a resident fall should include a review of the resident systems and description of injuries. AHRQ guidelines further showed that residents should have increased monitoring during the first 72 hours after a fall and each shift, the nurse should record a review of systems, noting any worsening or improvement of symptoms as well as the treatment provided. Reference to the fall should be clearly documented in the nurse's notes. Fall circumstances should be investigated.
According to the AHRQ Internet Citation, titled, Understanding Omissions of Care in Nursing Homes, dated October 2019, showed, Adverse events and poor health outcomes are continuing challenges for nursing home residents and staff. Research has shown that many resident harms are avoidable and may be caused by situations in which residents do not receive needed care, often called omissions of care.
RESIDENT 26
Review of Resident 26's admission Minimum Data Set assessment (MDS) dated [DATE] showed the resident admitted with history of stroke with hemiplegia (partial paralysis), traumatic brain injury, and falls.
During an interview and observation on 10/19/2022 at 2:23 PM Resident 26 stated that they had multiple falls, most recently a couple days ago. Resident 26 showed a bruise and swelling to the left elbow and stated it hurt to move it. Further observation showed bruising to both feet and upper left portion of resident's back and an abrasion to the right lower leg. Resident 26 further stated that they had hit their head.
Review of the facility's policy titled Fall Management, dated 05/26/2021, showed the purpose was to address injury and provide care after a fall with the procedure to include observing and checking for injury after a fall, perform neurological evaluation for all unwitnessed falls and witnessed falls with injury to the head or face.
Review of Resident 26's electronic health record (EHR) showed a progress note dated 10/17/2022 at 4:56 AM which stated that Resident 26 was observed laying on their back near the foot of their bed, laying in puddle of urine and that the resident complained of pain to both elbows and buttock with a red mark noted to buttocks and left elbow and small superficial abrasion to the right lower leg.
Review of Resident 26's EHR on 10/22/2022 showed a note dated 10/17/2022 at 4:11 PM reviewing the fall. No documentation of resident assessment or monitoring for latent injury was found in the resident's EHR for the dates of 10/18/2022 through 10/22/2022.
Observation and interview on 10/20/2022 at 2:00 PM, showed Resident 26 ambulating in hall with a walker. Resident 26 stated that they could not put any pressure on the left elbow, and that it was very tender. Resident 26 pulled up the left shirtsleeve and showed the elbow had continued swollen and discolored.
During an interview on 10/24/2022 at 11:14 AM Staff H, Registered Nurse (RN), stated that if a resident's fall was unwitnessed the nurse would complete a head-to-toe assessment, start neurological assessments in case they hit their head, and notify the family, Director of Nursing, Resident Care Manager, and the provider. Staff H further stated that the resident should be placed on alert to monitor for three days. Staff H stated she was unaware of any bruising or swelling Resident 26 had sustained because of the recent fall.
During an interview on 10/24/2022 at 11:40 AM Staff C, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated that Resident 26 had a fall on 10/17/2022 and that Resident 26 should have been placed on alert and monitored for three days and neurologic assessments completed. Staff C further stated that they did not feel Resident 26's fall was followed up on appropriately.
During an interview on 10/24/2022 at 1:26 PM Staff B, Director of Nursing Services (DNS), stated that it was her expectation that Resident 26 should have been placed on alert to monitor for latent injuries and neurological checks been initiated. Staff B further stated that the bruising and swelling to Resident 26's left elbow should have been reported to the provider for follow up but was not.
RESIDENT 262
Observation on 10/25/2022 at 11:51 AM showed Resident 262 lying in bed with eyes closed, neck brace in place, and with a greenish/purplish fading discoloration over the left eyebrow about the size of a quarter.
Review of the admission Record undated on 10/20/2022 showed that Resident 292 admitted on [DATE] with diagnoses to include displaced fracture [bone breaks into two or more pieces and moves out of alignment] of the second cervical vertebra [upper neck bone], and dementia (a group of thinking and social symptoms that interferes with daily functioning) with other behavioral disturbance.
Review of the Nursing Documentation Evaluation form dated 10/18/2022 showed that Resident 262 did not follow directions, had a high fall risk, poor safety awareness, and fell 30 minutes post admission. It further showed that Resident 262 had on a C collar, (neck brace) from a previous fall while at home.
Review of Resident 262's order summary report dated 10/24/2022 showed that there were no orders to treat or monitor an abrasion above the left eyebrow or for the use of a C collar.
Review of the active/current care plan on 10/25/2022 showed that Resident 262's care plan did not show that the resident had actual falls but rather was at risk for falls and did not address the left eyebrow abrasion or the use of a neck brace/cervical collar.
Review of Resident 262's incident report dated 10/18/2022 showed that Resident 262 had two falls throughout the shift, falls occurred while the resident was alone in the room, and first aid was provided to the left eyebrow abrasion [damaged by scraping]. It did not show documentation of the size of the abrasion over the left eyebrow, if the injury over the left eyebrow occurred after the first fall or the second fall, if the neck brace was in place or not at the time of falls, documentation of neurological checks due to unwitnessed falls and injury to face, documentation to show the provider was notified of both falls or that alert charting was completed to monitor for latent injuries.
During an interview on 10/25/2022 at 8:44 AM, after reviewing Resident 262's electronic health record (EHR) and 10/18/2022 incident report investigation regarding unwitnessed falls, Staff C, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated that documentation should have included notification of the physician/provider, timely notification to family, neurological checks, documented assessment and monitoring of abrasion, and alert charting documented each shift to monitor for latent injuries. Additionally, Staff C stated, there should have been a care plan revision to show actual falls occurred, and this did not meet expectations.
During an interview on 10/25/2022 at 9:12 AM, Staff B, Director of Nursing Services (DNS), stated that residents with an unwitnessed fall should have neurological checks initiated/completed on paper then sent to Medical Records to be scanned into the resident's EHR. After reviewing Resident 262's 10/18/2022 unwitnessed falls incident report investigation and EHR, Staff B stated Resident 262's first fall happened at 5:30 PM and that she had interviewed Resident 262 on 10/18/2022 at 7:00 PM; however, she was not able to say when the second fall happened. Staff B stated that she was unable to locate post fall monitoring and documentation for latent injury or regarding Resident 262's abrasion and found no documentation that the provider was notified. Staff B stated that Resident 262's responsible party was not notified timely, there were no neurological checks completed, the care plan should have been revised to show the resident had two actual falls, and this did not meet expectations.
During an interview on 10/25/2022 at 12:00 PM, Staff T, Nursing Assistant Noncertified, stated that Resident 262 wore the neck brace and was not aware of when it should be on or off. Staff T stated that the use of the brace was not in the [NAME] (directions to care for the resident). Additionally, Staff T stated that yesterday [10/24/2022] Resident 262 had the brace off when returning from dialysis (treatment to filter wastes and water from the blood) at around 2:30 PM and remained off until Staff T left the facility at 6:00 PM.
During an interview on 10/25/2022 at 12:22 PM, Staff B, DNS, stated that Resident 262 did not have a physician order for the cervical collar and there should have been one for placement. Additionally, Staff B stated that Resident 262 should have had an order to check the skin under the cervical collar every shift to include who may apply and remove it and the times it should happen; however, the provider needed to be consulted prior to removal of the cervical collar and that this needed to be followed up on as soon as possible.
Reference WAC 388-97-1620(2)(b)(ii)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the use of an indwelling urinary catheter (a tu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the use of an indwelling urinary catheter (a tube which drains urine from the bladder into a collection bag) had the correct sized urinary catheter as ordered by the provider for one of two residents (Resident 103) reviewed for Urinary Catheters. This failure placed the residents at risk for further complications, prolonged therapy, and unmet care needs.
Findings included .
Review of a quarterly Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 34 was admitted on [DATE] with multiple diagnoses to include neurogenic bladder (a lack of bladder control due to a brain, spinal cord or nerve problem), multiple sclerosis (chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue), had urogenital implants (injection of material into the urethra [the duct by which urine is conveyed out of the body from the bladder] to help control urine leakage caused by a weak urinary sphincter) and depression. In addition, the MDS showed that Resident 34 was able to make needs known, required assistance with activities of daily living and had an indwelling suprapubic urinary catheter (a hollow flexible tube that is used to drain urine from the bladder. The tube is inserted into the bladder through a cut in the lower abdomen, a few inches below the navel.)
Review of Resident 34's Medication Administration Record (MAR) dated September and October 2022, showed a provider's order for a suprapubic catheter 18 FR (French- a measurement of the diameter size of the catheter) with 30cc balloon (size of balloon to secure the catheter) . for diagnoses of neurogenic bladder. The order further showed that the licensed nurse (LN) may change when necessary for leakage or dislodgement as per the providers orders.
Review of Resident 34's care plan initiated on 02/07/2022 showed that the resident had an indwelling suprapubic catheter due to neurogenic bladder. In addition, interventions included catheter care twice a day and when necessary.
During an interview and observation on 10/25/2022 at 12:29 PM, Staff U, Registered Nurse (RN), stated that Resident 34's suprapubic catheter was to be assessed each shift to ensure that the urinary catheter functioned and that there were no signs of infection. In addition, Staff U stated that the LNs were to ensure that the resident had the correct sized urinary catheter. When asked what the size of the foley catheter Resident 34 was currently using, Staff U, RN, stated that it was supposed to be 18 FR and with a 30cc balloon. Observation of Resident 34's suprapubic catheter with Staff U showed that the resident was using a 16 FR catheter.
During an interview on 10/25/2022 at 1:03 PM, Staff M, Licensed Practical Nurse/Residential Care Manager (LPN/RCM), stated that LNs were required to check when monitoring the suprapubic catheter to ensure that the correct size was in place.
During an interview on 10/25/2022 at 1:17 PM, Staff B, Director of Nursing (DNS), stated that it was her expectation that the resident had the correct size suprapubic catheter inserted as per the providers order and that the LNs were to check to ensure that it was correct when they assessed the site every shift.
Reference WAC 388-97-1060(3)(c)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to monitor and accurately document fluids consumed to ens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to monitor and accurately document fluids consumed to ensure fluid restrictions (a diet which limits the amount of daily fluid intake) was implemented per physician's orders for one of five residents (Resident 31) reviewed for Nutrition. These failures placed the resident at risk for medical complications and a diminished quality of life.
Findings included .
During an interview on 10/20/2022 at 1:32 PM Resident 31 stated, I think I am on fluid restriction. However, Resident 31 was not sure of the amount the resident was able to consume.
Review of the current/active physician orders on 10/21/2022 showed Resident 31 had an order dated 08/16/2022 for two-gram (gm, a measurement of mass) Sodium (salt) diet, regular texture, 2000 milliliters (ml, a measurement of volume) fluid restriction. Additionally, there was an order dated 08/17/2022 that showed, Monitor Daily Fluid Restriction Total 2000 ml (must match diet order); Breakfast tray 240 ml; Fluids day shift 580 ml; Lunch tray 240 ml; Fluids Evening Shift 580 ml; Dinner tray 240 ml; Fluids Night Shift 120 ml. every shift for CHF [congestive heart failure].
Multiple observations on 10/20/2022, 10/21/2022, 10/25/2022 and 10/26/2022 showed Resident 31 with a water pitcher and a straw stuck in it on the overbed table for easy access to consume fluid.
Review of the Resident 31's care plan and [NAME] (directions to take care of a resident) on 10/26/2022 did not show documentation of what the fluid restrictions were and did not show how much fluid nursing was to provide each shift and how much dietary was to provide during meals.
During an interview on 10/26/2022 at 9:02 AM, Staff V, Nursing Assistant Noncertified, stated that Resident 31 was on fluid restrictions that included two drinks with every meal and that a water pitcher could be provided twice a day. Staff V stated that she was not sure of the exact amount of fluid that Resident 31 was to be provided during the shift. Staff V stated that they would enter the amount of fluids Resident 31 drank into the tablet (electronic health record system) at the nurse's station at the end of their shift.
During an interview on 10/26/2022 at 11:00 AM Staff S, Registered Nurse, stated that Resident 31 was on a 2000 ml fluid restriction that should be monitored and documented in the Medication Administration Record (MAR) by the licensed nurses and documented in the electronic health record system by the aides.
During an interview on 10/26/2022 at 12:23 PM, Staff B, Director of Nursing Services, stated that residents on fluid restrictions should not technically have a water pitcher at the bedside. After looking at Resident 31's October 2022 MAR and electronic health record (EHR) Staff B stated that the MAR had holes/blanks where fluid intake should have been documented and there were no totals of fluids taken in a 24-hour period and there should have been. Staff B stated that the documentation by the aides in the EHR under tasks had missing documentation and included entries that showed not applicable, which were not accurate, and this did not meet expectations.
Refer to F656 for additional information.
Reference WAC 388-97-1060 (3)(h)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently conduct and document pre and post hemodialysis (treatm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently conduct and document pre and post hemodialysis (treatment to filter wastes and water from the blood) assessments and ensure consistent ongoing communication and collaboration with the dialysis center regarding dialysis care and services for one of one resident (Resident 262) reviewed for Dialysis. This failure had the potential to place the resident at risk for unmet care needs and medical complications.
Findings included .
Review of the facility's policy and procedure titled, Dialysis Care, dated 08/25/2021 showed that nursing staff, dialysis provider staff, and the attending physician would collaborate on a regular basis concerning the resident's care. It further showed, i. The Nursing Staff will send a dialysis communication form to the dialysis center every time a resident is scheduled for off site dialysis. ii. The provider's dialysis nurse will be responsible for documentation of dialysis treatment. iii. Documentation will be maintained in the resident's medical record.
Review of the admission Record undated on 10/20/2022 showed that Resident 262 admitted on [DATE] with diagnoses to include kidney disease, dependent on dialysis treatment, and dementia (a group of thinking and social symptoms that interferes with daily functioning).
Review of the physician order dated 10/19/2022 showed that Resident 262 was to receive dialysis services on Monday, Wednesday, and Friday at the dialysis center.
Review of Resident 262's electronic health records on 10/20/2022 showed no Hemodialysis Communication Record, documentation.
During an interview on 10/26/2022 at 10:14 AM, Staff S, Registered Nurse, stated that there was a Hemodialysis Communication Record form that nursing filled out Pre-Hemodialysis Treatment and then the form went to dialysis with the resident for the dialysis center to fill out their portion of the form [Dialysis Center treatment documentation]. Staff S stated that upon the resident's return from the dialysis center, nursing was to finish filling out the Post Hemodialysis Treatment information on the form, send the form to Medical Records to be scanned into the resident's EHR in the Miscellaneous tab. Staff S stated that they were unable to locate Resident 262's Hemodialysis Communication Records for 10/19/2022 and 10/21/2022; however, they found an incomplete form initiated on 10/24/2022 that was not signed or dated by a nurse, and was not scanned into the resident's EHR and they should have been.
During an interview on 10/26/2022 at 12:06 PM Staff B, Director of Nursing Services, stated that she was unable to locate Hemodialysis Communication Records in Resident 262's EHR and there should have been. Additionally, Staff B stated that Resident 262's Hemodialysis Communication Record dated 10/24/2022 should have been completed with a nurse's signature and date and that this did not meet expectations.
Reference WAC 388-97-1900(1)(6)(a-c)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0742
(Tag F0742)
Could have caused harm · This affected 1 resident
Based on interview, observation, and record review the facility failed to implement Pre-admission Screening and Resident Review Level II (PASRR Level II, an assessment of required mental health interv...
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Based on interview, observation, and record review the facility failed to implement Pre-admission Screening and Resident Review Level II (PASRR Level II, an assessment of required mental health interventions) for one of five residents (Resident 18) reviewed for Behavioral/Emotional and Unnecessary Medications. The failed practice placed the resident at risk for poor psychosocial outcomes and a decreased quality of life.
Findings included .
During an interview on 10/19/2022 at 3:36 PM Resident 18 stated that they had panic attacks and depression related to the loss of their children, that staff gave them medication for it, but the resident did not feel like it helped much. Resident 18 further stated that they would like to start counseling.
During an interview on 10/24/2022 at 8:55 AM Resident 18 stated that they asked for therapy but have never been talked to about it.
Observation and interview on 10/24/2022 at 10:54 AM, showed Staff H, Registered Nurse, sat at the Resident 18's bedside and Resident 18 asked Staff H not to leave and to stay as they were having a panic attack. Resident 18 was breathing hard and moving rhythmically in bed. Resident 18 stated that these attacks happened almost every day, but she usually didn't know what causes it. Resident 18 stated the medication the nurse gave usually helped.
During an interview 10/24/2022 at 10:54 AM Resident 18 stated the resident was feeling better, but really would like to have counseling. Resident 18 used to get counseling and it helped a lot, but the resident had not had it in a long time.
Review of Resident 18's care plan showed an intervention dated 09/21/2021 for staff to refer to behavioral health services as needed.
Review of Resident 13's medical record showed a PASRR Level II was completed on 06/20/2022 and the determination showed the resident required specialized behavioral health services.
During an interview on 10/24/2022 at 11:22 AM Staff J, Director of Social Services, stated that Resident 13's PASRR Level II determination should have been care planned and implemented. Staff J further stated that the facility recently changed mental health providers and that Resident 13 had not received mental health services since the PASRR Level II was completed in June and should have.
During an interview on 10/24/2022 at 1:43 PM, Staff B, Director of Nursing Services, stated that it was her expectation that PASRR Level II recommendations were followed up on and Resident 13's were not and should have been.
NO ASSOCIATED WAC
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure freedom from unnecessary medications for one of five residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure freedom from unnecessary medications for one of five residents (Residents 3) reviewed for Unnecessary Medication Use. Failure to provide non-pharmacological interventions (approaches, therapies, or treatments that do not involve drugs) prior to giving as needed (PRN) pain medications, placed the resident at risk for receiving unnecessary medications and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Pain Management, dated 10/24/2022, showed, Staff will continually observe and monitor patients for comfort and presence of pain and will implement strategies in accordance with professional standards of practice, the patient-centered plan of care, and the patient's choices related to pain management. This policy further showed that non-pharmacological interventions and effectiveness should be monitored and documented.
Review of the admission Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 3 admitted on [DATE] with a diagnosis of low back pain and was able to make needs known.
Review of the activities of daily living care plan showed that Resident 3 had an intervention initiated/created on 07/07/2022 that showed, Monitor for pain. Attempt non-pharmacologic interventions to alleviate pain and document effectiveness.
Review of the physician orders dated 07/07/2022 showed that Resident 3 was prescribed acetaminophen two tablets every six hours PRN for mild pain. Additionally, Resident 3 had an order that showed, Document Non-Pharmacological Interventions(s) A. Heat B. Repositioning C. Relaxation breathing D. Food/Fluid E. Massage F. Exercise G. Immobilization of joint H. Other: write in progress note as needed Document Results R- results non-pharm (-) ineffective (+) effective.
Review of the Medication Administration Records (MARs) of both orders dated 07/07/2022 for PRN acetaminophen pain medication and non-pharmacological interventions for the months dated 2022 showed the following: Resident 3 was provided PRN acetaminophen eight times in August, one time in September and one time in October with no documentation that non-pharmacological interventions were provided/offered prior to the administration of the PRN pain medication.
During an interview on 10/24/2022 at 11:15 AM, after reviewing Resident 3's electronic health records (EHR), Staff C, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), confirmed that Resident 3 had PRN acetaminophen administered on 08/01/2022, 08/06/2022, 08/14/2022, 08/20/2022, 08/24/2022, 08/27/2022, 08/28/2022, and 08/31/2022 with no documented non-pharmacological interventions provided prior to administration. Additionally, Staff C stated that Resident 3 was provided PRN acetaminophen on 09/28/2022 and on 10/16/2022 with no documented non-pharmacological interventions provided prior to administration and there should have been.
During an interview on 10/24/2022 at 12:03 PM, Staff B, Director of Nursing Services (DNS), stated that a resident's pain assessment, pain level, and non-pharmacological interventions should be offered and documented prior to the administration of a PRN pain medication to a resident. Staff B further stated that nursing should have offered/provided and documented non-pharmacological interventions prior to administering PRN pain medications to Resident 3 and that the resident's documentation did not meet expectations.
Reference WAC 388-97-1060(3)(k)(i)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to promptly notify the ordering provider of laboratory results that fell outside of clinical reference ranges for one of six sample residents ...
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Based on interview and record review, the facility failed to promptly notify the ordering provider of laboratory results that fell outside of clinical reference ranges for one of six sample residents (Resident 99) reviewed for Urinary Tract Infection/Unnecessary Medications. This failure placed the resident at risk for complications related to a urinary tract infection, a decline in condition and a decreased quality of life.
Findings included .
Review of Resident 99's admission Minimum Data Set assessment (MDS) showed an admission date of 09/15/2022 with diagnosis to include urinary tract infection (UTI).
During an interview on 10/20/2022 at 10:50 AM Resident 99 stated, It burns and stings when I pee.
Review of Resident 99's progress note dated 10/10/2022 at 5:49 PM showed a call was placed to the on-call practitioner requesting a urinalysis (UA) for complaints of dysuria (painful urination).
Review of Resident 99's progress note dated 10/11/2022 at 5:56 AM showed that a urine sample was obtained.
Review of a document titled Physician Communication dated 10/12/2022 showed the provider was notified Resident 99 had some mucus and burning with urination, and the provider recommended a UA with culture and sensitivity (a laboratory test to identify organisms).
Review of a progress note dated 10/12/2022 at 1:20 PM showed that the UA results were reported to the provider, and to notify the provider when culture results were received.
Review of Resident 99's electronic health record (EHR) on 10/24/2022 at 10:32 AM showed no further documentation related to culture results.
During an interview on 10/24/2022 at 11:03 AM Staff E, Nurse-Infection control (NIC) stated that the floor nurses were responsible to follow up with the provider with any lab results and that it did not happen for Resident 99.
Review of an Infection Control Note dated 10/24/2022 at 11:44 AM showed that the provider was notified of the lab results to include culture and sensitivity and an antibiotic was ordered [10 days after initial laboratory results].
During an interview on 10/24/2022 at 1:35 PM, Staff B, Director of Nursing Services (DNS), stated that it was her expectation that the nurse on the floor, the Resident Care Manager or the infection control nurse should address any lab results with the ordering provider promptly. Staff B further stated that this did not happen for Resident 99's most recent urinalysis results and should have.
Reference WAC 388-97-1260(3)(a), (4)(b), -0320(1)(b)
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 96
Multiple observations from 10/19/2022 through 10/21/2022 showed Resident 96 in bed with unkempt hair, beard, and clo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 96
Multiple observations from 10/19/2022 through 10/21/2022 showed Resident 96 in bed with unkempt hair, beard, and clothing.
During an interview on 10/19/2022 at 10:23 AM, Resident 96 stated they were supposed to get showers a couple times a week, but had gone without one for three weeks once, and for six weeks another time.
Review of Resident 96's MDS, dated [DATE], showed the resident was dependent for showering/bathing.
Review of Resident 96's care plan, dated 07/12/2022, showed they were to be provided with extensive assistance for bathing. It also showed the resident's preference was to be showered. There was no bathing frequency listed.
Review of Resident 96's [NAME] (directions to provide care to the resident) on 10/21/2022 at 12:56 PM showed it was important for the resident to choose how to be bathed and they preferred showers. There was no bathing frequency listed.
Review of Resident 96's task sheet 30-day lookback on 10/21/2022 showed bed baths given on 09/29/2022 and 10/06/2022. It also documented a shower on 10/21/2022.
During an interview on 10/24/2022 at 11:16 AM, Staff O, CNA, stated they provided bed baths for Resident 96 when able and confirmed the orders read for a shower once a week.
During an interview on 10/24/2022 at 1:13 PM, Staff M, LPN/RCM, stated bed baths were charted only if complete and confirmed that two bed baths and one shower were given to Resident 96 in September and October 2022.
RESIDENT 97
During an interview on 10/19/2022 at 3:15 PM, Resident 97 stated staff did not help them with too many baths and had not been asked about bathing preferences.
Review of Resident 97's MDS, dated [DATE], showed the resident was dependent for showering/bathing and bathing was marked for not occurred the previous seven days.
Review of Resident 97's care plan, dated 10/07/2022, showed the resident required assistance/was dependent for ADL care in bathing, grooming, personal hygiene, the resident often refused/declined hygiene/care from staff, offer assistance each shift, notify nurse of denials, the resident preferred sponge baths when available, and there was no bathing schedule listed.
Review of Resident 97's [NAME] on 10/21/2022 at 11:49 AM showed it is important for the resident to choose how to bathe and prefers sponge baths when available. There was no set bathing schedule listed.
Review of Resident 97's tasks showed no entries for any bathing or refusals of bathing for October 2022.
During an interview on 10/24/2022 at 11:22 AM, Staff O, CNA, stated Resident 97 often refused care and Staff O had never given the resident a bed bath.
During an interview on 10/24/2022 at 8:56 AM, Staff P, LPN, stated Resident 97 often refused care and was unsure of how often the resident was bathed.
During an interview on 10/24/2022 at 1:13 PM, Staff M, LPN/RCM, stated bed baths were charted only if completed and confirmed there were no bed baths listed for Resident 97 for the month of October 2022. Staff M further stated that the bath/shower schedule had not occurred per schedule.
During an interview on 10/25/2022 at 9:40 AM, Staff B, DNS, stated the shower schedules should be followed for all residents, with a goal of one-two baths/showers occurring weekly. Staff B stated that this showering goal was not always met, and this did not meet expectations.
Reference WAC 388-97-1060(2)(c)
RESIDENT 90
During an interview on 10/20/2022 at 11:03 AM, Resident 90 stated that the facility did not provide showers/bathing and the resident could not remember the last time a shower/bath had been provided.
Review of Resident 90's 09/21/2022 quarterly MDS showed that the resident required limited physical assistance of one person for personal hygiene. Further review showed that bathing was not assessed because the activity had not occurred in the lookback period.
Review of Resident 90's 09/14/2022 initiated care plan showed a focus area for ADLs with an intervention to provide extensive assistance of one person for bathing.
During an interview on 10/24/2022 at 10:52 AM, Resident 90 stated that a shower had not been provided.
During an interview on 10/24/2022 at 1:51 PM, Staff M, LPN/RCM, stated that residents were to be provided a shower once a week. Staff M further stated that Resident 90 had been provided showers on 10/11/2022 and 10/21/2022 and that this was not enough. Staff M also stated that the facility was having difficulty providing scheduled showers.
During an interview on 10/25/2022 at 1:54 PM, Staff R, Certified Nursing Assistant (CNA), stated that she was a shower aid and was instructed to provide showers once a week per a shower schedule. Staff R further stated that she had difficulty providing residents showers as scheduled as she was regularly asked to perform other duties.
During an interview on 10/25/2022 at 1:55 PM, Staff B, DNS, stated that showers should occur once or twice a week per the shower schedule.
RESIDENT 3
During an interview on 10/20/2022 at 12:46 PM, Resident 3 stated that since admission to the facility Resident 3 has had one bed bath and one shower and staff were aware that the resident would like to be bathed at least once a week.
Review of the admission MDS dated [DATE] showed that Resident 3 admitted on [DATE], required extensive assistance with ADLs and was able to make needs known.
Review of Resident 3's care plan initiated on 07/07/2022 showed that Resident 3 was at risk for decreased ability to perform ADLs and was to be provided total assist of two persons for bed bath. This care plan did not specify when or how often bed baths were to be provided.
During an interview on 10/24/2022 at 10:11 AM Resident 3 stated that the resident still had not been offered a bed bath and had given up asking for one.
During an interview on 10/24/2022 at 2:14 PM, Staff W, CNA, stated that residents were to receive a shower/bathed once a week and if there were no shower aides scheduled then the aides on the floor would give the showers. Additionally, Staff W stated that there was a shower schedule posted at the South Hall nurse's station and showers could be documented in the computer when provided; however, on the North Hall there was a binder to document baths.
During an interview on 10/24/2022 at 2:24 PM Staff C, LPN/RCM, stated that a shower schedule was kept by the nurse's station and showers were to be documented in the computer system by the aides. Staff C stated that Resident 3's bathing documentation under tasks, from 09/27/2022 through to 10/21/2022, showed the resident received a shower on 10/04/2022 and a bed bath on 10/11/2022 and 10/14/2022; however, there were multiple documented, Not Applicable, noted in the documentation and should not have been. Staff C stated that documentation options for bathing if not provided should be refused or resident not available and that this did not meet expectations.
During an interview on 10/25/2022 at 11:26 AM, after looking at Resident 3's documentation under tasks regarding bathing, Staff B, Director of Nursing Services (DNS), stated that documentation did not meet expectations because Resident 3's preference was to be bathed one to two times weekly and the resident was bathed three times in four weeks. Additionally, Staff B stated that staff should not have documented Not Applicable, related to bathing because they should document not available or refused, or that the resident got bathed and the type of bathing.
Based on observation, interview and record review, the facility failed to provide the necessary care and services to ensure that residents received their showers as scheduled for five of seven residents (Residents 103, 90, 96, 97, and 3) reviewed for activities of daily living (ADLs). This failure placed the residents at risk for medical complications, unmet needs, and a diminished quality of life.
Findings included .
Review of a document titled, Activities of Daily Living (ADLs), dated 06/01/2021, showed that based on the comprehensive assessment of a resident/patient and consistent with the patients' needs and choices, the Center must provide the necessary care and services to ensure that a patient's activities of daily living (ADL) activities are maintained or improved and do not diminish unless circumstances of the individual's clinical condition demonstrates that a change was unavoidable.
RESIDENT 103
Review of the quarterly Minimum Data Set (MDS, a required assessment tool) dated 07/15/2022, showed that Resident 103 admitted on [DATE] with multiple diagnoses to include heart and lung disease, abnormal gait (walking) and mobility, muscle weakness and obesity. The MDS showed that Resident 103 was able to make needs known and required extensive assistance with ADLs.
Review of Resident 103's care plan dated 03/08/2022 showed a focus area related to ADLs which showed that the resident was at risk for decreased ability to perform ADLs. Additionally, interventions showed that the resident was total dependence and required assistance of two-three (staff) for dressing, assistance with personal hygiene (grooming) and total dependence of two (staff) maximum assistance for bathing.
During an interview and observation on 10/20/2022 at 1:29 PM, Resident 103 stated that the facility did not have enough aides get out of bed in the morning and cleaned up. In addition, the resident stated that they did not have a shower for quite some time. Resident 103 laid in bed in a hospital gown and was unshaven.
Review of Resident 103's electronic health record (EHR) task sheet showed that Resident 103 received a bed bath/sponge on 09/28/2022 and 10/15/2022.
During an interview on 10/21/2022 at 11:25 AM, Staff BB, Nursing Assistant Noncertified ([NAME]), stated that Resident 103 was supposed to get a shower weekly; however, Staff BB stated that the facility was a bit short staffed, and I don't remember the last time the resident had received a shower. Furthermore, Staff BB, stated, I have not had time to clean [Resident 103] up yet today.
During an interview on 10/21/2022 at 11:35 AM, Staff M, Licensed Practical Nurse/Resident Care Manager (LPN/RCM) stated that she had recently taken over position two months ago and noticed that showers were not being done; however, she had recently implemented additional staff to get the residents showers done.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 15
During an interview on 10/20/2022 at 8:55 AM, Resident 15 stated that rehabilitation went very slowly, and they were...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 15
During an interview on 10/20/2022 at 8:55 AM, Resident 15 stated that rehabilitation went very slowly, and they were unsure if they were supposed to be on a restorative program.
Review of Resident 15's orders, dated 09/28/2022, showed the resident was discharged from skilled therapy and orders for a restorative program were written for continued functional exercise.
Review of Resident 15's progress notes, dated 09/30/2022, showed a restorative program from therapy services implemented as follows: active range of motion exercises for bilateral lower extremities three times a week.
Review of Resident 15's restorative therapy log showed no entries for October 2022. Any refusals of participation were also not documented.
During an interview on 10/24/2022 at 11:28 AM, Staff L, Director of Rehabilitation Services, stated that Resident 15 was last discharged from OT on 07/08/2022 and from PT on 09/27/2022 and orders for a restorative program were written.
RESIDENT 96
During an interview on 10/19/2022 at 10:54 AM, Resident 96 stated their rehabilitation services were inconsistent and they did not know if they were to receive restorative services.
Review of Resident 96's orders, dated 11/10/2020, showed Resident 96 was discharged from skilled therapy services and orders for a restorative program were written for continued functional exercise.
Review of Resident 96's care plan, dated 07/25/2022, showed the resident demonstrated loss of range of motion in bilateral lower extremities, with the goal to maintain strength and mobility in lower extremities. Interventions listed included restorative range of motion programs to be done three times a week and as needed.
Review of Resident 96's restorative therapy log showed no entries for October 2022. Any refusals of participation were also not documented.
During an interview on 10/24/2022 at 11:28 AM, Staff L, Director of Rehabilitation Services, stated that Resident 96 was last discharged from OT on 07/04/2022 and from PT on 07/21/2022 and orders for a restorative program were written.
RESIDENT 97
During an interview on 10/20/2022 at 9:35 AM, Resident 97 stated they did not know when a restorative aide came around and the resident would not participate if they did not feel well.
Review of Resident 97's orders, dated 07/01/2022, showed the resident was discharged from skilled therapy services and orders for a restorative program were written for continued functional exercise
Review of Resident 97's care plan, dated 10/07/2022, showed resident demonstrated loss of range of motion in bilateral upper extremities related to functional deterioration. The goal was active range of motion exercises to bilateral lower extremities with a restorative range of motion program to be done three times a week and as needed.
Review of Resident 97's restorative therapy log showed no entries for October 2022. Any refusals of participation were also not documented.
During an interview on 10/24/2022 at 11:28 AM, Staff L, Director of Rehabilitation Services, stated that Resident 97 was discharged from OT on 04/25/2022 and from PT on 06/29/2022 and orders for a restorative program were written.
During an interview on 10/24/2022 at 1:20 PM, Staff M, LPN/RCM, stated they did not provide oversight of the restorative programs, were unsure of where the programs would be documented in the care plan, and tracking of the programs were not done in the electronic health record. Staff M further added the restorative aide documented the activities onto a paper log and provided copies to Staff M; however, Staff M did not consistently track participation.
During an interview on 10/25/2022 at 9:05 AM, Staff N, CNA/RNA, stated the rehabilitation department wrote the restorative orders on paper and gave it to the restorative aides, who in turn gave the orders to Staff M. Tracking participation in the restorative program was the responsibility of the restorative aides who used a paper tracking system. Staff N stated they were often unable to perform their restorative program tasks due to being asked to complete other tasks.
During an interview on 10/25/2022 at 9:45 AM, Staff B, DNS, stated they did not have the staff in place to have a fully functional restorative program and the current system did not meet the expectations of the restorative program goals.
Reference WAC 388-97-1060 (3)(d)(j)(ix)
RESIDENT 9
During an interview on 10/20/2022 at 10:04 AM Resident 9 stated that they were supposed to have therapy, but the last treatment was on Friday. Resident 9 stated, I haven't heard from them since, and it's been 6 days. Resident 9 further stated that they wanted to be able to go home but were worried that if they just laid here that won't happen.
Review of a document titled Rehab Restorative Transition Program dated 09/28/2022 showed Resident 9 was to walk with a front wheeled walker for 25 feet and use the therapy bands three time a week.
During an interview on 10/24/2022 at 9:16 AM, Staff K, CNA/RNA, stated that Resident 9 was on a restorative program three times a week for walking and that Resident 9 had restorative on Thursday last week, Staff K further stated that they had been working as a CNA and other things lately and had not been able to get Resident 9's programs done.
During an interview on 10/25/2022 at 10:13 AM Staff N, CNA/RNA, stated they were unaware Resident 9 was on a restorative program at the time.
Review on 10/25/2022 at 10:18 AM of the document titled Restorative Nursing Flow sheet showed no documented restorative programs for the month of October 2022.
RESIDENT 18
During an interview on 10/19/2022 at 3:34 PM Resident 18 stated that they didn't know if they got therapy or restorative. Resident 18 stated that some weeks they got it and then nothing for weeks.
Review of document titled RNA Orders Template showed an order dated 04/19/2022 for Resident 18 to ambulate with a walker three times a week.
Review on 10/22/2022 at 2:01 PM of Resident 18's annual MDS showed the resident admitted on [DATE] with a right hip fracture and received no restorative services.
Review on 10/22/2022 at 2:02 PM of Resident 18's care plan showed the resident was to receive Restorative Range of Motion with a goal for active range of motion to both arms with red elastic bands three times a week and as needed with an initiation date of 01/10/2022.
During an interview on 10/25/2022 at 10:13 AM Staff N, CNA/RNA, stated that Resident 18 did elastic band upper extremity exercises sometimes but had not been documenting them.
Review on 10/25/2022 at 10:18 AM of the document titled Restorative Nursing Flow sheet showed no documented restorative programs for the month of October 2022.
Based on observation, interview and record review, the facility failed to provide services to prevent decline or increase residents' range of motion for eight of nine residents (Residents 107, 61, 3, 18, 96, 9, 97, and 15) reviewed for Position/Mobility and/or Restorative. This failure placed residents at risk of a decrease in range of motion, inability to perform activities of daily living, and a diminished quality of life.
Findings included .
Review of a document titled, Restorative Nursing, showed that the Center may provide restorative nursing programs for patients who were admitted with restorative needs, but are not candidates for formalized rehabilitation therapy, have restorative needs provided when the need arises while on a longer term stay and would benefit from restorative programs in conjunction with formalized rehabilitation therapy. The program was to be coordinated by nursing and adjust to living as independently and safely as possible. In addition, the program was designed to attain and maintain optimal physical, mental, and psychological functioning. Finally, the program was to be implemented according to the specifics of the care plan and evaluated quarterly.
RESIDENT 61
During an interview on 10/19/2022 at 3:55 PM, Resident 61 stated that the resident should receive nursing restorative services (a program to assist residents in movement/exercises to prevent a decline in range of motion/deconditioning), but that these services were not being provided.
Review of Resident 61's 09/16/2022 Minimum Data Set assessment (MDS) showed that the resident had impairment to bilateral (both sides) upper and lower extremities (arms and legs).
Review of Resident 61's care plan on 10/25/2022 showed a focus area for nursing restorative services with an intervention to provide upper and lower extremity passive stretching three times a week and as needed.
Review of Resident 61's nursing restorative flow sheet for October 2022 on 10/25/2022 showed that the resident had been provided services three times in October out of nine opportunities.
During an interview on 10/25/2022 at 9:27 AM, Staff M, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated that residents' nursing restorative services were recorded on the restorative nursing flow sheet. Staff M further stated that her expectation was that nursing restorative services would be provided per care plan. Staff M also stated that Resident 61 had not received nursing restorative services per care plan and that this did not meet her expectation.
During an interview on 10/25/2022 at 9:57 AM, Staff B, Director of Nursing Services (DNS), stated that the facility did not currently have a functioning nursing restorative program due to restorative aids being asked to perform other duties. Staff B further stated that the nursing restorative service provided to Resident 61 did not meet her expectation.
RESIDENT 3
During an interview on 10/24/2022 Resident 3 stated that they provided exercises to the resident's legs every once in a while, and it was nice to get them stretched out.
Review of the admission MDS dated [DATE] showed that Resident 3 admitted to the facility on [DATE], required extensive assistance with activities of daily living (ADLs), and was able to make needs known. This MDS did not show that Resident 3 had received restorative services.
Review of the care plan on 10/21/2022 showed a focus area for Resident 3 to receive Restorative Range of Motion. Interventions included PROM to both lower extremities three times per week and as needed with an initiated date of 07/13/2022.
Review of Resident 3's Restorative Nursing Flow Sheet undated on 10/25/2022 at 9:40 AM located in the Restorative binder under the October tab showed that Resident 3 had been provided services twice out of nine opportunities.
During an interview on 10/25/2022 at 9:43 AM, Staff N, CNA/RNA, stated that Resident 3's paper Restorative Nursing Flow sheet found in the binder should have been documented with the month and year for October 2022. Staff N stated that Resident 3 got restorative on the 3rd and the 6th of this month (October) and that was all that was documented. Staff N stated that sometimes the Restorative aide would get pulled from Restorative to work the floor and so Restorative may not get completed at times.
RESIDENT 107
Review of the quarterly MDS dated [DATE], showed that Resident 107 was admitted on [DATE] with multiple diagnoses to include heart disease, diabetes, hemiplegia (paralysis of one side of the body), and depression. Resident 107 was able to make needs known.
During an interview and observation on 10/19/2022 at 10:57 AM, Resident 107 laid in bed with the wrist bent and appeared contracted with right hand turned inward at the wrists. Resident 107 stated that, My right side is paralyzed, and the staff were doing restorative therapy with me, but they stopped.
Review of Resident 107's care plan dated 07/01/2022 showed that the resident would have restorative range of motion services due to Resident 107's demonstrated loss of range of motion in the bilateral lower extremities (legs) due to deterioration related to a cerebral vascular accident (stroke). Several interventions included Passive Range of Motion (PROM) was to be applied which consisted of five repetitions for three sets three times every week and when necessary. In addition, PROM was to be applied to the Right Upper Extremities (RUE, shoulder, elbow, and hand) three times a week and when necessary.
Review of a document titled, Occupational Therapy- OT Discharge Summary, dated 07/12/2022 showed that Resident 107 was discharge to the long-term setting and was referred to Restorative Nursing Program (RNP). An additional document titled, Physical Therapy -PT Discharge Summary, dated 06/06/2022 also showed a recommendation to be referred to RNP and that the resident's prognosis to maintain current level of function was excellent with participation in RNP.
Review of Resident 107's electronic health record (EHR) on 10/24/2002 at 12:30 PM showed no documentation of a restorative nursing program.
During an interview on 10/24/2022 at 9:41 AM, Staff N, Certified Nursing Assistant/Restorative Nursing Assistant (CNA/RNA), stated that another aide usually worked with Resident 107, and that the aide had worked last night. Staff N, CNA/RNA, further stated that the documentation was handwritten on paper; however, he was unable to produce any documentation that Resident 107 had received RNP for the month of October 2022.
During an interview on 10/25/2022 at 9:46 PM, Staff Q, Health Information Manager, stated that Resident 107 did not have any restorative nursing program documentation in the resident's EHR; however, she believed that it was being documented on paper.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision when outside the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision when outside the facility to prevent accidents for one of eight residents (Resident 61) and failed to assess for the safe ability to smoke for one of eight residents (Resident 3) reviewed for Accidents/Smoking. This failure placed residents at risk for burn injuries and a diminished quality of life.
Findings included .
RESIDENT 61
Observation on 10/19/2022 at 10:42 AM showed Resident 61 escorted outside by three staff to the sidewalk in front the facility. Further observation showed that the staff returned into the facility. Observation then showed a different resident placed a cigarette into Resident 61's mouth and lit the cigarette for Resident 61. Observation also showed that the cigarette wobbled in Resident 61's mouth and the resident was unable to use their hands to manipulate the cigarette. Observation showed that Resident 61's clothing had two burn holes on the left shoulder.
During an interview on 10/19/2022 at 12:07 PM, Resident 61 stated that staff assisted the resident outside when they asked, and the resident would wait outside until a staff came to work to request to be taken back into the facility. Resident 61 further stated that the facility staff were aware that the resident smoked when outside and that they received cigarettes from other residents who smoked.
During an interview on 10/19/2022 at 2:18 PM, Staff A, Administrator (ADM), stated that the facility assessed residents who wanted to smoke for safety and that Resident 61 had been assessed to be unsafe to smoke. Staff A further stated that Resident 61 should be supervised outside as the resident was unable to self-propel in a wheelchair.
Review of Resident 61's 09/06/2022 smoking evaluation showed that the resident was unsafe to smoke.
During an interview on 10/25/2022 at 1:43 PM, Staff M, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated that Resident 61 was unable to self-propel in a wheelchair and that the resident was not safe to be left outside without supervision as the resident was unable to re-enter the facility. Staff M further stated that Resident 61 was assessed to be unsafe smoking, the facility was aware that the resident was non-compliant with the facility smoking policy, and the facility was aware the resident was being provided cigarettes by others.
During an interview on 10/25/2022 at 2:03 PM, Staff B, Director of Nursing Services (DNS), stated that Resident 61 was unable to self-propel in a wheelchair. Staff B further stated that there were safety concerns related to Resident 61 being left outside as the resident could not re-enter the facility. Staff B also stated that the facility was aware that Resident 61 was non-compliant with the facility's smoking policy and Resident 61 should not be left outside with other residents who smoked.
RESIDENT 3
Observation and interview on 10/20/2022 at 12:51 PM, showed Resident 3 smoking off campus in a wheelchair on the sidewalk with another resident. Resident 3 stated that they were able to go out by themself. Resident 3 used a fork to smoke that the resident stated was brought from home.
Review of the admission Minimum Data Set assessment (MDS) dated [DATE] showed that Resident 3 admitted on [DATE], had impairment of both upper extremities (shoulder, elbow, wrist, hand), required extensive assistance with activities of daily living, and was able to make needs known. This MDS further showed that Resident 3 had No tobacco use.
In a follow-up interview on 10/24/2022 at 10:05 AM Resident 3 stated that when they first admitted to the facility the staff were aware they smoked, and it was allowed if they went off the property. Additionally, Resident 3 stated that they used a fork strapped to their hand and placed the cigarette in-between the tines of the fork and a friend would light the cigarette for them to be able to smoke. Resident 3 stated that smoking supplies were kept in their purse or in a locked drawer in their room when not with them.
Review of Resident 3's progress note dated 10/04/2022 at 11:00 AM showed, Res [Resident] educated on limiting smoking cigarettes as well, however res declines.
Review of Resident 3's smoking evaluation showed that it was completed on 10/19/2022. Further review did not show a smoking evaluation prior to this date.
Review of Resident 3's care plan on 10/21/2022 had a focus area that showed, Patient may smoke independently off property per smoking assessment, date initiated on 10/19/2022.
During an interview on 10/26/2022 at 10:48 AM, Staff S, Registered Nurse (RN), stated that when it was first identified that Resident 3 wanted to smoke, they should have done a smoking assessment at that time and a care plan revision should have been completed.
During an interview on 10/26/2022 at 12:48 PM, Staff B, DNS, stated that they should have completed a smoking evaluation and revised Resident 3's care plan when it was first identified that the resident wanted to smoke or had been smoking and that this did not meet expectations.
Reference WAC 388-97-1060 (3)(g)
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive, and served at an appetizing temperature for 12 of 13 residents (Residents 35, 107...
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Based on observation, interview and record review, the facility failed to provide food that was palatable, attractive, and served at an appetizing temperature for 12 of 13 residents (Residents 35, 107, 90, 18, 69, 34, 108, 9, 61, 31, 105, and 3) reviewed for Food. This failure placed residents at risk of weight loss, depressed mood, and a diminished quality of life.
Findings included .
RESIDENT 35
During an interview on 10/19/2022 at 10:46 AM, Resident 35 stated that the facility food was not palatable and frequently cold.
During an interview on 10/21/2022 at 11:16 AM, Resident 35 stated that the previous day's enchiladas did not appear appetizing and felt the kitchen staff were unskilled at preparing palatable, attractive food.
RESIDENT 107
During an interview on 10/19/2022 at 10:51 AM, Resident 107 stated that the food was unpalatable and the meat was often too chewy.
During an interview on 10/25/2022 at 8:59 AM, Staff X, CNA, stated that Resident 107 felt the breakfast was repetitious due to always being served eggs and that the food was often cold.
RESIDENT 90
During an interview on 10/20/2022 at 11:06 AM, Resident 90 stated that the food was only palatable if starch rich diets were preferred. Resident 90 further stated that the resident only ate enough food to survive and returned the rest of the food due to being unpalatable.
During an interview on 10/24/2022 at 10:54 AM, Resident 90 stated that the resident had not eaten breakfast because it was French toast, which upset the resident's stomach. Resident 90 further stated that the resident had only had juice and coffee for breakfast and was not offered an alternative breakfast.
RESIDENT 18
During an interview on 10/19/2022 at 3:27 PM, Resident 18 stated that the facility's food was usually cold.
During an interview on 10/26/2022 at 12:30 PM, Resident 18 stated that the resident did not like the facility food as it was repetitive and not palatable half the time. Resident 18 further stated that the zucchini provided at lunch was mushy.
RESIDENT 69
During an interview on 10/20/2022 at 11:42 AM, Resident 69 stated that the food was not flavorful and felt it was institutionalized.
During an interview on 10/21/2022 at 11:23 AM, Resident 69 stated that the resident had not eaten the eggs provided at breakfast because they were not palatable.
During an interview on 10/24/2022 at 2:46 PM, Resident 69 stated that the green beans served at lunch were not palatable, the potatoes tough, and the chocolate cake tasted stale. Resident 69 further stated that the lunch was also not at an appetizing temperature.
RESIDENT 34
During an interview on 10/20/2022 at 10:46 AM, Resident 34 stated that the facility's food was unpalatable and was concerned about losing weight because the resident was not eating as much.
RESIDENT 108
During an interview on 10/20/2022 at 9:42 AM, Resident 108 stated that the food was occasionally unpalatable.
RESIDENT 9
During an interview on 10/20/2022 at 10:10 AM, Resident 9 stated that the food was frequently cold and that the toast was untoasted bread.
RESIDENT 61
During an interview on 10/19/2022 at 3:51 PM, Resident 61 stated that the food was always unpalatable.
RESIDENT 31
During an interview on 10/19/2022 at 3:36 PM, Resident 31 stated that the food lacked flavor and was repetitious. Resident 31 further stated that the resident occasionally got the wrong menu items. Resident 31 stated that during one dinner the facility had not provided a dinner tray. Resident 31 stated that the missing dinner tray was reported to staff and the resident was provided with a sandwich, crackers, and pudding. Resident 31 stated that the resident contacted family to bring food to the facility to eat.
During an interview on 10/21/2022 at 11:36 AM, Resident 31 stated that that morning's breakfast was unpalatable due to a lack of flavor.
RESIDENT 105
During an interview on 10/19/2022 at 3:38 PM, Resident 105 stated that the food was always unpalatable, especially breakfast. Resident 105 further stated that he frequently ordered food into the facility due to the unpalatability of the food.
RESIDENT 3
During an interview on 10/20/2022 at 12:25 PM, Resident 3 stated that the food either lacked flavor or was over seasoned. Resident 3 further stated that the food was frequently unpalatable.
KITCHEN OBSERVATION
Observation of the facility kitchen's tray line on 10/26/2022 at 11:54 AM showed staff serving steamed zucchini, white rice, cornbread, and a bowl of chili. Further observation showed that the zucchini and rice were served with a cupped ladle and unmanipulated after. Observation showed that this resulted in two domed mounds of food and the appearance that the plate was half empty.
TEST TRAY
Observation of a test food tray on 10/26/2022 at 11:59 AM showed a plate with a domed mound of steamed zucchini, a domed mound of white rice, a square of cornbread and half the plate was empty. Observation showed warm water pooled beneath the mound of zucchini. Taste testing of the zucchini showed that it lacked texture and flavor. Taste testing of the white rice showed that it lacked seasoning. Observation of the tray showed that a single pat of butter was the only seasoning provided. Taste testing showed that the food was room temperature.
RESIDENT COUNCIL
Review of the Resident Council Minutes dated 06/30/2022 showed Discussion of Old/Unfinished Business section with concerns of residents not being woken by staff when delivering trays which resulted in cold meals. Further review showed that an in-service training had been provided due to this issue but was not being consistently followed. Continued review showed concerns with the snack program being mismanaged.
Review of the Resident Council Minutes dated 08/30/2022 showed the following concerns: (1) Meat, potatoes, and gravy were too salty; (2) Late meal delivery; (3) Alternate meal items not delivered as ordered; (4) Receiving foods marked as disliked; and (5) Portion control, either too much or too little. Further review showed that the kitchen manager was not in attendance, so a Resident Council Concern Form was completed.
Review of the Resident Council Minutes dated 09/27/2022 showed no resolution of the food concerns reported at the previous meeting in the Discussion of Old/Unfinished Business section.
DIETARY COMMITTEE MINUTES
Review of the Dietary Committee Minutes dated 04/26/2022 showed a survey of residents' concerns related to kitchen services. Further review showed a request for more varied meals/concerns with repetitious menu.
Review of provided documentation showed that the May 2022 Dietary Committee was postponed due to an outbreak. No documentation was provided for June, July, or August 2022.
Review of the Dietary Committee Minutes dated 10/20/2022 showed a concern with the facility's food vendor related to palatability of food.
GRIEVANCE LOG
Review of the facility's Grievance Log from May through October 2022 showed two food grievances in May, two food grievances in July, two food grievances in August, and one food grievance in October.
During an interview on 10/16/2022 at 12:15 PM, Staff Y, Regional Registered Dietician, stated that the test tray provided by the facility had issues which affected the attractiveness of the meal. Staff Y further stated that the empty space was not attractive, and the mounds of zucchini and white rice should be manipulated to cover more of the plate and to generally have a better presentation. Staff Y also stated that the zucchini was bland because it did not have seasoning, and that it was not seasoned so that it could be served to both residents with and without sodium restrictions. Staff Y stated that the zucchini was a soft texture so that it could be served to residents with and without food texture restrictions. Staff Y further stated that it was not a usual practice to eat white rice without seasoning, and that the pat of butter was provided to add flavor to the rice. Staff Y also stated that the facility kitchen would prepare food with low texture and no sodium so fewer food items needed to be prepared.
During an interview on 10/26/2022 at 12:38 PM, Staff Z, Registered Nurse, stated that the residents frequently expressed concern with the temperature of foods and portion sizes. Staff Z further stated that these issues had persisted for months, and that the facility management was aware.
During an interview on 10/26/2022 at 2:03 PM, Staff AA, Dietary Manager, stated that she attended Resident Council and a Dietary Committee Meeting to elicit feedback from residents regarding food concerns. Staff AA further stated that she was aware of issues with food temperature and that it was due to staff on the hallways not timely passing out food trays. Staff AA also stated that she was unaware of the concerns regarding the facility's food vendor from the 10/20/2022 Dietary Committee.
During an interview on 10/27/2022 at 9:14 AM, Staff A, Administrator, stated that her expectation was that food provided to residents mimicked restaurant quality food. After being provided with the findings related to food, Staff A stated that the facility's food program did not meet her expectations.
Reference WAC 388-97-1100(1), (2)
.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to ensure proper use of Personal Protective Equipment (PPE, equipment worn to minimize exposure to infectious diseases/illnesses)...
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Based on observation, interview, and record review the facility failed to ensure proper use of Personal Protective Equipment (PPE, equipment worn to minimize exposure to infectious diseases/illnesses) as required for transmission-based precautions (TBP, precautions/PPE used with known or suspected infectious diseases/illnesses) for two staff (Staff D and F) in one of two wings (South wing). Also, the facility failed to complete the collection and analyzation of infection control data, identification of trends and complete follow-up activities in response to those trends for four of four months (July, August, September and October 2022) reviewed for Infection Control. These failures placed residents, visitors, and staff at risk for communicable diseases, related complications, and a decreased quality of life.
Findings included .
TRANSMISSION BASED PRECAUTIONS.
Review of the facility's policy titled, Infection Control dated 03/23/2022 showed that newly admitted and/or re-admitted Residents would be cohorted according to the County, State, Centers for Medicare, and Medicaid Services (CMS), and Centers for Disease Control (CDC) Guidelines.
Review of the document titled, Interim Recommendations for SARS-CoV-2 Infection Prevention and Control in Healthcare Settings, updated 04/22/2022, showed that healthcare personnel in close contact with patients presumed or confirmed COVID (a highly infectious respiratory illness caused by a virus) positive, or in observation/quarantine must wear an N95 respirator (a mask that filters 95% of airborne particles), gown, gloves, and eye protection for each encounter.
Review of the Washington State Department of Health (DOH) quarantine precautions sign posted by newly admitted resident's doors on 10/24/2022 showed an effective date of 03/16/2022 directing that staff must clean hands when entering and leaving a room, wear a respirator (fit tested N95), wear eye protection (face shield or goggles), gown and gloves when entering the room and remove on exiting the room.
Observation on 10/24/2022 at 9:09 AM, Staff D, showed Licensed Practical Nurse (LPN) entering Resident 3's room and there was a quarantine precautions sign posted outside the door. Staff D had on a face shield and surgical mask; however, she did not have on a N95 respirator mask, gloves, or a gown as directed on the sign. Staff D exited the room and did not change her PPE.
Observation on 10/25/2022 at 12:29 PM showed Staff F, Nursing Assistant Noncertified, sat next to the bed assisting Resident 309 to eat a lunch meal. There was a quarantine precautions sign posted on the outside of the door. Staff F had on a gown, gloves, and surgical mask. An N95 respirator was not used.
During an interview on 10/25/2022 at 1:07 PM Staff E, Nurse-Infection Control (NIC), stated that it was the expectation when a resident was on quarantine precautions that staff put on a gown, gloves, eye protection and a fit tested N95 respirator mask when they entered the room and removed them when they exited the room.
During an interview on 10/26/2022 at 8:59 AM Staff B, Director of Nursing Services (DNS), stated that it was the expectation for staff entering a precautions room to read the sign posted and follow the directions. Staff B further stated that for rooms in quarantine precautions, staff should have put on a N95 respirator mask, gown, gloves, and eye protection on entry into the room and removed them on exiting the room.
TRACKING AND TRENDING
Review of the facility's policy titled IC102 Infection Control Outcome and Process Surveillance and Reporting, dated 11/15/2021 showed that the infection preventionist would complete a Monthly Infection Control Report, compare current infection control data to past data, perform root cause analysis to identify trends and performance issues, implement measures to address those trends and report the results to Quality Assurance Performance Improvement (QAPI) Committee.
Review of the facility's policy titled, IC101 Cultures/Culture Reports showed the infection preventionist would compare culture results with antibiogram (a lab report detailing present organisms in the facility) to monitor prevalence of resistant organisms at the facility.
Review of the facility's policy titled, IC100 Criteria for Determining Infections, last reviewed on 11/15/2021 showed that identification of infection should not be based on a single piece of evidence. Microbiologic findings should be used only to confirm clinical evidence of infection. Similarly, physician diagnosis should be accompanied by compatible signs and symptoms of infection. It further showed, residents should be evaluated using McGeers or Loebs criteria (a set of signs and symptoms used to determine active infection) prior to the start of an antibiotic.
Review on 10/25/2022 at 1:07 PM showed the data on the facility's infection line listings for July, August, September, and October through 10/27/2022 did not include the identified organisms. Additionally, there were no symptom surveillance forms for the months of July, August or September 2022, and no monthly infection control summary reports or documentation of follow up activities.
During an interview on 10/25/2022 at 1:07 PM, Staff E, NIC, stated that she completed the symptom surveillance forms after she identified a resident had already started an antibiotic. Staff E also stated that she was not currently tracking the organisms, reviewing pharmacy reports or the antibiogram and was not aware of the Monthly Infection Control Report requirements.
During an interview on 10/25/2022 at 2:32 PM, Staff G, Licensed Practical Nurse (prior NIC), stated that trending and the monthly summary was, last done in June 2022.
During an interview on 10/26/2022 at 8:59 AM, Staff B, DNS, stated that it was the expectation that the line listing be completed, and it should track the organisms. Staff B further stated that the infection preventionist should be analyzing that data monthly, planning to address any identified issues and that residents' symptoms should be assessed to meet criteria before contacting the provider for treatment.
Refer to F881.
Reference WAC 388-97-1320(1)(a)
.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program, to promote a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program, to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of antibiotic resistance for four of four months (July, August, September and through the 27th of October 2022) when reviewed for Infection Control. These failures placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics and increased resistance to antibiotic therapies.
Review of the facility's policy and procedure titled, IC402 Antibiotic Stewardship, with a revision date of 05/01/2022 showed that the center Front-Line Nursing Staff would communicate patient status to providers in a timely manner and discuss with providers if the patient met criteria for antibiotic use. This document also showed that nursing staff should contact providers for reassessment of the ongoing need for and choice of an antibiotic within 48-72 hours of the initiation of an antibiotic (known as time-out), and that the infection control nurse should monitor the outcomes of antibiotic use and rates of resistant organisms using the antibiogram (a lab report detailing organisms in the facility) and a monthly Infection Control Report.
Review of the policy titled, IC100 Criteria for Determining Infections, dated 11/15/2021 showed that the goal was to provide consistent criteria for classifying and identifying infections with the use of McGeers or Loebs criteria (a set of signs and symptoms used) to determine active infection. Furthermore, it showed that identification of infections should not be based on a single piece of evidence. Microbiologic findings should be used only to confirm clinical evidence of infection.
Review on 10/25/2022 at 1:07 PM showed that the data on the resident infection line listings [a tracking tool for facility infections] for July, August, September 2022 through October 27, 2022, did not include the criteria Surveillance Data Collection forms for the months of July, August, or September 2022, and did not include any documentation of antibiotic time out's to evaluate the appropriateness of prescribed antibiotics. Furthermore, there were no monthly summaries to monitor outcomes of antibiotic use and the facilities rates of antibiotic resistant organisms.
RESIDENT 99
Review of Resident 99's admission Minimum Data Set assessment (MDS) dated [DATE] showed that the resident admitted on [DATE] with a diagnosis of a urinary tract infection (UTI).
During an interview on 10/20/2022 at 10:50 AM Resident 99 stated, It burns and stings when I pee.
Review of Resident 99's progress note dated 10/10/2022 at 5:49 PM showed a call was placed to the on-call practitioner requesting a urinalysis (UA, a test used to identify infection in the urine) for complaints of dysuria (painful urination).
Review of Resident 99's progress note dated 10/11/2022 at 5:56 AM showed that a urine sample was obtained.
Review of a document titled Physician Communication, dated 10/12/2022 showed the provider was notified of Resident 99 having some mucus and burning with urination. There was no documentation of a resident assessment included on the form; however, the provider recommended a urinalysis with culture and sensitivity [testing to determine type of organisms present in urine].
Review of Resident 99's progress note dated 10/12/2022 at 1:20 PM showed, UA results reported to provider. Culture pending. There were no notes related to Resident 99 being assessed for criteria for UTI found in the medical record.
During an interview on 10/24/2022 at 11:03 AM Staff E, Nurse-Infection Control (NIC), stated that staff should have documented a change of condition, encouraged fluids, placed Resident 99 on alert to monitor for symptoms, completed a Surveillance Data Collection form and contacted the provider with the results. Staff E further stated that the floor nurses were responsible to follow up with the provider with any lab results and that these things did not happen for Resident 99.
Review of Resident 99's Infection Control Note dated 10/24/2022 showed that the provider was notified of the UA results and would treat based on Culture and Sensitivity lab results dated 10/16/2022.
Review of Resident 99's physician orders showed a new order dated 10/24/2022 for levofloxacin (an antibiotic medication) 500 milligram one time a day every other day for 10 days.
Review of Resident 99's electronic health record (EHR) on 10/25/2022 at 12:30 PM showed no documentation that Resident 99 was assessed to determine if criteria for active infection were met. Additionally, there was no provider documentation of the rationale for the decision to treat Resident 99's UTI without meeting criteria.
During an interview on 10/25/2022 at 1:07 PM, Staff E stated that she completed the Surveillance Data Collection forms after she identified a resident had already started an antibiotic. Staff E also stated that she was not currently tracking the organisms, reviewing the antibiogram and was not aware of the monthly Infection Control Report summary requirements.
During an interview on 10/26/2022 at 8:59 AM, Staff B, Director of Nursing Services, stated that it was her expectation that any infections should meet criteria before contacting the provider and starting treatment; however, this process was not followed for Resident 99. Staff B further stated that it was her expectation that the infection control nurse completed the resident infection line listings to track the organisms, any resistance patterns and should be analyzing that data monthly on the Infection Control Report.
NO ASSOCIATED WAC
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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
- "What changes have you made since the serious inspection findings?"
- "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
- • Multiple safety concerns identified: 1 life-threatening violation(s), 3 harm violation(s), $134,350 in fines. Review inspection reports carefully.
- • 95 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $134,350 in fines. Extremely high, among the most fined facilities in Washington. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: Trust Score of 0/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Linden Grove Health's CMS Rating?
CMS assigns LINDEN GROVE HEALTH CARE CENTER 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 Linden Grove Health Staffed?
CMS rates LINDEN GROVE HEALTH CARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 49%, compared to the Washington average of 46%.
What Have Inspectors Found at Linden Grove Health?
State health inspectors documented 95 deficiencies at LINDEN GROVE HEALTH CARE CENTER during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, and 91 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Linden Grove Health?
LINDEN GROVE HEALTH CARE CENTER 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 GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 130 certified beds and approximately 101 residents (about 78% occupancy), it is a mid-sized facility located in PUYALLUP, Washington.
How Does Linden Grove Health Compare to Other Washington Nursing Homes?
Compared to the 100 nursing homes in Washington, LINDEN GROVE HEALTH CARE CENTER's overall rating (1 stars) is below the state average of 3.2, staff turnover (49%) 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 Linden Grove Health?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Linden Grove Health Safe?
Based on CMS inspection data, LINDEN GROVE HEALTH CARE CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Washington. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Linden Grove Health Stick Around?
LINDEN GROVE HEALTH CARE CENTER has a staff turnover rate of 49%, 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 Linden Grove Health Ever Fined?
LINDEN GROVE HEALTH CARE CENTER has been fined $134,350 across 4 penalty actions. This is 3.9x the Washington average of $34,422. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Linden Grove Health on Any Federal Watch List?
LINDEN GROVE HEALTH CARE CENTER 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.