RICHLAND POST ACUTE
For profit - Limited Liability company
71 Beds
PACS GROUP
Data: November 2025
Trust Grade
45/100
#116 of 190 in WA
Photo by Richland Post Acute (Formerly known as Richland Rehabilitation Center)
Photo by Richland Post Acute (Formerly known as Richland Rehabilitation Center)
Photo by Richland Post Acute (Formerly known as Richland Rehabilitation Center)
1 / 5 photos
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Richland Post Acute has a Trust Grade of D, indicating below-average performance with some notable concerns. It ranks #116 out of 190 facilities in Washington, placing it in the bottom half, and #3 out of 4 in Benton County, meaning only one local option is better. The facility is trending positively, having reduced the number of issues from 20 in 2024 to 12 in 2025. Staffing is rated average with a 3/5, and the turnover rate of 41% is below the state average, suggesting some stability among staff. However, the facility has $57,194 in fines, which is concerning, and there are significant issues including a resident developing a pressure injury due to inadequate care and failure to maintain the garbage area properly, risking unsanitary conditions. On a positive note, Richland Post Acute provides more RN coverage than 90% of facilities in the state, which can help catch potential problems.
- Trust Score
- D
- In Washington
- #116/190
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 41% turnover. Near Washington's 48% average. Typical for the industry.
- Penalties ⚠ Watch
- $57,194 in fines. Higher than 88% of Washington facilities, suggesting repeated compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 80 minutes of Registered Nurse (RN) attention daily — more than 97% of Washington nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 39 deficiencies on record. Higher than average. Multiple issues found across inspections.
45/100
Bottom 39%
Needs review
20 → 12 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 20 issues
2025: 12 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (41%)
7 points below Washington average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Washington average (3.2)
Meets federal standards, typical of most facilities
Staff Turnover: 41%
Near Washington avg (46%)
Typical for the industry
Federal Fines: $57,194
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: PACS GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 39 deficiencies on record
1 actual harm
Jul 2025
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
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 identify a change in condition for 1 of 3 residents (Resident 1) re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify a change in condition for 1 of 3 residents (Resident 1) reviewed for assessments. The failure to perform an assessment disallowed an opportunity to adequately evaluate the resident's medical condition, which potentially caused a delay in treatment.
Findings included .
<Resident 1>
Review of Resident 1's medical record showed they were admitted on [DATE] with diagnoses including an upper arm fracture, pancreatic cancer, and diabetes (a disease that results in too much sugar in the blood). Review of the admission summary note dated 06/21/2025 showed the resident was alert and oriented to self, was able to conversate about their health and was able to follow directions without difficulty. The admission summary notes also showed Resident 1 had a foley catheter (a flexible tube used to drain urine from the bladder into a collection bag).
Review of Resident 1's vitals sign records showed on 06/25/2025 at 7:05 AM, there was one set of vital signs recorded as followed; blood pressure 113/94 ([BP]-systolic the force of blood pushing against the walls of the blood vessels and the diastolic resting pressure between heartbeats; Normal BP 120/80), heart rate 67 (HR-normal rate 60-100), oxygen saturation 92% (normal range 95-100%). There were no additional recorded vital signs for the day.
During an interview on 06/27/2025 at 10:54 AM, Resident 1's Representative, (RR), stated they had arrived at the nursing home facility to accompany Resident 1 to an appointment on 06/25/2025. The RR stated they had to wait at the nurse's station for 45 minutes for their transportation to arrive. The RR stated during this time, Resident 1 was slumped over and leaning far to the right in a wheelchair and was hard to arouse. The RR stated when they voiced their concern to staff at the nurse's station, nobody checked on Resident 1. The RR stated the transport ride was 20 minutes and upon arrival at the medical appointment, clinic staff were very concerned about Resident 1's condition. The RR stated the clinic staff performed a quick assessment and called emergency services and transported Resident 1 to the emergency room. The RR further stated Resident 1 was admitted to the hospital and was placed on comfort care until they pass away.
During an interview on 06/27/2025 at 11:22 AM, Staff A, Nursing Assistant, stated they noticed a change in Resident 1 during lunchtime on 06/25/2025. Staff A stated Resident 1 was not responding to them very well. Staff A stated they assisted a nurse with Resident 1's dressing change after lunch and noticed when Resident 1 was holding onto a grab bar during the dressing change in the restroom, they became weak and seemed like they wanted to drop. Staff A stated after the dressing change, they assisted Resident 1 to dress and then wheeled them to the nurse's station to wait for their transport to the medical appointment. Staff A noticed Resident 1 was heavily leaning to the right and not responding to voice or visual commands. Staff A stated other staff members came to adjust Resident 1 in the wheelchair by placing blankets on their right side to prop them up. Staff A stated they were not asked by a nurse to take any vital signs.
During an interview on 06/27/2025 at 12:16 PM, Staff B, Registered Nurse, stated Resident 1 was sleepy as the resident had not taken a nap on 06/25/2025. Staff B stated Resident 1 was leaning to their right side and they propped them up to straighten them out in the wheelchair. Staff B stated they thought it was odd for Resident 1 to be sleepy. They did not chart any assessments for Resident 1 as they were only to document by exception (documentation for deviations from a resident's established norm or expected outcome). Staff B stated Resident 1's vital signs were normal earlier in the day and they did not have an indication to perform an assessment for their sleepiness. Additionally, Staff B did not obtain a current set of vital signs.
Review of the 06/25/2025 ambulance report showed emergency medical services (EMS) was notified on 06/25/2025 at 2:39 PM to respond for Resident 1 with an altered level of consciousness (LOC) at a medical providers office appointment. The report showed Resident 1 had been weaker and had an altered LOC prior to the appointment. The EMS findings showed Resident 1 slumped over in a wheelchair, responsive to sternal rub (a vigorous rub to the breastbone), pupils were constricted, low BP and urine in the foley catheter bag was dark with visible debris. The report showed the following BPs obtained by EMS:
2:51 PM, BP 69/47;
2:55 PM, BP 50/30;
2:58 PM, BP 60/36;
3:03 PM, BP 61/43;
3:06 PM, BP 79/45.
Review of the hospital emergency notes dated 06/25/2025, showed Resident 1 presented with shock (a serious life-threatening medical emergency that can cause extremely low blood pressure, confusion, unconsciousness and sleepiness) and treatment included high flow oxygen support and medication to increase blood pressure.
During an interview on 06/27/2025 at 10:19 AM, a medical clinic Collateral Contact I, (CCI), stated Resident 1 had a 3:00 PM medical appointment on 06/25/2025 and had arrived by a transport service and was not appropriate for the appointment in the condition they presented in. CCI stated Resident 1 was slumped over in a wheelchair and was unable to be aroused without a sternal rub when they arrived for a medical appointment. CCI stated the staff obtained vital signs which showed Resident 1's blood pressure measured 51/33.
During an interview on 06/27/2025 at 12:55 PM, Staff C, Director of Nursing, stated when a resident seemed different the staff should perform an immediate assessment and obtain vital signs and then notify the provider and await further instructions. Staff B stated Resident 1 should have had an assessment and vital signs obtained and based on the findings laid down in bed and decided if the resident needed to be transported to the emergency room.
During an interview on 06/27/2025 at 4:01 PM, Collateral Contact II, (CCII), stated upon arrival at the nursing facility on 06/25/2025 at 2:12 PM, Resident 1 was slumped over in a wheelchair and their face was almost to their knees. CCII asked a staff member which resident they would be transporting and a staff member pointed at Resident 1 and stated, Ya that's what we are dealing with today. CCII stated they placed Resident 1 into the transport vehicle and had to lift Resident 1's upper body to place the seatbelt on. CCII stated during the transport Resident 1 was unarousable and they were extremely concerned about their well-being.
Reference WAC: 388-97-1060(1)
Jun 2025
9 deficiencies
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 the necessary respiratory care and services co...
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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 necessary respiratory care and services consistent with professional standards of practice for 1 of 1 resident (Resident 165), reviewed for respiratory care with tracheostomy tubes (a mechanical device inserted into a surgically created opening made in the neck, known as a tracheostomy, which assists with breathing), by failing to ensure; A) residents had the required emergent tracheostomy tube equipment immediately accessible, at the resident's bedside, B) nursing staff comprehensively assessed and documented a residents tracheostomy tube care, C) nursing staff had the required training/competencies (a series of knowledge, abilities, skills, experiences and behaviors, which leads to effective performance of staff regarding resident cares) to perform tracheostomy care and emergency interventions and, D) policies and procedures for residents requiring specific types of respiratory care/services regarding emergency care along with staffing implementation of emergency intervention and provision (the action of providing or supplying something) of appropriate equipment at the residents bedside. This failure placed the resident at an increased risk for negative outcomes in case of accidental extubation (the unintentional removal of the tracheostomy tube) and unmet care needs.
Findings included .
Review of the facility's policy titled, Tracheostomy Care, dated April 2022, and Changing a Disposable Inner Cannula (a tube situated inside the tracheostomy tube that can be discharged after its use) reviewed March 2019, showed that facility staff were to perform tracheostomy care per the physician's order, change a tracheostomy's disposable inner cannula at least once per day and that facility staff should refer to the Lippincott Manual (a reference for fundamental nursing tasks according to established standards of practice). Additionally, the policies showed no information on staff training/competencies (a series of knowledge, abilities, skills, experiences and behaviors, which leads to effective performance of staff regarding resident cares) of emergency intervention for respiratory (matters related to the lungs) complications or the appropriate equipment needed at the resident's bedside for immediate access in case of unplanned extubation.
Review of Lippincott Nursing Procedures 8th edition, dated 2019, showed during tracheostomy care when changing the tracheostomy ties (straps that hold the tracheostomy tube in place), .research overwhelmingly recommends a two-person technique for changing a tracheostomy tube securing device to prevent tube dislodgment .
Review of Lippincott Manual of Nursing Practice 11th edition, dated 2019, showed that residents with tracheostomies needed emergency equipment available at all times, at the residents bedside and included an extra tracheostomy tubes (inner and outer tracheostomy tubes), bag/mask resuscitation device (also called an Ambu bag, is a device for rapidly providing rescue breathing during emergency situations), obturator (a device that guides the outer tracheostomy tube through the surgically created opening in the neck and needed for emergent unplanned extubations).
Review of the facility's policy titled, Training Requirements, dated July 2019 showed that new and existing facility staff would receive job specific training. The training would be specific to the facility's resident population and federal and state mandated training requirements. Additionally, the facility would utilize the facility assessment to ensure training addressed the facility resident population.
Review of the Facility Assessment for 07/19/2023 to 07/18/2024, showed the facility identified tracheostomies in their resident population and that nursing staff would have the required training/competencies to care for the residents.
<Resident 165>
Review of the resident medical record showed they were admitted on [DATE] with diagnoses including left leg fracture/hip surgery, long term respiratory failure, cerebral palsy (a disorder developed in early childhood that affects the bodies movement, muscle coordination, that can lead to stiff/weak muscles and involuntary/uncontrollable movements of body parts), asthma (a disease where irritants that are breathed into the lungs can cause the body's airway to constrict and restrict airflow into the lungs) and obstructive sleep apnea (a condition where the walls of the throat relax and narrow during sleep, interrupting normal breathing). The 06/07/2025 comprehensive assessment showed the resident had moderately impaired cognition but was able to understand others and make their needs known. Resident 165 needed substantial to maximal assistance from nursing staff for their personal hygiene, mouth hygiene and upper body dressing. Additionally, Resident 165 required special treatment/procedures for their tracheostomy.
Review of Resident 165's admission assessment dated [DATE] showed the resident had a tracheostomy and Resident self manages Trach care- nursing to supervise. The record showed no further assessment/evaluation of the resident's level of ability regarding tracheostomy care, how the resident/staff were to participate/assist in the tracheostomy treatment.
Review of Resident 165's care plan, dated 06/06/2025 and updated 06/17/2025 showed no resident specific goals, interventions/tasks for Resident 165's tracheostomy.
During a concurrent observation and interview on 06/21/2025 at 7:09 PM showed Resident 165 in their bed, tracheostomy in place with brown, thick discharge around the bottom edge of the resident's tracheostomy tube holder. The resident had a Passy Muir (a one valve that allows a resident to speak) and was able to converse. The resident made contradicting (information that was the opposite of the previous information already obtained) statements and was confused on how tracheostomy care was performed/completed at their home versus the last two weeks in the facility and if tracheostomy care was being completed by the nursing staff or not.
During a concurrent observation and follow-up interview on 06/23/2025 at 8:07 AM, the resident stated their home care giver (referring to a private care giver that visits the resident while at home to provide care) completed all their tracheostomy care and changed out whole tracheostomy (inner/outer tubes and tube holder) one time every week. Resident 165 stated the inner tracheostomy tube was supposed to be changed every day but had not been changed out in the past two days. The resident then stated that it might have been the facility's nursing staff that was changing out their tracheostomy tubes. Resident 165 informed the surveyor that they were no longer completing their own tracheostomy care due to the increased risk of infections, which was why they had a home care giver that changed it. Additionally, observations showed that tracheostomy supplies in/on the resident nightstand did not have the emergency obturator or Ambu bag with tracheostomy attachment equipment at the resident's bedside.
Review of Resident 165 treatment administration record for June 2025, showed:
•
Orders for staff to change the resident's inner cannula every day and as needed. The documentation showed from 06/07/2025 to 06/23/2025 every day, except 06/23/2025, Staff O, Registered Nurse (RN), Staff P, RN and Staff Q, Licensed Practical Nurse (LPN), documented that Resident 165's tracheostomy care was completed.
•
Orders for staff to change the resident's tracheostomy ties/tube holder every day and .nursing to supervise resident with task. From 06/09/2025 to 06/23/2025 showed that every day, except 06/23/2025, Staff O, Staff P, RN and Staff Q documented that Resident 165's tracheostomy care was completed per their supervision.
•
Orders for staff to change the resident's outer/inner tracheostomy tubes every week and nursing was to supervise the resident with the task. Documentation showed that Staff P, per their supervision, completed the care on 06/09/2025 and 06/16/2025.
Review of Staff P's progress notes on Resident 165 daily assessments for 06/07/2025, 06/09/2025, 06/10/2025, 06/15/2025 and 06/16/2025, showed the resident was alert/oriented and managed their own tracheostomy care under nurse supervision and emergency tracheostomy suctioning was at the resident's bedside. The documentation showed no further assessment/evaluation of the resident's level of ability regarding their tracheostomy care, how the resident/Staff P might have participated, or what type of supervision was needed regarding the resident's tracheostomy care.
Review of Staff O's progress notes on Resident 165 daily assessments for 06/07/2025, 06/08/2025, 06/11/2025, 06/12/2025, 06/13/2025, 06/14/2025, 06/17/2025, 06/18/2025, 06/19/2025 and 06/20/2025, showed that tracheostomy care was completed and no further evaluation of the resident's level of ability regarding their tracheostomy care, how the resident/Staff O might have participated in the residents tracheostomy care, or what type of supervision was needed regarding the resident's tracheostomy care.
Review of Staff Q's progress notes on Resident 165 daily assessments for 06/21/2025 and 06/22/2025 showed the resident was alert/oriented, with no assessment of the resident's level of ability regarding their tracheostomy care, how the resident/Staff Q might have participated in Resident 165's tracheostomy care, or what type of supervision was needed regarding the resident's tracheostomy care.
During an interview on 06/23/2025 at 12:36 PM, Staff K, Resident Care Manager, stated that when a resident was admitted to the facility with a tracheostomy, they put orders for tracheostomy care, which included changing out the inner tracheostomy tube, the tube holder and tracheostomy ties every day. Staff K stated that an obturator and Ambu bag were to be placed at the resident's bedside. Staff K stated that when a resident performed their own tracheostomy care, an evaluation of the resident's ability to perform the task would be completed.
During an interview over the phone on 06/23/2025 at 2:15 PM, Staff Q stated they were not the routine nurse that cared for Resident 165 .I may have done something (regarding Resident 165's tracheostomy care) but I do not recall .
During an interview over the phone on 06/24/2025 at 2:18 PM, when asked about completing Resident 165 tracheostomy inner/outer tube changes and tracheostomy ties/tube holder changes, Staff P stated they had offered to do Resident 165's tracheostomy care but the resident had refused, and Staff P had not competed tracheostomy care. Staff P stated they had not observed Resident 165 change out the tracheostomy tube, tube holder, and ties but had verified that the resident could communicate how to perform their own tracheostomy care.
During an interview on 06/24/2025 at 2:38 PM, Staff A, Administrator, was informed that Staff O still needed to be interviewed for the ongoing investigation and discussed the need to complete interviews with Staff Q and Staff P. Staff A stated that Staff O, Q and P had not completed training or competencies regarding resident tracheostomy care (staff were unavailable for contact).
During an interview on 06/24/2025 at 2:49 PM, Staff K stated that an assessment should have been completed regarding Resident 165's level of ability to perform their tracheostomy care, how the resident participated/completed their tracheostomy care and what supervision would be required by staff. Staff K stated they had not completed an assessment regarding the resident's ability to perform their tracheostomy care. Staff K stated the orders to have the inner/outer tracheostomy tube changed were not correct because that would mean staff would be changing out the whole tracheostomy tube, which was not what the staff should be completing. Staff K stated the correct process with Resident 165's tracheostomy care was not being followed, and nursing staff should not be charting that it was completed.
During an interview on 06/24/2025 at 3:03 PM, Staff D, Infection Control Nurse and Staff R, Central Supply, Staff D stated that during Resident 165's admission, an assessment of the resident's ability to perform their tracheostomy care and what supervision would be required by the nursing staff should have been completed. Staff D and Staff R stated that emergency equipment, an Ambu bag, had not been in the resident's room. Staff D stated they did not know when the obturator was placed in the resident's room, but it had been in plain view on 06/24/2025, inside the resident's nightstand and would have been seen by the surveyor if it was there on 06/23/2025, but Staff D confirmed that it was currently at the resident's bedside.
During an interview on 06/25/2025 at 7:43 AM, Staff B, Director of Nursing Services, stated they were unable to find an evaluation of Resident 165's ability to perform their own tracheostomy care in the resident's record and so Staff B completed one. Staff B stated that Resident 165 could not perform their own tracheostomy care and needed assistance from nursing staff. Staff B stated Resident 165 knew the process for their tracheostomy changes but required staff to complete the task.
During an interview on 06/25/2025 at 8:59 AM, Staff B and Staff D stated they expected that nursing staff would have the required training/competencies completed and that emergent tracheostomy tube equipment would have been readily available at the resident's bedside, but the correct process was not followed. When inquired about nursing staff documenting supervision/completion on Resident 165's treatment administration for the tracheostomy inner/outer tube change out and the tracheostomy ties/tube holder change out, even though Resident 165 was unable to perform their own tracheostomy care, Staff B and Staff D were unable to comment nor present any documentation.
During an interview on 06/25/2025 at 11:41 AM, Staff M, Assistant Regional Director for Clinical Services, stated that it was expected that nursing staff would conduct an evaluation regarding Resident 165's ability to perform their own tracheostomy care. Staff M stated the expectation would be for nursing staff to have received the training/competencies if a newly admitted resident had a tracheostomy.
Reference: WAC 388-97-1060(3)(j)(iv)
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 and interview, the facility failed to ensure expired medications were properly disposed of for 1 of 1 medication rooms (Medication Room) reviewed for medication storage. This fail...
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Based on observation and interview, the facility failed to ensure expired medications were properly disposed of for 1 of 1 medication rooms (Medication Room) reviewed for medication storage. This failure placed the residents at risk for receiving expired, ineffective, and/or compromised medications.
Findings included .
Review of the policy titled, Storage of Medication, dated 01/2023, showed outdated medications would be immediately removed from stock and disposed of.
An observation on 06/21/2025 at 2:19 PM with Staff E, Licensed Practical Nurse (LPN), showed the medication room contained the following:
•
Blood collection needles, four boxes, each containing 48 needles, expired 03/31/2025.
•
Adult multivitamins, one partial bottle containing 32 tablets, expired 02/2025.
•
Non-steroidal pain reliever, one bottle of 100 tablets, expired 03/2025.
•
Magnesium with calcium supplement, one partial bottle of 26 tablets, expired 09/2024.
•
Vitamin D, one partial bottle of 84 tablets, expired 05/2025.
•
Dairy lactase enzyme supplements, two bottles of 60 caplets each, expired 04/2025.
•
Vitamin E supplements, one partial bottle of 84 tablets, expired 04/2025.
•
Allergy medication, one partial bottle (eight tablets), expired 12/2024 and one full bottle (100 tablets), expired 01/2025.
•
Iron supplement, one partial bottle of 24 tablets, expired 02/2025.
•
Oral pain relief gel, three tubes, expired 02/2024, 07/2024, and 02/2025.
•
Moisture mouth gel, eight tubes, expired 12/2024.
•
Glucose (a source of energy in the body) control solution (used to verify the accuracy of glucose testing meters), one kit, expired 11/14/2023.
During an interview on 06/21/2025 at 3:33 PM, Staff F, LPN, stated partial bottles of medications should not be stored in the same area as the full bottles. They stated the expired medications should not have been in with the non-expired medications. They stated they did not know if anyone was responsible or assigned to checking the medication room for expired medications.
During an interview on 06/23/2025 at 2:17 PM, Staff A, Administrator, stated the process included the Director of Nursing Services providing oversight. There should be a process for the nurses to perform routine checks and dispose of expired medications.
Reference: WAC 388-97-1300(2)(4)(i)
CONCERN
(D)
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 ensure influenza and pneumococcal immunizations were offered and ri...
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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 influenza and pneumococcal immunizations were offered and risks and benefits of the immunizations were provided to 2 of 5 residents (Resident 30 and 42) reviewed for immunization and infection control. This failure placed the residents at risk for illness, lack of knowledge to make medical decisions, and spread of communicable diseases.
Findings included .
Review of a policy titled, Influenza and Pneumococcal Immunizations, revised 10/03/2023, showed the facility would offer the influenza and pneumococcal immunizations to residents. The facility would review the risks and benefits of the immunization with the resident and/or their representative. The resident and/or their representative could refuse the immunizations. Immunization declinations and the reason for the declination were recorded in the resident's medical record.
<Resident 30>
Review of the medical record showed Resident 30 was admitted to the facility on [DATE] with diagnoses including a stroke (a condition that occurs when a blood clot or broken vessel prevents blood from getting to the brain), immunodeficiency (a weakened immune system that makes it less effective at fighting off infections and diseases), and anxiety. The 04/06/2025 comprehensive assessment showed Resident 30 required partial to moderate assistance of one staff member for activities of daily living (ADLs). The assessment also showed Resident 30 had an intact cognition.
Record review of Resident 30's medical record showed they were not offered an influenza or pneumococcal immunization. The record also showed no documentation of education provided on the risks and benefits of the immunization.
During an interview on 06/23/2025 at 1:34 PM, Resident 30 stated they did not remember anyone reviewing immunizations with them.
<Resident 42>
Review of the medical record showed Resident 42 was admitted to the facility on [DATE] with diagnoses including a urinary tract infection, malnutrition, and repeated falls. The 05/11/2025 comprehensive assessment showed Resident 42 required moderate/maximum assistance of one staff member for ADLs. The assessment also showed Resident 42 had a moderately impaired cognition.
Review of Resident 42's medical record showed no documentation that a pneumococcal immunization was offered, or risks and benefits had been provided to the resident or their representative.
During an interview on 06/21/2025 on 2:48 PM, Staff D, Infection Control Nurse, stated they reviewed all new admission immunizations upon admission. They stated if the resident did not have influenza or pneumococcal immunizations, they would offer them. Staff D stated they provided education, risks, and benefits for immunizations. They stated when a resident declined immunizations, they would document that on the consent/declination form. During a follow-up interview on 06/23/2025, Staff D stated they spoke to Resident 30 and Resident 42 regarding immunizations. They stated both Resident 30 and Resident 42 did not remember any previous conversations regarding immunizations and both residents declined needing them.
During an interview on 06/23/2025 at 1:53 PM, Staff B, Director of Nursing Services, stated the process for ensuring residents were immunized included reviewing the immunizations upon admission, offering the immunizations and obtaining a consent. They stated the resident would have the option to decline the immunization and that would also be documented. Staff B stated the process would include providing risks and benefits to the residents and documenting that.
During an interview on 06/23/2025 at 2:05 PM, Staff A, Administrator, stated they were confident the residents were offered immunizations but there was no documentation in the record.
Reference: WAC 388-97-1340(1)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0940
(Tag F0940)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure implementation and maintenance of an effective training program for new or existing staff, prior to staff independently providing ser...
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Based on interview and record review the facility failed to ensure implementation and maintenance of an effective training program for new or existing staff, prior to staff independently providing services to residents and annually, related to; A) effective communications, resident's rights/facility's responsibilities, abuse/neglect and dementia management regarding abuse prevention, infection prevention/control, and compliance/ethics program trainings for 1 of 3 staff (Staff Q) reviewed for training requirements and, B) Quality Assurance and Performance Improvement (QAPI, a process to maintain and improve safety/quality of residents in a nursing home) training for 3 of 3 staff (Staff Q, O, and P) reviewed for training requirements. This failure placed residents at increased risk for unmet care needs and inadequate care from unqualified staff.
Findings included .
Review of the facility's policy titled, Training Requirements, dated July 2019 showed that new and existing facility staff would receive job specific training. The training would be specific to the facility's resident population and federal and state mandated training requirements. Additionally, the facility would utilize the facility assessment to ensure training addressed the facility resident population.
Review of the Facility Assessment for 07/19/2023 to 07/18/2024, showed the facility identified their resident population and that nursing staff would have the required training to care for the residents.
During an interview on 06/24/2025 at 1:51 PM, Staff A, Administrator, stated that nursing staff completed their annual required training through Relias (an electronic/online training platform for healthcare).
Review of staff personal records for Staff Q, License Practical Nurse, hired 01/31/2025, showed no documentation that Staff Q had completed the required training regarding effective communications, resident's rights/facility's responsibilities, abuse/neglect and dementia management regarding abuse prevention, infection prevention/control, compliance/ethics and QAPI.
Review of the 2024/2025 Relias training records for Staff O, Registered Nurse (RN), hired 02/03/2015, showed no documentation that Staff O had completed the required annual training for QAPI.
Review of the 2024/2025 Relias training records for Staff P, RN, hired 07/28/2020, showed no documentation that Staff P had completed the required annual training for QAPI.
During an interview on 06/27/2025 at 10:50 AM, Staff A stated they were still looking for QAPI training for Staff O and Staff P. Staff A stated that Staff Q was a new staff member and they were still looking for all of the staff members required training. Staff A stated they would be setting up a better process next year with obtaining and documenting the required training on new and existing staff.
Reference: WAC 388-97-1680(2)(b)(i, ii)(c)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
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 maintain a dignified dining experience for 2 of 7 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 maintain a dignified dining experience for 2 of 7 residents (Residents 25 and 215) reviewed for dignity during dining. The facility did not provide timely meals to Residents 25 and 215 who waited for their meals after the other residents had been served. This failure placed residents at risk for decreased dignity and overall, wellbeing.
Findings included .
<Resident 25>
Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including osteoporosis (a disease that weakens bones and worsens over time), muscle weakness and history of a recent fall with left knee and hip pain. Review of the residents care plan dated 06/10/2025 showed the resident was cognitively intact, ambulated with a walker and required minimal assistance from staff for basic self care tasks.
<Dinner Meal>
During an observation on 06/21/2025 at 5:11 PM dinner trays arrived in the main dining room and facility staff passed them out to the residents seated at their tables.
During an observation on 06/21/2025 at 5:29 PM, Resident 25 sat at a table across from another resident who had been served their dinner tray and was eating. Continued observation showed Resident 25 had not received their dinner tray. The other residents in the dining room had also been served their dinner trays. Resident 25 stated, I am pretty hungry, apparently my food went out on the hall cart and didn't make it to the dining room. Resident 25 further stated This is not unusual for this place.
During an observation on 06/21/2025 at 5:47 PM, showed Resident 25's dinner tray was brought into the dining room and placed in front of them. Numerous other residents had completed their meal and had left or were leaving the dining room when Resident 25 received their dinner tray. The resident had waited 36 minutes for their dinner tray to arrive after the other residents had been served and begun eating their dinner.
During an interview on 06/21/2025 at 5:55 PM Staff H, Nursing Assistant (NA), stated Sometimes residents change their minds where they want to eat and their meal tray goes to a hall cart instead of the dining room.
<Resident 215>
Review of the residents medical record showed they had recently admitted to the facility on [DATE] with a history of a stroke (occurs when a blood vessel or vessels are blocked in the brain) and acute hemolytic anemia (a blood disorder that occurs when red blood cells are destroyed faster than the body replaces them). Review of Resident 215's care plan showed they required staff assistance for activities of daily living (ADLs) except for eating which was independent after set-up.
<Breakfast Meal>
An observation on 06/22/2025 at 7:51 AM, showed residents in the main dining room had received their breakfast trays. At 7:59 AM additional trays arrived on a cart and staff passed out breakfast trays to the residents seated at the tables.
During an observation on 06/22/2025 at 8:17 AM, Resident 215 sat across from another resident who had been served breakfast, Resident 215 did not have a breakfast tray and was watching the other resident eat. Resident 215 stated to staff Can I get some cereal or something to eat? At 8:24 AM staff brought Resident 215 their breakfast tray (33 minutes after serving out had begun). Additionally, the residents seated at Resident 215's table had completed their breakfast and left Resident 215 eating alone.
<Lunch Meal>
During an observation on 06/23/2025 at 12:04 PM, the lunch trays arrived in the dining room and staff passed them out to the residents seated at the tables.
During an observation on 06/23/2025 at 12:12 PM, Resident 25 sat at a table in the dining room. The other residents in the dining room were served their lunch except for Resident 25. The resident stated to staff Can I get some coffee or something? Staff I, Activities Director, left and returned to the dining room at 12:18 PM with Resident 25's lunch tray and stated they had found the resident's tray on a hall cart. Resident 25 did not receive their lunch tray until after all the other residents had been served and were eating.
During an interview on 06/24/2025 at 10:57 AM, Staff B, Director of Nursing Services, stated they would expect the residents in the dining room to be served meal trays all together so that other residents without food did not have to wait while the other residents enjoyed their meals.
Reference: WAC 388-97-0180(1-4)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
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 review and validate the Preadmission Screening and Resident Reviews...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews ([PASRR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) accuracy and have the required Level 2 referral sent if residents had a positive Level 1 PASRR as required for 3 of 6 residents (Resident 27, 19 and 47) reviewed for PASRR. This failure placed the residents at risk for inappropriate long term care placement and not receiving necessary mental health care and services.
Findings included .
<Resident 27>
Review of the medical record showed Resident 27 was admitted on [DATE] with diagnoses including dementia (a progressive disease that destroys memory and other important mental functions), major depressive disorder (MDD, a mood disorder of persistent feelings of sadness, loss of interest, changes in sleep affecting how a person feels, thinks and behaves) and anxiety. Review of the 05/22/2025 comprehensive assessment showed Resident 27 required substantial/maximal assistance of one to two staff for activities of daily living (ADLs) and had severely impaired cognition.
Review of Resident 27's Level I PASRR, dated 05/17/2025, showed no documentation of Resident 27's diagnoses of MDD or anxiety. Further review showed a [NAME] II referral had not been completed.
During an interview on 06/23/2025 at 1:22 PM, Staff N, Admissions Director, stated when residents were going to be admitted to the facility, they reviewed PASRR's for accuracy. Staff N stated when the PASRR's were not accurate they reached out to the hospital to ensure they were corrected before the resident was admitted to the facility. Staff N stated they did not catch Resident 27's PASSR prior to their arrival at the facility.
<Resident 19>
Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including depression and cellulitis of the lower legs (an infection of the skin and tissues beneath causing redness swelling and pain). The most recent comprehensive assessment dated [DATE] showed the resident was cognitively intact. The assessment further showed the resident exhibited moderate depression symptoms as indicated by their Patient Health Questionnaire-9 (PHQ-9 a nine item diagnostic tool used to screen for depression).
Review of Resident 19's Level 1 PASRR assessment dated [DATE] identified that the resident had a diagnosis of a mood disorder (depression) which would require a referral for a Level 2 PASRR assessment be requested for any follow up with mental health services as needed. The resident's record showed no Level 2 PASRR had been requested or received by the facility.
During an interview on 06/24/2024 at 12:16 PM, Staff J, Social Services Director, reviewed Resident 19's record and stated they were unable to find a referral for a Level 2 PASRR as required, It should have been requested by the hospital before the resident was admitted here.
<Resident 47>
Review of the resident medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a stomach wound, depression, anxiety and Post-Traumatic Stress Disorder (PTSD, a mental health condition that's caused by an extremely stressful or terrifying event). The 05/20/2025 comprehensive assessment showed the resident was cognitively intact and able to make their needs known.
Review of Resident 47's PASRR, dated 05/13/2025, showed no documentation of the residents PTSD diagnosis.
During an interview on 06/24/2025 at 10:04 AM, Staff J stated they, and another staff member reviewed resident PASRR's after admission to the facility for accuracy. Staff J stated that Resident 47's PASRR was not accurate and it should have had the diagnosis of PTSD.
Reference: WAC 388-97-1975(1)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
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 develop a baseline care plan (BCP) within 48 hours of admission to t...
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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 a baseline care plan (BCP) within 48 hours of admission to the facility for 7 of 17 residents (Resident 19, 310, 47, 165, 213, 27, and 221) reviewed for BCP. The facility failed to document resident specific goals, physician orders, dietary orders, therapy services, and social service needs to include Preadmission Screening and Resident Review (PASRR a federally mandated process that ensures residents admitted to a nursing home were properly assessed for their mental health needs and appropriate placement). Additionally, a written summary of the BCP had not been provided to the residents and or their representatives, that included the components of the BCP. This failed practice placed residents at risk for unmet care needs and potential complications in their health status.
Findings included .
Review of a policy titled Care Plans-Baseline, revised 03/2022, showed the BCP needed to provided effective, person-centered resident care that met professional standards of quality care and included the minimum healthcare information to provide care. The minimum healthcare information included, initial goals based on admission orders, physician orders, dietary orders, therapy services, social services and Pre-admission Screening and Resident Review (PASRR- a federally required form that is used to help ensure individuals were not inappropriately placed in nursing homes for long term care).The policy further showed the resident and/or representative were provided a written summary of the BCP and a summary of their medications and a provision of the summary was documented in their medical record.
<Resident 19>
Review of the resident's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including cellulitis (a bacterial skin infection that causes redness, swelling and pain) in their lower legs, diabetes (a chronic disease which results in too much sugar in the blood) and depression. Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact and required substantial assistance for daily care activities involving their lower extremities.
Review of the care plan dated 05/08/2025 showed no required components for a BCP had been developed or documented on the resident's care plan within 48 hours of admission to the facility.
During an interview on 06/22/2025 at 10:22 AM, Resident 19 stated they had not received a care plan in writing or had their medications reviewed with them when after admitting to the facility and that might have come in handy because I had questions about my medications when I first got here.
<Resident 310>
Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including cellulitis of the face and chest wall and bipolar disorder (a disorder associated with mood swings from depression to manic episodes). Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact and required moderate assistance for dressing, grooming and personal hygiene.
Review of the care plan dated 06/12/2025 showed no required components for a BCP had been developed within 48 hours of admission to the facility.
<Resident 47>
Review of the resident medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a stomach wound, asthma (a disease where irritants that are breathed into the lungs can cause the body's airway to constrict and restrict airflow into the lungs), Post-Traumatic Stress Disorder (PTSD, a mental health condition that's caused by an extremely stressful or terrifying event) and heart complications. The 05/20/2025 comprehensive assessment showed the resident was cognitively intact, able to make their needs known and had an indwelling urinary catheter (IUC, a tube placed in the bladder which drains urine out into a collection bag).
Record review of Resident 47's BCP, dated 05/19/2025, showed no resident specific goals or interventions for physician orders, dietary orders, social services or care and treatment of their IUC or PTSD.
<Resident 165>
Review of the resident medical record showed the resident was admitted to the facility on [DATE] with diagnoses including left leg fracture/hip surgery, long term respiratory failure, cerebral palsy (a disorder developed in early childhood that affects the bodies movement, muscle coordination, that can lead to stiff/weak muscles and involuntary/uncontrollable movements of body parts), asthma and obstructive sleep apnea (a condition where the walls of the throat relax and narrow during sleep, interrupting normal breathing). The 06/07/2025 comprehensive assessment showed the resident had moderately impaired cognition but was able to understand others and make their needs known. Resident 165 required substantial to maximal assistance from nursing staff for their personal hygiene, mouth hygiene and upper body dressing. Additionally, Resident 165 required special treatment/procedures for their tracheostomy tube (a mechanical device inserted into a surgically created opening made in the neck, known as a tracheostomy, which assists with breathing).
Record review of Resident 165's BCP, dated 06/06/2025, showed no resident specific goals or interventions for physician orders, dietary orders, social services or care and treatment of their tracheostomy tube.
<Resident 213>
Review of the medical record showed Resident 213 was admitted on [DATE] with diagnoses including cellulitis, pressure ulcers (damage to an area of the skin caused by constant pressure on an area that causes tissue damage), end-stage renal disease ( a condition in which the kidneys lose the ability to remove waste and balance fluids in the body) and dependence on renal (kidney) dialysis (a procedure to remove waste products and excess fluid from the blood). Review of a nursing skilled note dated 06/21/2025 showed Resident 213 required maximum assistance of one to two staff for activities of daily living (ADLs) and was able to make their needs known.
Review of Resident 213's BCP dated 06/22/2025 showed no resident specific goals or interventions for physician orders, dietary orders, social services or care and treatment of their medical conditions.
<Resident 27>
Review of the medical record showed Resident 27 was admitted on [DATE] with diagnoses including metabolic encephalopathy (a condition caused by a chemical imbalance in the blood that affects thinking, memory, mood and alertness), aftercare for joint replacement surgery, and dementia (a progressive disease that destroys memory and other important mental functions). Review of the 05/22/2025 comprehensive assessment showed Resident 27 required substantial/maximal assistance of one to two staff for ADLs and had severely impaired cognition.
Review of Resident 27's BCP dated 05/17/2025 showed no resident specific goals or interventions for physician orders, dietary orders, social services or care and treatment of their medical conditions.
<Resident 221>
Review of the medical record showed Resident 221 was admitted on [DATE] with diagnoses including aftercare of healing of broken hip socket, stroke (a medical emergency that occurs when blood flow the brain is disrupted and deprives the brain of oxygen, leading to brain damage, disability or death) with left sided weakness, and respiratory failure. Review of the 06/06/2025 admission assessment showed Resident 221 required substantial/dependent of one to two staff ADLs and had moderately impaired cognition.
Review of Resident 221's BCP dated 06/02/2025 showed no resident specific goals or interventions for physician orders, dietary orders, social services or care and treatment of their medical conditions.
During an interview on 06/23/2025 at 11:26 AM, Staff K, Resident Care Manager (RCM), stated they completed an assessment of the resident when they were admitted , to develop a care plan that met the basic needs of the resident. Staff K stated the first care plan developed does not include initial goals, physician orders, therapy goals or social services information and further stated I put what they need to have for their basic care needs.
During an interview on 06/23/2025 at 11:56 AM, Staff L, RCM stated they included on the initial care plan basic activities of daily care needs which did not include the other required components of a BCP. Staff L stated they would only include medications if the resident asked, I was not aware of this requirement for a BCP to be developed within 48 hours.
During an interview on 06/24/2025 at 10:47 AM, Staff M, Assistant Regional Director for Clinical Services, stated they had reviewed Resident's 19, 310, 47, 165, 213, 27, and 221 records and acknowledged that no BCP's had been developed for residents within 48 hours of admission to the facility.
Reference: WAC 388-97-1020(3)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and/or implement comprehensive resident centere...
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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 develop and/or implement comprehensive resident centered care plans for 3 of 6 residents (Residents 21, 27 and 47) reviewed for care planning. This failure placed residents at risk for unmet care needs.
Findings included .
Review of a policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022 showed the facility would develop and implement a comprehensive, person-centered care plan that had measurable objectives to meet the resident's physical, psychosocial and functional needs created from the resident's comprehensive assessment.
<Resident 21>
Review of Resident 21's medical record showed they were re-admitted on [DATE] with diagnoses including dementia with behavioral disturbance (a progressive disease that destroys memory and other important mental functions, with agitation, physical aggression, wandering, and hoarding), diabetes (a disease that results in too much sugar in the blood), depression and anxiety. The 03/20/2025 comprehensive assessment showed Resident 21 required substantial/dependent assistance of one to two staff members for activities of daily living (ADLs) and had moderate impaired cognition.
Review of Resident 21's social history assessment dated [DATE], showed they chewed tobacco.
Review of Resident 21's care plan showed no resident focus areas, goals or interventions for tobacco use.
During an observation and interview on 06/21/2025 at 3:32 PM, Resident 21 was lying in their bed with their bedside table next to them. The bedside table contained two opened cans of chewing tobacco. Resident 21 stated they had been chewing tobacco for years and they swallowed the tobacco.
During an interview on 06/24/2025 at 11:46 AM, Staff A, Administrator, stated residents who used tobacco would need to be reviewed and the facility would need to determine how to meet their needs. Staff A stated their tobacco usage would need to be identified on their care plans. Staff A stated they were unaware if this had been completed for Resident 21.
<Resident 27>
Review of the medical record showed Resident 27 was admitted on [DATE] with diagnoses including metabolic encephalopathy (a condition caused by a chemical imbalance in the blood that affects thinking, memory, mood and alertness), aftercare for joint replacement surgery, and dementia (a progressive disease that destroys memory and other important mental functions). Review of the 05/22/2025 comprehensive assessment showed Resident 27 required substantial/maximal assistance of one to two staff for ADLs and had severely impaired cognition.
Review of Resident 27's care plan showed no identified areas related to their diagnoses, medications, nutrition, pain, fall risk, or mood and behavior.
<Resident 47>
Review of the resident medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a stomach wound, asthma (a disease where irritants that are breathed into the lungs can cause the body's airway to constrict and restrict airflow into the lungs), Post-Traumatic Stress Disorder (PTSD, a mental health condition that can be caused by experiencing or witnessing life-threatening, extremely stressful or terrifying events) and heart complications. The 05/20/2025 comprehensive assessment showed the resident was cognitively intact, able to make their needs known.
Review of Resident 47's social history assessment dated [DATE] showed the resident had been evaluated for significant life events (a tool used to provide insight into a resident's prior trauma history) and five of the 17 questions were marked positive for having occurred with the resident.
Record review of Resident 47's care plan, updated 06/12/2025 showed no care plan development had been completed regarding the resident's diagnosis of PTSD or the evaluation regarding the resident traumatic history.
During an interview on 06/24/2025 at 12:35 PM, Staff B, Director of Nursing, stated they expected resident care plans to be comprehensive and person-centered. Staff B stated their comprehensive assessment should initiate the care area assessments (CAA-triggered responses related to the resident's problems, needs or strengths) to include nutrition, skin, falls, toileting, pain and diagnoses. The care plan needed to be individualized and encompass the resident's moods, behaviors, medications and any other identified concerns.
Reference: WAC 388-97-1020(1)(2)(a)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0847
(Tag F0847)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to explain the arbitration agreement (a legal document that required the use of a third party to resolve a dispute) in its entirety, including...
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Based on interview and record review, the facility failed to explain the arbitration agreement (a legal document that required the use of a third party to resolve a dispute) in its entirety, including the right to cancel the agreement within 30 calendar days, in a manner and language that the resident understood for 3 of 4 residents (Resident 30, 40, and 52) reviewed for binding arbitration. This failure placed the residents at risk for losing legal protection, lack of understanding of the legal document, and the right to a jury or court hearing.
Findings included .
Review of an undated document titled, Alternative Dispute Resolution Agreement Between Resident and Facility (ADR), showed that signing an arbitration agreement was not a condition of admission and the decision to sign the agreement was entirely voluntary. The agreement could be cancelled by the resident by delivering written notice of the cancellation to the facility no later than 30 days after the resident or their representative signed the agreement. The agreement showed the resident and/or their representative had received a copy of the agreement, had read or had been read by their representative, either or both of whom understands the agreement and had the opportunity to ask any questions related to the agreement.
<Resident 30>
Review of the medical record showed Resident 30 was admitted to the facility with diagnoses including cerebral infarction (a condition where a part of the brain tissue dies due to a lack of blood supply), respiratory failure, and anxiety. The 04/06/2025 comprehensive assessment showed Resident 30 required partial to moderate assistance of one staff member for activities of daily living (ADLs). The assessment also showed Resident 30 had an intact cognition.
Review of Resident 30's medical record showed they signed an ADR on 10/03/2024.
During a Resident Council (a group of residents that meet regularly to improve the quality of life and care in the nursing home) meeting on 06/22/2025 at 4:02 PM, Resident 30 stated they put a bunch of stuff in front of you, and you had to sign it to be admitted .
<Resident 40>
Review of the medical record showed Resident 40 was admitted to the facility with diagnoses including after care for a surgical amputation (the removal of all or part of a limb or extremity), infection at the amputation site, and respiratory failure. The 06/02/2025 comprehensive assessment showed Resident 40 required partial assistance of one staff member for ADLs. The assessment also showed Resident 40 had an intact cognition.
Review of Resident 40's medical record showed they signed an ADR on 04/08/2025.
During an interview on 06/23/2025 at 1:12 PM, Resident 40 stated the facility did not explain the ADR in detail. They stated they were not told they could cancel the ADR in 30 days. Resident 40 stated they felt they needed to sign the agreement to be admitted to the facility. They stated they were not told it was optional, but it was presented as we need you to sign it.
<Resident 52>
Review of the medical record showed Resident 52 was admitted to the facility with diagnoses including aftercare of injuries sustained in a motor vehicle collision, diabetes (a group of diseases that result in too much sugar in the blood), and muscle weakness. The 05/31/2025 comprehensive assessment showed Resident 52 required partial to dependent assistance of one to two staff members for ADLs. The assessment also showed Resident 52 was cognitively intact.
Review of Resident 52's medical record showed they signed an ADR on 05/28/2025.
During an interview on 06/23/2025 at 1:28 PM, Resident 52 stated the facility did not explain the ADR. They stated they did not know they signed the ADR and were not aware they had 30 days to cancel it.
During an interview on 06/23/2025 at 11:53 AM, Staff N, Admissions Director, stated the ADRs were part of the admissions packet. They stated they reviewed all the forms in the admissions packet with the resident or their representative, including the options of not signing the ADR and the ability to cancel the agreement within 30 days of signing. Staff N stated they had trained Staff G, Transportation Specialist/Nursing Assistant, on the process for reviewing ADRs.
During an interview on 06/23/2025 at 1:47 PM, Staff G stated they completed admission paperwork and ADRs with new admissions. They stated they explained the ADR was a way to use an arbitrator rather than suing the facility. Staff G stated they informed the new admissions that they had 30 days to cancel their admission paperwork, not specifically the ADR.
During an interview on 06/23/2025 at 2:08 PM, Staff A, Administrator, stated the process of completing the ADR included explaining to the resident that it was a binding agreement that was an amicable (friendly or peaceful) way to solve disagreements with the facility that was a quicker process (than using a jury) avoiding costs and time. They stated the ADR was not a condition of admission to the facility. Staff A stated Staff N trained Staff G on completion of the admission paperwork, including the ADR, and was unsure why the residents felt the ADR was not explained to them.
Reference: WAC 388-97-1620(2)(b)(i)
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to report an incident of neglect regarding a fall to the State agency...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to report an incident of neglect regarding a fall to the State agency as required, involving 1 of 3 residents (Resident 1), reviewed for falls. This failed practice placed residents at risk for harm and diminished protection and oversight from the State agency.
Findings included .
Review of the facility policy titled, Abuse - Screening, Training, Identification, Investigation, Reporting, and Protection, revised on 01/2023, showed if the allegation involves neglect, that does not involve abuse or serious injury, the incident is reported within 24 hours to the state survey agency, as required.
<Resident 1>
Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors). Review of a comprehensive assessment, dated 12/07/2024, showed Resident 1 had severe cognitive loss. Review of Resident 1's plan of care, dated 12/17/2024, showed Resident 1 required two staff to assist with transfers and toileting.
Review of a facility investigation report, dated 12/26/2024 at 4:02 PM, showed Resident 1 had a witnessed assisted fall to the floor when being transferred from their bed to the wheelchair by Staff A, Nursing Assistant. Despite the resident's plan of care showing they required two staff for transfers, Staff A transferred the resident alone and was not strong enough to hold the resident. Resident 1 did not sustain any injuries from the fall.
On 01/15/2025 at 3:08 PM, Staff D, Administrator, stated the incident involving Resident 1 was not reported to the state agency as they did not see it as an incident of neglect.
Refer to F689 for additional information.
Reference (WAC) 388-97-0640(6)(c)
This is a repeat deficiency from the Statement of Deficiencies dated 08/12/2024.
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 interviews and record review, the facility failed to supervise to ensure staff provided care according to the resident'...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to supervise to ensure staff provided care according to the resident's plan of care and facility policy to prevent falls for 1 of 3 residents (Resident 1), reviewed for falls. This failed practice resulted in potential injuries to Resident 1 when they fell to the floor. Failure to follow residents' plans of care placed residents at risk for injury, falls, and a diminished quality of life.
Findings included .
Review of the facility policy titled, Gait Belt Policy and Procedure, not dated, showed it was the policy of the facility to use a gait belt with any resident that was not independent. If the resident was unsteady with their gait or unable to transfer independently, a gait belt should be used.
<Resident 1>
Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors). Review of a comprehensive assessment, dated 12/07/2024, showed Resident 1 had severe cognitive loss. Review of Resident 1's plan of care, dated 12/17/2024, showed Resident 1 required 2 staff to assist with transfers and toileting.
Review of a fall assessment, dated 12/04/2024, showed Resident 1 was at high risk for falls.
Review of Progress Notes, dated 12/26/2024 at 8:37 PM, showed Resident 1 was being transferred from bed to wheelchair by one staff. The resident's knees buckled and the Nursing Assistant (NA) guided the resident to the floor on their knees. The resident did not sustain any injuries. The resident was unable to assist with the transfer at all due to their inability to bear any weight.
Review of the facility investigation report, dated 12/26/2024 at 4:02 PM, showed at approximately 4:00 PM Resident 1 was being assisted from their bed to the wheelchair by Staff A, NA. The resident was unable to assist with any part of the transfer.
Review of a post-fall assessment for Resident 1's fall on 12/26/2024, dated 12/30/2024, showed the resident was unable to independently come to a standing position, exhibited a loss of balance with standing, required hands-on assistance to move from place to place, and they had a decrease in muscle coordination. Staff A was transferring the resident alone and they were not strong enough to hold the resident when the resident did not assist with the transfer.
On 01/15/2025 at 9:25 AM, Staff B, Physical Therapist, stated Resident 1 had poor body control with weakness and fatigue. The resident's head and shoulder would lean to the left side and they required significant assistance to stand. The resident needed two staff to assist with mobility.
On 01/15/2025 at 2:32 PM, Staff A, stated they had transferred Resident 1 by themselves at the time of the fall on 12/26/2024. Staff A stated they had received report from the day shift NA who stated the resident required one staff for transfers with a gait belt. Staff A stated the resident's spouse was in the room at the time of the fall and had stated prior to the fall that often the resident was tired after meals. Staff A stated they transferred the resident and they buckled and fell on the floor on their knees. The resident's spouse informed Staff A the resident required two staff to assist with transfers and the care directives showing that were on the inside of the resident's closet door. Staff A stated it did not appear they used a gait belt during the transfer of Resident 1.
On 01/15/2025 at 11:38 AM, Staff C, NA, stated the resident's spouse was in the resident's room at the time of the fall on 12/26/2024. Staff A was not using a gait belt at the time of the fall, as Staff C had to ask for one to transfer Resident 1 back into bed following the fall.
On 01/09/2025 at 11:50 AM, Resident 1's spouse, stated a NA came into the resident's room on 12/26/2024 and was going to transfer the resident by themselves. The spouse informed Staff A the resident required two staff per their plan of care and the instructions on the inside of their closet door. Staff A grabbed the back of the resident's sweat pants and proceeded to stand the resident up, which resulted in them falling to the floor. The spouse stated Staff A did not utilize a gait belt during the transfer. The resident was six feet tall and weighed 230 pounds (review of the resident's medical record showed the resident's weight on 12/22/2024 was 220.5 pounds).
Reference (WAC) 388-97-1060(3)(g)
This is a repeat deficiency from the Statement of Deficiencies dated 08/12/2024.
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 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 develop and implement an effective discharge planning process that ...
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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 an effective discharge planning process that addressed the resident's goals and needs, that involved the resident and the interdisciplinary team [(IDT) a group of healthcare professionals from different disciplines to help residents receive the care they need] for 2 of 4 residents (Resident 1 and 2) reviewed for discharge planning process. The failure to develop and implement a discharge plan consistent with the resident's needs and expressed discharge goals, placed the resident at risk for decreased self-worth and dissatisfaction with their living situation.
Findings included .
<Resident 1>
Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including respiratory failure with hypoxia (a condition in which the body doesn't have enough oxygen in the tissues), heart disease, and kidney disease. The 10/28/2024 comprehensive assessment showed Resident 1 required substantial/maximum assistance of one staff member for activities of daily living (ADLs) and had a severely impaired cognition. The assessment also showed Resident 1's overall goal for discharge was to return to the community. Resident 1 discharged to home from the facility against medical advice on 11/20/2024.
Review of Resident 1's comprehensive care plan dated 11/21/2024, showed no documentation that a comprehensive, person-centered discharge plan had been initiated for the resident. The care plan did not include information that identified the resident's discharge goals, needs, barriers to discharge, or the potential discharge location.
During an interview on 12/23/2024 at 3:44 PM, Resident 1's Representative (RR) stated they had caregivers in place at home to care for Resident 1. The RR stated, all they (Resident1) wanted was to be at home.
<Resident 2>
Review of the medical record showed Resident 2 was admitted to the facility on [DATE] with diagnoses including heart failure, pneumonia (an infection of the lungs that causes inflammation of the air sacs), and kidney failure. The 12/11/2024 comprehensive assessment showed Resident 2 required supervision/partial assistance of one staff member for ADLs. The assessment also showed Resident 2 had an intact cognition and wanted to discharge to the community. Resident 2 discharged from the facility to the hospital on [DATE].
Record review of Resident 2's care plan dated 12/05/2024, showed no documentation that a comprehensive, person-centered discharge plan had been initiated for the resident. The care plan did not include information that identified the resident's discharge goals, needs, barriers to discharge, or the potential discharge location.
During an interview on 12/30/2024 at 1:21 PM, Staff B, Social Services Director, stated the process for discharge planning started during their initial meet and greet meeting when the resident first arrived at the facility. They stated they set up an initial care conference, completed a social services assessment, and determined the resident's/representative's goals for discharge. Staff B stated after gathering the information, they added the discharge plan to the resident's care plan. Staff B stated they had a conversation with Resident 1's Representative on the same day Resident 1 had admitted to the facility. They stated the RR wanted to take Resident 1 home right away and had told Staff B that they did not think the facility was the right place for Resident 1. Staff B stated Resident 1 had caregivers at home through Veterans Administration (VA) services, along with a provider that made house calls, and therapy services from the VA. Staff B stated the RR would stop by their office almost daily, stating they wanted to take Resident 1 home. Staff B stated Resident 2 wanted to discharge to home and had services in place. Staff B stated it was their responsibility to ensure residents had a discharge plan entered on their care plan.
During an interview on 12/31/2024 at 3:38 PM, Staff A, Administrator, stated discharge goals were identified at the initial care conference. They stated a discharge plan should have been included on the resident's comprehensive care plan.
Reference: WAC 388-97-0080(3)(a)(5)(7)(a-c)
Aug 2024
17 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
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 the prevention, development, and worsening of ...
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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 prevention, development, and worsening of a facility-acquired pressure injury (PI) for 1 of 4 residents (Resident 23) reviewed for PIs. The facility did not consistently provide ordered wound treatments, perform/document skin assessments, or obtain/implement Durable Medical Equipment (DME, medically necessary equipment used by people with a medical condition, disability, or injury) as ordered. Resident 23 experienced harm when they developed an avoidable PI that was not present upon admission. This failure placed Resident 23 at risk for further wound complication and unmet care needs.
Findings included .
Review of the National PI Advisory Panel's (NPIAP, the leading expert in PIs/wounds) guidelines and definitions, dated September 2016, defined PI stages as follows:
•
Stage 1 PI has intact skin with a localized area of non-blanchable erythema (redness).
•
Stage 2 PI is a partial thickness skin loss with exposed dermis (the top inner layers of skin).
•
Stage 3 PI is a full thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer. Slough (dead tissue) and or eschar (dried blood and tissue) may be visible, granulation tissue and epibole (rolled or curled under edges) may include with undermining (a pocket of dead space under the visible wound edges) and tunneling (a passageway under the wounds surface which may be shallow or deep and impairs wound closure).
•
Stage 4 PI is a full thickness loss of skin and tissue with exposed or directly palpable fascia (a layer of connective tissue), muscle, tendon, ligament, cartilage, or bone in the ulcer. Epibole undermining and tunneling often occur.
•
Unstageable PI is a full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen.
<Resident 23>
Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include an in-operable left fibula (lower, outer leg bone) fracture, diabetes (a condition that happens when the sugar [glucose] in your blood is too high), and end stage kidney disease. The 05/26/2024 comprehensive assessment, showed the resident's cognition was severely impaired and required the assistance of one to two staff for all activities of daily living. The assessment further showed the resident admitted without pressure injuries.
During an observation on 08/05/2024 at 2:05 PM, Resident 23 was lying in their bed, had a Podus boot (PB, an off-loading device that floats [suspending in the air] the heel, eliminating pressure or friction, and enhances blood circulation for healing) over a soft, white splint (a device that supports and protects a broken bone or injured tissue) to their left lower extremity (LLE). The splint was placed underneath the back part of the leg and extended from their toes to their upper thigh, and their leg was internally rotated (the leg was turned towards the center of the body), with the inner part of the LLE lying flat on the bed. The boot had an attached phalange (an arm that keeps the leg from rotating and acts like a kickstand) that was to be used to maintain proper positioning of the LLE, but the phalange had not been used to maintain the LLE in an upward/correct position (toes to the ceiling).
During an observation on 08/07/2024 at 9:18 AM, Resident 23 was lying in bed, they had a gauze wound dressing to their LLE below the knee, with 08/04/2024 handwritten in black marker, that was saturated with areas of red and brown drainage. Staff J, Nursing Assistant (NA) and Staff K, NA, repositioned Resident 23 while providing care, the LLE lied flat and internally rotated on the bed and did not move or turn when moving the resident from side to side. Neither Staff J or K positioned the phalange on the PB, nor did they provide any positioning of the LLE so that Resident 23's leg was in the correct position. Additionally, the top of the white soft splint had brownish stains, which Staff J and Staff K identified as dried bowel movement.
A concurrent observation and interview on 08/07/2024 at 11:52 AM, Staff I, Registered Nurse (RN), and Staff D, Licensed Practical Nurse/Resident Care Manager, provided wound care to Resident 23. Staff I removed the PB from the LLE, then the soft white splint, followed by a dressing to the top of the left foot and another to the heel. Under the dressing to the top of the foot was a dime-sized wound, reddened, top layer of skin missing, and on the heel was an opened wound the size of a golf ball that had blackened areas, white areas, and areas of red flesh, the wound dressing was moist with brown and red wound drainage. The wound was identified by Staff D as pressure injuries obtained from the soft white splint. Neither Staff I nor Staff D positioned the phalange on the PB to the appropriate position when the wound care was completed. At the top of the LLE, towards the outer part of the knee area showed 08/07/2024 handwritten in black marker and Staff I stated they had replaced that prior to this wound care because it was saturated with wound drainage.
An observation on 08/08/2024 at 2:41 PM, showed Resident 23 was sitting in their wheelchair (w/c) with their LLE resting, internally rotated, on the elevated footrest of the w/c. The PB phalange was not positioned to keep the LLE positioned correctly and there were no positioning devices in place to assist with maintaining the LLE in the correct position.
Review of the Orthopedic Surgeon's (specialist who focuses on injuries and diseases affecting the musculoskeletal system) orders on 05/31/2024 showed orders for decubitus [wounds that occur from prolonged pressure on your skin] precautions and a PB with a side phalange to prevent rotation of the LLE. Further review, showed an order on 06/26/2024 for a Hip-Knee-Ankle-Foot Orthosis (HKAFO, used for rotation control of the lower extremity) that was to be supplied by a named DME clinic (No follow-up, notes, or orthosis had been obtained regarding the order).
Review of Resident 23's 05/23/2024 care plan (CP) showed no directive for positioning of the LLE, no directives for the PB with the phalange, and no updates for current skin integrity status since 06/03/2024. The care plan showed decubitus precautions with no further directives.
Review of Resident 23's June 2024 Treatment Administration Record (TAR), showed a treatment order on 06/18/2024 to an unstageable PI on the left outer knee that was discontinued on 06/19/2024, an order on 06/19/2024 to an unstageable PI on the left heel to be completed twice daily and as needed (PRN)( eight of 23 treatment opportunities were not completed) and on 06/20/2024 an order for a blister on the left outer knee to be completed daily and PRN (six of 11 treatment opportunities were not completed). Review of the July 2024 TAR showed the left heel had 10 out of 36 treatment opportunities not completed, and for the left outer knee, 12 out of 30 treatment opportunities were not completed.
During an interview on 08/08/2024 at 2:53 PM, Staff D stated they had attempted to refer Resident 23 to an outside wound provider, but Resident 23 was denied services by the provider due to their current medical coverage. Staff D stated they were informed it would be double dipping [obtaining money from two mutual sources at the same time] because the facility already contracted with another wound provider. Staff D stated the resident could not receive services from the facilities contracted wound care provider because they received dialysis treatments (a treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) at an outside dialysis facility on Tuesdays, Thursdays, and Saturdays for approximately eight hours and would leave the facility at 7:00 AM. Staff D stated the contracted wound care provider could only see residents in the facility on Tuesdays and was unable to see Resident 23 due to their conflicting schedules. Staff D stated neither the contracted wound care provider nor the dialysis facility was willing to adjust their schedules to meet the needs of the resident. Staff D stated the Resident's Representative (RR) allowed Resident 23 to miss a dialysis treatment on 07/30/2024 to accommodate the contracted wound care provider's schedule, so the resident could be seen.
An observation on 08/09/2024 at 12:45 PM, showed Resident 23 lying in bed, their LLE placed on the top of a pillow, the PB was on but the Velcro that held the boot closed was not attached, causing the white soft portion of the splint to slide off the hardened portion of the splint, leaving the LLE with no support. The LLE was internally rotated, resting on the bed.
During an interview on 08/09/2024 at 12:48 PM, Staff J stated they were normally assigned to Resident 23 and when provided care to the resident, required two staff because their LLE always had to be kept straight. Staff J stated they were told to float Resident 23's legs on a pillow and were not provided training on the PB phalange placement. Staff J stated they were allowed to remove the boot for cares but not the soft splint .
Review of the May 2024 through July 2024 Licensed Nurse (LN) Tasks document showed an order on 05/29/2024 for weekly skin checks to be completed every Wednesday on evening shift. On 05/23/2024 an order to monitor the circulation, motion, sensation (CMS) and skin breakdown to the LLE soft cast every shift and document assessment daily. The LNs were to document a plus (+) and minus (-) signs as additional documentation, but the record showed no documentation from 05/23/2024 to 06/17/2024.
During an interview on 08/09/2024 at 1:22 PM, Staff L, RN, stated the splint was originally placed on the outer portion of the left foot/leg to support the fracture of the outer bone and when Resident 23 developed pressure injuries from the splint, the splint was moved to the underside of the left foot/leg. Staff L stated they checked the skin under the brace every shift and documented their findings in their daily progress notes.
During an observation on 08/12/2024 at 11:00 AM, Resident 23 was lying in bed, PB phalange was not positioned, and no positioning devices were used to keep the LLE in the correct position. The LLE was internally rotated.
During an interview on 08/12/2024 at 11:10 AM, Staff K stated they had not been provided specific training on the positioning of the LLE or the placement of the PB phalange. Staff K stated they positioned Resident 23 so that their LLE was floated on a pillow.
Review of Nursing Progress notes on 06/07/2024 at 1:31 PM, showed the first documentation on the status of the left lower extremity CMS intact to left lower extremity (LLE) but nothing about the skin underneath the brace (15 days after admission). Notes on 06/10/2024 at 2:17 PM, 06/11/2024 at 6:00 PM, on 06/17/2024 at 12:55 PM, and on 06/18/2024 at 5:27 PM, showed the CMS was intact to the LLE and no documentation about removing the brace or the status of the skin. A note on 06/19/2024 at 9:51 AM, showed the care staff reported skin concerns to the resident's LLE. Two nurses then went in to assess Resident 23's skin.
Review of the 06/19/2024 Skin Evaluation assessment, showed the left knee (outer) had a four centimeter (cm, a unit of measure) by 2.2 cm circular intact blister. The left heel showed a 3.9 cm by 3.2 cm circular unstageable PI, the left shin had a 0.2 cm by 0.2 cm circular abrasion, and the left inner thigh had a five cm by 0.3 cm irregular shaped abrasion with a pink wound bed. The 07/17/2024 skin assessment showed the left outer knee blister had deteriorated and changed to an unstageable PI which measured at 3.9 cm by 4.7 cm by 0.1 cm depth with an irregular shape, dead tissue, and moderate red clear drainage. The left heel measured at 4.2 cm by 6.3 cm by 0.1 cm depth with dead tissue.
Review of the contracted wound provider notes on 07/30/2024 (41 days after wounds developed), showed Resident 23 had splint on lower extremity and when splint was removed/loosened in order to change, areas of breakdown were noted. Resident 23's wounds were assessed as; 1) left heel, stage 3 PI, measured 3.3 cm by 5.4 cm by 0.2 cm depth with dead tissue, 2) left outer knee, stage 3, measured 3.0 cm by 1.3 cm by 0.7 cm depth, with yellow fibrin (dead tissue within a wound), and undermining at 11 o'clock of 0.8 cm with moderate drainage. The note showed the left heel and outer knee PIs needed to be surgically debrided (a procedure to remove debris or infected/dead tissue from a wound for the wounds to heal). Measurements after debridement showed the left heel was 3.4 cm by 5.5 cm by 0.3 cm depth and the left outer knee was 3.1 cm by 1.4 cm by 0.8 cm depth and both PIs were full thickness PIs.
During an interview on 08/12/2024 at 11:30 AM, Staff B, Interim Director of Nursing Services, stated the NA's had not been trained on the PB with the phalange, or the proper positioning of the residents LLE to keep the leg from internally rotating and did not find any directives on the [NAME] (nursing directives for a resident's plan of care). Staff B further stated the nurses were to document their skin checks underneath braces if the Orthopedic Surgeon did not have orders to not remove the brace. Staff B further stated Resident 23 had a referral to an outside wound provider but in Resident 23's case, they were unable to see them.
During an interview on 08/13/2024 at 7:58 AM, Collateral Contact (CC) stated they received a wound referral for Resident 23 on 07/10/2024 and had to send it back to the prescribing provider to update with additional information that was needed. The CC stated they did not deny Resident 23 wound care services and when they received the updated information they needed from the provider, they reached out to the RR of the resident to schedule an appointment on 07/29/2024. The CC stated the time lapse of 19 days between receiving the referral, returning it to the prescriber, and receiving it back would have depended on how quick the provider sent them the updated referral information they requested. The time lapse was not on the part of the CC.
During an interview on 08/15/2024 at 1:33 PM, Staff D stated Resident 23 was seen by their Orthopedic Surgeon after they obtained the PIs, and the surgeon did not order any additional treatment interventions for treating the PIs. Staff D stated the RR wanted them to obtain a second opinion after the 06/26/2024 visit because they did not agree with the surgeon not having a better treatment plan. Staff D stated Resident 23's RRs had attended that appointment with the resident but did not provide notes pertaining to the outcome of the visit and the facility did not call the surgeon's office to request the appointment notes so were not aware the Orthopedic Surgeon had ordered the HKAFO orthosis (Staff D was informed of the orthosis during a telehealth meeting with the family on 08/13/2024). Staff D stated following that meeting, they had given the order for the orthosis to Staff A and Staff B for their review since the orthosis was costly.
Reference: WAC 388-97-1060 (3)(b)
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
Based on observation, interview, and record review, the facility failed to ensure protection of residents from their Alleged Perpetrator (AP), after allegations of abuse/neglect were reported to the f...
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Based on observation, interview, and record review, the facility failed to ensure protection of residents from their Alleged Perpetrator (AP), after allegations of abuse/neglect were reported to the facility for 1 of 6 residents (Resident 51) reviewed for abuse/neglect. This failure placed all residents at an increased risk for unidentified abuse and/or further abuse, and unmet psychosocial care needs.
Findings included .
<Resident 51>
Review of the resident's medical record showed the resident admitted to the facility with diagnoses of a coccyx (the bone at the end of the spinal column) fracture and heart failure. The 06/26/2024 comprehensive assessment showed the resident was cognitively intact and experienced frequent pain.
During an interview on 08/05/2024 at 10:59 AM, Resident 51 made an allegation against a male staff member that worked at night. Resident 51 described the staff member as light skin colored, slightly balding head, taller than average, with a mustache/beard. Later identified as Staff F, Licensed Practical Nurse. Resident 51 stated they were afraid when Staff F worked, they would not get adequate pain management because they felt like Staff F was singling them out and judging them as if they were a junkie [a slang term for a drug addict or a fan of something] for asking for pain medication. Resident 51stated they felt they needed to lie about their pain level to get their pain medication from Staff F which made it look as if their pain was always bad. Resident 51 stated Staff F made them stick their tongue out after they received their pain medication to ensure Resident 51 swallowed the pills and then would return five to ten minutes later to ask if the pain medication was effective. Staff 51 further stated they no longer wanted Staff F providing them care.
During an interview on 08/06/2024 at 4:00 PM, Staff A, Administrator, was reported Resident 51's allegation and the identified staff member. Staff A stated they would immediately start an investigation. Additionally, at 5:30 PM, Staff A stated that Staff F had been moved to another hall.
Review of an undated document provided by Staff A, on 08/09/2024 at 11:36 AM, showed a partially completed investigation summary into Resident 51's allegation. The document showed a post incident action that Staff F would be removed from Resident 51's care.
An observation and concurrent interview on 08/09/2024 at 2:40 PM, Staff F was observed sitting on the edge of Resident 51's bed, leaning in towards the resident to talk to the resident about their pain medications and how Resident 51 must have misunderstood Staff F's assessment of their pain medications. Staff F told Resident 51 that they needed to tell them their real pain level and then would be back to reassess their pain, because that's what they are supposed to do as a nurse. Staff S, LPN, was also present in the room with Staff F but not sitting on the bed. Both Staff F and Staff S exited the room. Then, Staff F was asked about the discussion with Resident 51, Staff F while shaking? their head to the left and right, stated Resident 51 thought Staff F had been trivializing (minimizing) their pain .and was singling [Resident 51] out. Staff F stated they sat on the resident's bed to get down on their level and tell [Resident 51] face to face. When Staff F was asked about the investigation into the allegation made against them by Resident 51, Staff F stated they could not remember what was told to them by Staff A, other than Resident 51 thought Staff F singled them out. Staff F stated in a surprised voice oh s**t, I forgot all about [Staff A] telling me that I was supposed to change rooms with somebody so there weren't any further concerns and I forgot to do that.
A concurrent observation and interview on 08/09/2024 at 2:44 PM, showed Resident 51 lying in their bed, and stated [Staff F] freaked me out and sat on the edge of my bed. Resident 51 in an angry voice stated, you assured me [Staff F] wasn't coming back in here, and here [Staff F] was! Resident 51 stated Staff F began to apologize to the resident and explain to them what their job was as a nurse and that Resident 51 needed to make sure they told them the honest truth about their pain level when they brought in their pain medications. During a follow-up interview on 08/12/2024 at 11:04 AM, Resident 51 stated they felt afraid when Staff F came into their room because they did not know what to expect when they sat on their bed. Resident 51 did not understand why Staff F could not have just stood and talked to them.
During an interview on 08/09/2024 at 3:18 PM, Staff B, Interim Director of Nursing Services, stated Staff A did not communicate to them that Staff F was no longer allowed to provide care to Resident 51. Staff B stated they had checked with the scheduling coordinator, and they were not aware either. Staff B stated they had removed Staff F from Resident 51's care and going forward would no longer be providing care to Resident 51.
During an interview on 08/09/2024 at 4:38 PM, Staff A stated they educated Staff F on the allegation outcome earlier in the week and informed Staff F they were no longer allowed in that room. Staff A stated Staff F should not have gone in that room.
Reference: WAC 388-97-0640 (6)(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
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 report allegations of abuse and/or neglect to the Sta...
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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 report allegations of abuse and/or neglect to the State Agency for 2 of 6 residents (Residents 27 and 52) reviewed for abuse/neglect. This failure placed the residents at risk for unidentified and ongoing abuse/neglect.
Findings included .
Review of the Code of Federal Regulations 483.12 (c)(1), F609, Reporting of Alleged Violations showed, facility's must Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and the other officials (including to the State Survey Agency .
Review of the facility's policy titled, Abuse-Screening, Training, Identification, Investigation, Reporting, and Protection, dated January 2023, showed the facility was to report all allegations of abuse to the appropriate state agency.
<Resident 27>
Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnoses including heart complications and a bladder infection. The comprehensive assessment dated [DATE], showed the resident had a moderately intact cognition, was able to understand others, and make their needs known.
During an interview on 08/06/2024 at 9:15 AM, Resident 27 stated their former roommate tried to stab me with scissors. Resident 27 stated the former roommate (Resident 30) had moved out of their room the same day the incident had taken place, and they were unsure of what staff member they informed but had told facility staff about the incident.
Review of the facility incident reporting log for July and August 2024, showed no allegation of abuse had been reported regarding Resident 27 being threatened with scissors by Resident 30.
During an interview on 08/07/2024 at 1:03 PM, Staff C, Registered Nurse (RN)/Resident Care Manager (RCM) stated Resident 27 had informed them that Resident 30 had been yelling at Resident 27 to turn down the volume on the TV and then threatened Resident 27 with a pair of scissors. Staff C stated they had started to fill out a grievance form on 08/02/2024 but had not completed it.
Review of an uncompleted grievance form dated 08/02/2024, showed Resident 27 reported to Staff C that during the night of 08/01/2024 to 08/02/2024, (Resident 27) has been telling various staff members that (Resident 27's) roommate threatened (Resident 27) with scissors during the night.
During an interview on 08/08/2024 at 10:47 AM, Staff A, Administrator, stated they were unaware of Resident 27 being threatened by Resident 30 with scissors. Staff A stated that was an allegation of abuse from Resident 27, which should have been reported.
<Resident 52>
Review of Resident 52's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include heart complications, vascular dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain), and anxiety (a feeling of worry, nervousness, or unease). The comprehensive assessment dated [DATE] showed that Resident 52's cognition was impaired and unable to make sound decisions.
An observation on 08/07/2024 at 9:30 AM, showed Resident 52 wandering and exiting another resident's room (Rm 308). Resident 52 came out of room [ROOM NUMBER], walked down the 300-hall and wandered into room [ROOM NUMBER] and sat on the side a bed next to the window.
In an interview on 08/07/2024 at 9:46 AM, Staff O, Nursing Assistant (NA), stated Resident 52 gets turned around (to become lost, to lose one's way) and wandered around the facility, in and out of other resident rooms.
An observation on 08/07/2024 at 9:49 AM, Resident 52 was fully dressed, wander guard (bracelets that residents wear, sensors that monitor doors and that sends safety alerts in real time) to their left wrist and ambulating with a family member down the 100-hall. Resident 52 opened the exit door of the 100-hall (which had a keypad alarm) that did not alarm when the resident walked out the door.
In an interview on 08/08/2024 at 10:36 AM, Staff Q, RN, stated that Resident 52 wandered through out the facility and sometimes when they tried to redirect the resident, they would get combative.
Review of Resident 52's elopement (a resident who is incapable of adequately protecting themself, and who departs the health care facility unsupervised and undetected) risk assessment dated [DATE], showed the resident was a low elopement risk. The resident had not been reassessed for an elopement risk until after the second elopement incident on 08/06/2024.
Review of the incident reporting log for July and August 2024, showed the resident had elopement incidents logged but were not reported to the State Agency.
In an interview on 08/08/2024 at 3:15 PM, Staff B, Interim Director of Nursing Services, acknowledged that Resident 52 had an elopement on 08/06/2024 and stated they had started their investigation.
In an interview on 08/12/2024 at 10:56 AM, Staff A stated they were aware of Resident 52's elopement incidents and were correlating the incidents to the resident's visits from friends and family. Additionally, Staff A stated they did not report it to the State Agency.
Reference: WAC 388-97-0640 (6)(c)
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** Based on observation, interview, and record review, the facility failed to conduct a thorough investigation into an allegation 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 conduct a thorough investigation into an allegation of abuse and/or neglect and prevent an elopement for 2 of 5 residents (Resident 27 and 52) reviewed for abuse/neglect. This failure placed the residents at risk for unidentified and/or continued abuse, recurrent elopements, and unmet care needs.
Findings included .
Review of the facility's policy titled, Abuse-Screening, Training, Identification, Investigation, Reporting, and Protection, dated January 2023, showed that all allegation of abuse were to be thoroughly investigated.
<Resident 27>
Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnoses including heart complications and a bladder infection. The comprehensive assessment dated [DATE], showed the resident had a moderately intact cognition, was able to understand others and make their needs known.
During an interview on 08/06/2024 at 9:15 AM, Resident 27 stated their roommate (Resident 30) attempted to stab them with scissors during the night. Resident 27 stated they informed a facility staff member about the incident and then remembered Resident 30 being moved out of their room the same day the incident had taken place.
During an interview on 08/07/2024 at 1:03 PM, Staff C, Registered Nurse/Resident Care Manager (RN/RCM), stated Resident 27 had informed them that Resident 30 had threatened them with scissors during the nighttime after yelling at them to turn down the television volume. Staff C stated Resident 27 did not have any behaviors and had never made any allegations towards other residents before but did not think that Resident 30 could have got up on their own to threaten Resident 30. Staff C had started filling out a grievance form but was waiting for Resident 27's Representative to get back to them about the possibility that they had picked up the scissors, so Staff C had not completed it yet.
Review of an uncompleted grievance form dated 08/02/2024, showed Resident 27 reported to Staff C that during the night of 08/01/2024 to 08/02/2024, Resident 27 informed various staff that Resident 30 had threatened them with scissors during the night. This should also be reworded. Same exact statement in F609.
During an interview on 08/08/2024 at 10:47 AM, Staff A, Administrator, stated they were unaware of Resident 27 being threatened by Resident 30 with scissors and it had not been reported to them. Staff A stated that Resident 27's statement was an allegation of abuse and should have been investigated.
<Resident 52>
Review of Resident 52's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include Vascular dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain), anxiety (a feeling of worry, nervousness, or unease). The comprehensive assessment dated [DATE], showed Resident 52's cognition was impaired and they were unable to make sound decisions.
An observation on 08/07/2024 at 9:30 AM, showed Resident 52 wandering and exiting another resident's room (Rm 308). Resident 52 came out of room [ROOM NUMBER] looking down at the floor with a frown on their face, shaking their head. The resident then walked down the 300-hall wandered into room [ROOM NUMBER] where they sat on the side of another resident's bed next to the window.
An observation on 08/07/2024 at 9:49 AM, Resident 52 was fully dressed, wearing a wander guard ( bracelets that residents wear, sensors that monitor doors and that sends safety alerts in real time) to their left wrist and ambulating with a family member down the 100-hall. Resident 52 opened the exit door of the 100- hall (which had a keypad alarm) which did not alarm when the resident walked out the doorway.
Review of the facility's incident reporting log for July and August 2024 showed that the resident had elopement incidents logged.
Review of Resident 52's elopement risk assessment dated [DATE], showed the resident was a low elopement risk. The resident had not been reassessed for an elopement risk until after the second incident on 08/06/2024.
In an interview on 08/08/2024 at 3:15 PM, Staff B, Interim Director of Nursing Services, acknowledged that Resident 52 had an elopement on 08/06/2024 and they had begun their investigation.
In an interview on 08/12/2024 at 10:56 AM, Staff A stated that they were aware of Resident 52's elopement incidents and were correlating the incidents to the resident's visits from friends and family. Staff A stated they did not report the elopements to the State Agency, that they acknowledged that the risk of elopement was not on the resident's care plan timely, until after the 2nd elopement on 08/06/2024.
Reference: WAC 388-97-0640 (6)(a)(b)(c)
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 observation, interview, and record review, the facility failed to develop and/or implement comprehensive resident cente...
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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 develop and/or implement comprehensive resident centered care plans for 2 of 6 residents (Residents 34 and 51) reviewed for unnecessary medications and skin conditions. This failed practice put residents at risk for unmet care needs.
Findings included .
<Resident 34>
Review of the resident's medical record showed the resident admitted with diagnoses to include metastatic (cancer spreads beyond the place where it started to other areas of your body) breast and bone cancer (a disease resulting from uncontrolled growth and division of abnormal cells), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and elevated blood pressure (the blood pressure in the arteries is persistently elevated.) The 07/10/2024 comprehensive assessment, showed the resident's cognition was intact.
A concurrent observation and interview on 08/05/2024 at 3:27 PM, Resident 34 was observed to have redness to their right eye and the lower portion below the eye was swollen. The resident stated they had issues with their right eye since before admission to the facility and believed it to be an issue derived from their cancer. Resident 34 further stated they were currently being treated for cancer of their bones and breasts and was at the facility for therapy to get stronger so they could go home. The resident stated they were to continue with their cancer treatment as soon as they were strong enough. Resident 34 stated they did not know when that would be, and they had not been updated by anyone.
During review of Resident 34's August 2024 physician orders, showed the resident was currently being treated with medications for elevated blood pressure, anxiety, peripheral edema (swelling of the lower legs or hands), hypothyroidism (the thyroid gland does not produce enough hormones to keep the body running normally) and showed no treatment for the diagnoses of cancer.
During review of Resident 34's 07/23/2024 care plan, it showed no care plan had been developed for the resident's diagnoses of elevated blood pressure, hypothyroidism, peripheral edema, or anxiety. The care plan further showed no focus for the resident's cancer diagnoses.
<Resident 51>
Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include fracture of the tailbone, heart failure, and dermatitis (a general term for skin inflammation caused by various factors). The 06/26/2024 comprehensive assessment, showed the resident's cognition was intact.
During an interview on 08/06/2024 at 10:54 AM, Resident 51 stated they had a rash underneath both breast creases. Resident 51 stated they had used medicated powder but that had not worked to clear it up and the rash bothered them with burning and itching, and they had used pain medications for a fracture to their tailbone. Resident 51 further stated they did not have a clue what was happening with their care plan, or their discharge. Additionally, they had a care conference shortly after their admission to the facility but nothing since then.
During review of the 06/21/2024 care plan, showed no care plan had been developed for Resident 51's rash under their breasts or was the care plan resident centered. The care plan showed pain issues but did not reflect where the pain was located or resident specific interventions to manage the pain other than with medications. The skins integrity care plan showed the resident had a potential/actual impairment to the skin . related to and then it was blank with no further information. There also was no skin at-risk assessment score or category of risk (an assessment completed on admission that showed what the resident's risk of skin breakdown score and category were assessed to be).
During an interview on 08/08/2024 at 10:46 AM, Staff D, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated when resident 34 admitted to the facility, their understanding of the care plan was to treat the resident in a palliative manner (relieving symptoms without dealing with the cause of the condition) per the Resident's Representative, but then when Staff D talked to the resident, they decided that was not what they wanted. Staff D further stated they must not have updated the care plan to reflect either of the resident's wishes and needed to schedule a care conference to discuss what the care plan should be. Staff D stated they were not aware that Resident 51 continued with the rash underneath their breasts and that had not been communicated to them, nor do they recall not personalizing the care plan to be specific to the resident's care needs. Staff D stated they did not update the resident or resident's care plan if there were changes to their care plan each week after their Interdisciplinary team (IDT, different members of the care team to discuss the goals and treatments of the residents) meetings.
During an interview on 08/08/2024 at 9:43 AM, Staff M, Social Services Director, stated they had the initial care conference within five to seven days after admission to the facility. Staff M further stated the facility held meetings weekly to discuss the resident's progress with therapy or medical treatments, but if there were changes, they did not relay those updates with the residents regarding their care in the facility. Staff M further stated they did not recall communicating to the residents on admission that if they wanted updates more frequently than every quarter (90 days) or closer to discharge (usually 100 days), they could ask for them at any time.
Reference: WAC 388-97-1020 (1),(2)(a)(b)
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
Based on observation, interview, and record review the facility failed to provide care and services for 1 of 2 residents (Residents 51), reviewed for skin care when they did not obtain a skin treatmen...
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Based on observation, interview, and record review the facility failed to provide care and services for 1 of 2 residents (Residents 51), reviewed for skin care when they did not obtain a skin treatment order for an on-going rash for Resident 51. This failure placed the residents at risk for further skin irritation, discomfort, and pain.
Findings included .
<Resident 51>
Review of the resident's medical record showed the resident admitted to the facility with a fracture to their tailbone and dermatitis (a term for conditions that cause inflammation of the skin). The 06/26/2024 comprehensive assessment, showed Resident 51's cognition was intact.
A concurrent observation and interview on 08/06/2024 at 10:54 AM, Resident 51 was lying in bed, just had a shower, and complained of irritation under their breasts. The resident had bright red, shiny appearing skin underneath the creases of both breasts. Resident 51 stated the staff had been applying powder to their rash under their breasts but had not in a few days and thought they would since they just had a shower.
A concurrent observation and interview on 08/07/2024 at 8:41 AM and again on 08/08/2024 at 9:03 AM, Resident 51stated they still had not had any powder put on the rash under their breasts. Resident 51 stated they had two bottles of powder on the back of the toilet in their restroom, but no one had used it. An observation in Resident 51's bathroom, showed two bottles on the back of the tank of the toilet, labeled cornstarch powder and they had no labels on them to identify if they belonged to Resident 51 or their roommate.
Review of the resident's June 2024 Medication Administration Record (MAR) showed:
•
A 06/22/2024 order for Nystatin (a brand of medicated powder used to stop the growth of yeast) powder to be used for 14 days (ended on 07/05/2024) under the breasts daily every shift,
•
A 06/25/2024 order to monitor the rash under the breasts weekly on Tuesdays until rash resolved, and to document a plus sign if the rash had improvement and a negative sign if the rash had resolved or worsened
•
A 07/02/2024 order for weekly skin checks every Tuesday. The staff were to document a plus (+) sign if there were new skin issues identified, and a minus (-) sign if no new skin issues were identified.
Review of the August 2024 MAR showed on 08/06/2024 a skin assessment had been completed by Staff (AA), Licensed Practical Nurse, and documented the weekly skin assessment and the weekly rash assessment both with a minus sign. The MAR showed no new orders that new treatment had been obtained for the rash.
During an interview on 08/09/2024 at 1:03 PM, Staff AA stated their process for weekly skin checks would be to complete a head-to-toe visual check of the Resident's body and then to document findings, if any, on a weekly skin assessment sheet. Staff (AA) stated they assessed Resident 51's skin and it looked great and when asked about the redness under Resident 51's breasts, Staff AA stated they had an order for Nystatin powder they could put on the rash and if they did not, they would get one. During a follow-up interview on 08/12/2024 at 11:08 AM (three days later after informing the nurse of the redness), Staff AA stated they had not talked with the provider regarding new orders for Resident 51's rash and that the provider was in the facility that day and would discuss it with them.
During an interview on 08/12/2024 at 11:29 AM, Staff B, Interim Director of Nursing Services, stated their expectation for skin assessments would be to assess from head-to-toe thoroughly and document their findings on the weekly skin check document. Staff B stated they would then expect the nurse to compare the previous weeks skin check to the current one to see if there was anything new. Staff B stated if there were new skin issues identified or worsening skin issues, they would expect the nurse to complete an incident report and call the provider to obtain new treatment orders.
Reference: WAC 388-97-1060 (1)
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 provide the adequate supervision and safety monitoring...
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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 adequate supervision and safety monitoring for 1 of 1 resident (Resident 52) reviewed for elopements (the potential danger when a resident, often deemed impaired to make sound decisions, leaves the facility premises or safe area unauthorized, posing immediate threats to their health or safety). This failure placed the resident at risk for serious injury related to an inaccurate risk assessment for elopement.
Findings included .
Review of the facilities policy dated 10/2022 titled, Elopement/Wandering, showed Residents are evaluated for potential for elopement during the admission/readmission process, and when a change of condition is noted, resulting in cognitive or behavioral changes placing them at risk for elopement.
<Resident 52>
Review of Resident 52's medical record showed that the resident was admitted to the facility on [DATE] with diagnosis to include vascular dementia (Problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain), anxiety (a feeling of worry, nervousness, or unease), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and seizures (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain). The comprehensive assessment dated [DATE] showed that Resident 52's cognition was impaired and unable to make sound decisions. Additional review of Resident 52's EHR showed an elopement risk assessment dated [DATE] that the resident had a low risk for elopement.
Review of Interdisciplinary (a group of health care professionals with various areas of expertise who work together toward the goals of their residents/clients) weekly meeting notes dated 07/12/2024 through 08/01/2024, showed no concerns regarding mood or behavior. Further review of Resident 52's medical record progress notes showed the following:
•
Progress notes on 07/12/2024 at 7:52 PM, Resident 52 had trouble sleeping and had combative behavior with their care.
•
Progress notes on 07/16/2024 at 4:19 PM, showed Resident 52 had behaviors distressing others.
•
Progress notes on 07/24/2024 at 9:04 PM, showed Resident 52 had wandering behavior.
•
Progress notes on 07/25/2024 at 6:58 AM, showed Resident 52 had intrusive wandering behavior and observed exit seeking.
•
Progress notes on 07/28/2024 at 4:00 PM, showed Resident 52 had occasional behavior demonstrated.
Review of the July 1 thru July 31st, 2024, reporting log showed on 07/28/2024 Resident 52 had an elopement incident. Additional review of Resident 52's EHR showed no documentation of the elopement incident, re-assessment for elopement risk or care plan updates.
During an interview on 08/06/2024 at 9:51 AM, Resident 52's collateral contact (CC), stated Resident 52 had got out the window of their room when they first were admitted to the facility a couple of weeks ago. The CC explained Resident 52 now was wearing a wander guard alarm on their wrist as a result of the incident.
Review of the August 1 thru August 7th, 2024, reporting log showed Resident 52 had another elopement on 08/06/2024 at 2:30 AM and got outside into the courtyard. Staff were alerted to the resident's whereabouts when the door alarm went off as the resident was coming back inside the facility.
An observation on 08/07/2024 at 9:30 AM, showed Resident 52 wandering and exiting another resident's room (Rm 308), Resident 52 came out looking very upset shaking their head. The resident then walked down the 300-hall wandered into room [ROOM NUMBER] where they sat on the side of another resident's bed next to the window. During the same observation at 9:33 AM, Staff O, Nursing assistant (NA), entered room [ROOM NUMBER], stated to Resident 52 Let's go back to your room this room belongs to these gentlemen.
In an interview on 08/07/2024 at 9:46 AM, Staff O stated Resident 52 gets turned around and does wander around the facility in resident rooms.
An observation on 08/07/2024 at 9:49 AM, showed Resident 52 was fully dressed, wander guard to their left wrist, and ambulating with a family member down the 100-hall. Resident 52 opened the exit door which did not alarm when the resident walked out the doorway. The exit door had a keypad lock and was to alarm when opened per Staff O. The family member redirected the resident back into the facility and to their room.
In an interview on 08/08/2024 at 10:36 AM, Staff Q, Registered Nurse, stated that when Resident 52 wandered throughout the facility they sometimes attempted to redirect Resident 52, and they would get combative.
An observation on 08/08/2024 at 2:06 PM, showed the back courtyard had cement walkways, the walkway guided to three entrances to the facility. The first door entered the assisted feeding dining room, the second door was a side door that entered to the employee snack hall, and the third entrance was at the end of the 200-hall. Further observation of the courtyard walkway guided to two gates that had unlocked latch locks that opened to the parking lot.
An observation and interview on 08/08/2024 at 3:21 PM, Staff A, Administrator, provided a wander guard to Staff G, Maintenance Director, who attempted to use the wander guard out the main front door to check the functioning of the alarm system and the door did not alarm. Staff A took the wander guard to ensure Staff G obtained the wander guard that was working. Staff G stated the main door and the end door to 100-hall and end door of the 200-hall were keypad alarms only, and that the two sliding doors, the main entrance door, the double door in-between the activities room and main dining room were the only doors that were set up for the wander guard system. Staff G opened the door at the end of the 100-hall and the door did not alarm. Staff G stated the employees used the keypad alarms to exit and do not reset the alarms.
In an interview on 08/08/2024 at 3:33 PM, Staff B, Interim Director of Nursing Services, stated after talking with the night shift nurses, they found that Resident 52 woke up at 2:00 AM, appeared agitated, and redirection attempts were not successful with Resident 52.
In an interview on 08/09/2024 at 9:11 AM, Staff G stated they checked the wander guard system daily to ensure functionality and they did not keep copies or have a documented log of the wander guard checks.
In an interview on 08/09/2024 at 11:38 AM, Staff D, Licensed Practical Nurse/Resident Care Manager, stated the process for an elopement would be that the care staff and nurses that were involved performed a huddle to address the residents needs and be pro-active for the prevention of the elopements. The resident care manager would also go into detail about the resident's needs at the Interdisciplinary meetings to ensure that they included everyone that needed to be involved. Staff D stated that the care plan updates usually take up to 48 to 72 hours after the incident and the interventions get done immediately. The resident was included in the elopement book located at the nurse's station that had their demographics.
In an interview on 08/12/2024 at 10:56 AM, Staff A stated that the courtyard gates could be locked, but they do not lock them due to being the facility's fire egress requirement. Staff A stated they were aware of Resident 52's elopement and stated they did not report the elopement to the state agency. Additionally, Staff A stated they placed the risk of elopement on the care plan on 08/06/2024. Staff A acknowledged that the resident had an elopement prior to last week's elopement. and that they would have to educate Resident 52's Resident Care Manager on updating the care plan.
Reference WAC: 388-97-1060(3)(g)
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 ensure oxygen orders were obtained, the resident's res...
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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 oxygen orders were obtained, the resident's respiratory status was monitored, or the maintaining of respiratory equipment was completed for 2 of 3 residents (Residents 58 and 5) reviewed for respiratory care. were provided such care, consistent with professional standards of practice. This failed practice placed these residents at risk for unmet respiratory needs and potential negative outcome.
Findings included .
Review of the policy titled Respiratory Treatment dated 06/22/2022, showed residents were to receive respiratory treatments and monitoring, per their physician orders and when oxygen tubing and nebulizer (a machine used to turn liquid medications into a fine mist) masks were not in use they would be stored in a bag.
<Resident 58>
Review of the resident's medical record showed the resident admitted to the facility with Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease that makes breathing difficult and causes cough, mucus, and wheezing). The 07/16/2024 comprehensive assessment showed the resident had intact cognition.
During an observation on 08/05/2024 at 10:52 AM, Resident 58 had a nebulizer machine on the nightstand to the right of their bed, along with the nebulizer mask and tubing, connected, with a small amount of clear fluid in the bottom of the medicine chamber, without any covered protection to keep it clean. The resident had an oxygen concentrator (a medical device that is used as part of oxygen therapy) to the left side of the bed with attached oxygen tubing lying over the head of the bed not contained in a bag or a container to maintain cleanliness.
A concurrent observation and interview on 08/05/2024 at 2:43 PM, Resident 58 was lying in their bed, oxygen tubing lying on the floor to the left side of the bed, the nebulizer mask and tubing were connected to the machine and lying on the nightstand without being in a bag or container to maintain cleanliness. Resident 58 stated they used the oxygen for comfort and stated they had not used oxygen in their home prior to admission to the facility. The resident stated they had COPD and used the nebulizer machine when they would feel short of breath.
An observation made on 08/07/2024 at 8:52 AM, showed Resident 58 lying in bed with their oxygen tubing in place to their nose and their nebulizer mask with the tubing attached, lying on the nightstand, not contained in a bag or container.
On 08/08/2024 at 9:12 AM, showed the oxygen tubing hanging over the top of the Is television and the nebulizer mask with the tubing attached in the same place as observed on 08/08/2024.
During an interview on 08/09/2024 at 1:07 PM, Staff AA, Licensed Practical Nurse (LPN), stated their process for nebulizer masks after resident use was to wash them, hang them, and allow them to air dry, then place them in a bag and put them in the resident's drawer. The process for the oxygen tubing was to check the condition of the tubing daily and replace it if any cracks or soilage was observed, clean the machine, filters, and change the tubing once a week. Staff AA stated when the oxygen was not in use, the oxygen tubing t was placed in the plastic bag that was attached to the side of the oxygen concentrator machine.
Review of Resident 58's August2024 Medication Administration Record showed no orders for the use of oxygen therapy, to replace the tubing weekly, or to maintain the cleanliness of the oxygen concentrator. The record further showed an order for albuterol solution (a brand of liquid medication used to open the airways of the lungs) to be used with a nebulizer machine as needed (PRN). The medication did not have a pre/post assessment for monitoring effectiveness, nor were there orders to maintain the cleanliness of the machine, mask, or tubing.
During an interview on 08/12/2024 at 11:36 AM, Staff B, Interim Director of Nursing Services, stated their expectation for respiratory equipment (nebulizer mask, tubing, and oxygen tubing) would be to contain them in a bag when not in use to maintain cleanliness and the nebulizer masks should be cleaned, hung, and dried prior to containing in a bag. Staff B stated during the first few days of Resident 58's admission, the hospital sent them with oxygen, but no order for the oxygen use, and the nursing staff just continued that process. Staff B further stated the resident should have had an order to use the oxygen that showed the amount of oxygen that was to be used, frequency, and an assessment each shift of their oxygen saturation? status. Further, Staff B stated the resident should have had pre/post assessments that were to be completed when using the PRN nebulizer medications.
<Resident 5>
Review of Resident 5's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including heart complications and anxiety(define). The comprehensive assessment dated [DATE], showed the resident required staff assistance with activities of daily living and was cognitively intact.
An observation and concurrent interview on 08/06/2024 at 9:25 AM, showed a nebulizer mask fully assembled, condensation drops in the mask, and draped over the nebulizer machine with tubing connected to the machine. Resident 5 stated they received nebulizer treatments three times a day.
Observations on 08/07/2024 at 9:26 AM of the fully assembled nebulizer mask, tubing connected to the machine and the mask, lying on the nightstand without a bag. The same day at 3:54 PM, the nebulizer mask fully assembled was connected to the nebulizer machine and lying on top of the machine.
An observation and concurrent interview on 08/08/2024 at 9:33 AM, Resident 5 stated they received a nebulizer treatment in the morning and at night. Resident 5 stated they had just finished a treatment. The mask was fully assembled with condensation in the medicine chamber of the mask and was lying on the nightstand without a bag.
In an interview on 08/09/2024 at 1:29 PM, Staff E, LPN/Resident Care Manager, stated the expectation was after each administration of a nebulizer treatment the nurses were to take the mask apart, rinse out the chamber and place the supplies on a barrier to dry. Additionally, after being dried, it was to be placed in a bag so that the supplies were ready for the next use.
Reference: WAC 388-97-1060 (3)(j)(vi)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure dialysis (a process that removes your blood from your body, filters out toxins in a machine, and then sends your filte...
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Based on observation, interview, and record review, the facility failed to ensure dialysis (a process that removes your blood from your body, filters out toxins in a machine, and then sends your filtered blood back into your body) care and services were consistent with professional standards of practice for 1 of 1 resident (Resident 23) reviewed for dialysis care. The facility failed to administer morning medications consistently, to include insulin (a medication that helps regulate blood sugar levels) and monitoring blood sugar levels (a procedure that required a stick to the fingertip with a lancet, and a drop of blood placed on the tip of a test strip that is inserted into a machine to determine what the blood sugar level is) to the resident prior to leaving for dialysis. This failed practice placed Resident 23 at risk for complications and adverse side effects from inconsistent medication administration.
Findings included .
<Resident 23>
Review of resident 23's medical record showed the resident admitted to the facility with end stage kidney disease and required dialysis treatments and diabetes (condition that affects your blood sugar levels and can cause serious complications). The 05/26/2024 comprehensive assessment showed the resident's cognition was severely impaired.
Review of Resident 23's 08/01/2024 thorugh 08/08/2024 Medication Administration Record (MAR) showed an order on 05/25/2024 for dialysis treatments completed every Tuesday, Thursday, and Saturday. The record further showed medications ordered to be given daily in the morning for; aspirin (used for heart failure), docusate (used to soften stools), iron (used for anemia), multivitamin (used as a supplement), alprazolam (used for a mood disorder), sertraline (used for a mood disorder), memantine (used for a cognitive disorder), metoprolol (used for elevated blood pressure), omeprazole (used for a gastric stomach disorder), prostat (a liquid supplement used for wound healing), and lanthanum (used to lower levels of phosphorus [keeps the body from absorbing calcium] in the blood. The MAR showed as follows:
•
aspirin, docusate, iron, multivitamin, sertraline, memantine, metoprolol, omeprazole, and prostat had not been given on two out of eight days,
•
the lanthum, which was scheduled to be given at 8:00 AM and 12:00 PM, had not been given on four out of 16 shifts.
Review of the July 2024 MAR showed morning medications had not been given as follows:
•
aspirin, docusate, iron, multivitamin, sertraline, memantine, metoprolol, omeprazole, prostat, and lanthum were not given on 12 out of 31 shifts
•
alprazolam and an order for heparin (a brand of a medication used to thin the blood to prevent blood clots from forming, from 05/24/2024 to be given for two months) injections had not been given for ten out of 31 days.
Review of the June 2024 MAR showed as follows:
•
all morning medications had not been given on 13 out of 30 days.
All medications were not given on Resident 23's dialysis days (there was no notification to the provider or the dialysis facility).
Review of Resident 23's 08/01/2024 through 08/08/2024 Diabetic Administration Record (DAR) showed an order on 07/05/2024 for novolog (a brand of insulin) to be injected before each meal and at bedtime. Prior to administering the insulin, the blood sugar levels needed to be monitored. The record further showed an order on 05/24/2024 for basaglar (a brand of insulin) to be given once daily. The DAR showed as follows:
•
the basaglar insulin had not been given on two out of nine shifts,
•
the novolog insulin had not been given nor were the blood sugar levels monitored on six out of 18 shifts.
Review of the July 2024 DAR showed as follows:
•
the basaglar insulin had not been given on 12 out of 31 shifts,
•
the novolog insulin had not been given and blood sugar monitoring was not obtained on 23 out of 52 shifts.
Review of the June 2024 DAR showed as follows:
•
the basaglar insulin had not been given on 13 out of 30 shifts,
•
the novolog insulin had not been given and blood sugar monitoring had not been obtained on 25 out of 60 shifts.
All days the medication and and monitoring of the blood sugar were not completed, were Rsident 23's dialysis days.
During an interview on 08/09/2024 at 1:17 PM, Staff L, Registered Nurse, stated when they worked, they did not give Resident 23 their medications, insulin, or monitor their blood sugar levels prior to them leaving for dialysis because Resident 23 left the facility too early. Staff L stated Resident 23 left the facility at 7:00 AM and did not return until approximately 2:00 PM -2:30 PM, nearly the end of their shift. Staff L stated they completed a form prior to the resident leaving for dialysis with their vital signs and any other information the dialysis facility needed to know. Staff L stated they did not communicate on the form to the dialysis facility that the resident did not have medications, insulin, or their blood sugar levels monitored prior to leaving the facility.
During an interview on 08/09/2024 at 1:32 PM, Staff D, Licensed Practical Nurse/Resident Care Manager, stated they were not aware Resident 23 was not being given their morning medications, insulin, or having their blood sugar levels monitored consistently prior to leaving for dialysis. Staff D stated the medications were scheduled to be given prior to the resident leaving for dialysis and they believed the physician was most likely unaware Resident 23 was missing their medications.
During an interview on 08/12/2024 at 11:34 AM, Staff B, Interim Director of Nursing Services, stated Resident 23 should have been given their medications, including insulin and the monitoring of blood sugar levels, as ordered, prior to the resident leaving the facility for dialysis.
Reference: WAC 388-97-1900 (1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
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 that residents who were trauma survivors recei...
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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 that residents who were trauma survivors received trauma-informed care in accordance with professional standards of practice by not assessing or monitoring past experiences of Post Traumatic Stress Disorder [(PTSD) an anxiety disorder that develops in some people who have experienced a shocking, scary, or dangerous event) for 1 of 2 residents (Resident 13) reviewed for mood and behavior. This failure placed residents at risk for unidentified triggers and re-traumatization.
Findings included .
<Resident 13>
Review of the medical record showed Resident 13 was admitted to the facility on [DATE] with a diagnosis of PTSD. Resident 13's comprehensive assessment dated [DATE] showed they required minimal assistance of one staff member for activities of daily living (ADLs, daily actions like dressing, transferring and toileting) and had an intact cognition.
During an interview on 08/06/2024 at 1:55 PM, Resident 13 stated they had a very frightening event happen a few nights before. Resident 13 stated at 10:00 PM, a male resident entered their room and was staring at them lying in bed. Resident 13 stated they yelled and screamed loudly because it scared them, and it took several of the nurses to calm them down. Resident 13 stated a nurse had to stay with them before trying to go back to their room and sleep. Resident 13 stated the nurses explained the male resident had dementia (an impairment of brain function, which causes memory loss, forgetfulness and impaired thinking abilities) and wandered into other rooms sometimes because they did not know where they were and meant no harm. Resident 13 stated this explanation did not relieve their fear because they had a history of PTSD from being repeatedly raped in the middle of the night.
During the same interview on 08/06/2024 at 1:55 PM Resident 13 stated after they reported the event to the nurses that night, they felt like no one cared or followed up with them to assure them that there were things that could be put into place to prevent that male or any other from entering their room again. Resident 13 stated they had laid awake at night worrying about it ever since it happened and at times had been terrified to go to sleep.
Review of a document titled SNF (Skilled Nursing Facility) Trauma Screen dated 07/23/2024, showed Staff R, Social Services Assistant, had completed the assessment for Resident 13 which showed the resident did not want to discuss any past trauma at that time.
During an interview on 08/08/2024 at 11:30 AM, Staff R stated if PTSD was on a resident's diagnosis list when they were admitted they would complete a trauma screen, but if the resident said they did not want to talk about any trauma or PTSD, they did not continue asking any questions about it. Staff R stated when they heard a resident was having problems or showed signs of PTSD later in their stay, they would follow up with the resident again at that time. Staff R stated they had not been informed Resident 13 had experienced any recent trauma.
Review of Resident 13's care plan from 07/22/2024 to 08/09/2024, showed there were no focus areas or interventions associated with the resident's diagnosis of PTSD for the staff to monitor.
During an interview on 08/09/2024 at 10:46 AM, Resident 13 stated they had been told the male resident that entered Resident 13's room had gone home a few days earlier, and no one had come to speak with them about the event, their PTSD, or plans to prevent the event from happening again. Resident 13 stated they were glad they were discharging home the following day, so they did not have to worry about it any further.
Reference: WAC 388-97-1060(3)(e)
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
Based on interview and record review, the facility failed to ensure recommendations from the Pharmacist's monthly medication review (MMR) were reviewed and appropriately completed by the medical provi...
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Based on interview and record review, the facility failed to ensure recommendations from the Pharmacist's monthly medication review (MMR) were reviewed and appropriately completed by the medical provider for 1 of 5 residents (Resident 23) reviewed for unnecessary medications. This failed practice put the resident at risk for receiving duplicate therapy (more than one, same class of medication used for the same indication) of depression (a persistent feeling of sadness and loss of interest) medications that were unnecessary and a negative medical reaction.
Findings included .
Review of a policy titled Drug Regimen Review dated 04/2019, showed the pharmacist would review medications, to include drugs used in duplication [duplicate therapy] monthly and make recommendations as needed. Then the facility would notify the physician of the recommendations and the physician would follow-up in a timely fashion.
<Resident 23>
Review of the resident's medical record showed the resident admitted to the facility with diagnoses of dementia (a group of symptoms affecting memory, thinking and social abilities), anxiety (a feeling of worry, nervousness, or unease about an imminent event or something with an uncertain outcome), and depression. The 05/26/2024 comprehensive assessment showed the resident's cognition was severely impaired.
Review of Resident 23's August 2024 Medication Administration Record showed an order on 05/24/2024 for sertraline (a brand of anti-depressant medication) 50 milligrams (mg, a unit of measure) daily for depression and on 05/23/2024 an order for trazodone (a brand of anti-depressant medication) 100 mg daily at bedtime for depression and insomnia (inability to sleep).
Review of the Pharmacist's monthly medication reviews for May, June, and July 2024 showed a recommendation had been sent to the provider to review the use of two anti-depressant medications being used in conjunction together for the treatment of depression. Review of the May 2024 and July 2024 recommendations showed the provider had not responded to the Pharmacist's recommendations. The June 2024 recommendation showed the provider declined the Pharmacist's recommendation on 06/11/2024 but did not provide a written rationale for the reasons why the recommendation was declined per the regulation requirement.
During an interview on 08/09/2024 at 9:48 AM, Staff B, Interim Director of Nursing Services, stated the expectation would be for the Pharmacist's recommendations to be reviewed by the provider and completed in a timely manner and would expect them to be reviewed no later than within one week. Staff B stated they were not aware the provider did not complete the documentation required on the June 2024 recommendation.
Reference: WAC 388-97-1300 (4)(c)(d)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure 1) the labeling of several small containers of syrup on three trays located in dry 1 of 1 dry storage rooms in the kit...
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Based on observation, interview, and record review, the facility failed to ensure 1) the labeling of several small containers of syrup on three trays located in dry 1 of 1 dry storage rooms in the kitchen, and 2) the resident's nutritional refrigerator was kept in a sanitary manner and undated /expired foods were discarded for 1 of 1 nutritional refrigerators in the facility. These failures placed residents at risk for consuming contaminated, expired foods, and food-borne illness.
Findings included .
<Dry storage>
A concurrent observation and interview on 08/05/2024 at 9:45 AM, showed in the dry storage room, on the third shelf, had three trays of syrup poured into small condiment containers with no dates on containers to show expiration date. Staff Y, Dietary Director, acknowledged there were no dates on the condiment containers and stated, they need to have a date.
<Nutritional Refrigerator>
An observation on 08/06/2024 at 11:01 AM, of the nutritional refrigerator located in the dining room showed in the freezer there were large ice cream containers brought in with only a resident's name and no open or best by date observed. There were multiple (more than 10) multi-use ice packs within the freezer, a grocery bag with popsicles labeled with a resident's room number on the bag with no date. Within the refrigerator were three plastic see through storage food containers with fresh fruit inside, labeled with a resident's name, no best by date observed, and an unidentified food tray ( with an unknown type of sandwich, a container of milk and a cup of juice) . The bottom of the refrigerator had a dark brown substance, and the inside walls had old food ( dark brown hard particles) stuck to them.
In an interview on 08/06/2024 at 2:38 PM, Staff Y stated that the evening shift cook had the responsibility of checking the dates on the foods, and cleaning the refrigerator out daily. Staff Y stated they were unsure where the ice packs came from and that the nutritional refrigerator was a communal (shared, or used in common by members of a group or community) refrigerator. Additionally, Staff Y stated that resident families, staff, and the residents used the nutritional refrigerator.
An observation on 08/08/2024 at 8:53 AM, showed the nutritional refrigerator continued to have the three plastic food containers of fruit with a resident's name and no best by date observed. Further observation showed the bottom drawer contained an opened bag of beef sticks and a half drank bottled tea without best by dates observed. The bottom of the refrigerator underneath the drawer was a dark brown substance and the inside refrigerator walls had old food (dark brown hard particles) stuck to the side.
In a concurrent observation and interview on 08/09/2024 at 1:20 PM with Staff Y, showed the nutritional refrigerator with a dark brown substance underneath the bottom drawers. Staff Y acknowledged that the nutritional refrigerator had not been kept in a sanitary manner, took a picture, and stated they had work to do.
Reference WAC: 388-97-1100 (3)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
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 implement components of their infection prevention 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 implement components of their infection prevention and control precautions for, 1) hand hygiene and glove change for 2 of 6 residents (Resident 3 and 23) reviewed during daily resident cares and wound care treatment, and 2) Legionella (a bacteria that can cause a severe respiratory disease) testing protocols and procedures when control measures (actions or steps taken) were not met to reduce the risk of growth/spread of pathogens (bacteria, virus or other microorganisms that can cause diseases) in water for 1 of 1 water management program (WMP) reviewed for infection control. These failures placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases.
Findings included .
Review of Centers for Disease Control and Prevention (CDC) recommendations titled, Clinical Safety: Hand Hygiene for Healthcare Workers, dated 02/27/2024 showed that hand hygiene was to be implemented to reduce the harmful spread of infections in the healthcare setting. When conducting hand washing .rub hand together vigorously for at least 15 seconds .scrubbing hands and fingers with soap .
Review of the facility's policy titled, Hand Hygiene, revised 12/15/2021, showed, .hand hygiene is the primary means of preventing the transmission of infection . and hand hygiene was required when hands were visibly soiled, before and after direct contact with resident, before and after assisting a resident with personal care, before and after changing a resident wound dressing and after removing gloves and/or before applying new gloves.
Review of the Department of Social and Health Services, Dear Nursing Home Administrator Letter, guidance titled, Clarifying Requirements to Reduce Legionella Risk in Healthcare Facility Water Systems, dated 09/18/2018, showed the facility's WMP must, at a minimum:
•
Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system.
•
Develops and implements a WMP that considers the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) industry standard and the Center for Disease Control (CDC) toolkit.
•
Specifies testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained.
•
Maintains compliance with other applicable Federal, State and local requirements.
Review of the CDC toolkit titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 06/24/2021, showed that a process should be in place for when control measures are not being met (outside of acceptable ranges) and that a facility would need to take corrective action? to get control measures back within acceptable ranges. Control measures with acceptable ranges should be established for each control point along with what actions would be taken.
Review of the facility's policy titled, Water Management Plan, revised April 2019, showed the facility's areas of risk for the spread of Legionella, included Shower(s), Hot water heaters, Water storage tanks, Sinks, Whirlpool tubs, Drinking fountains, Unused sinks/showers. The facility's control measures included:
•
Flushing water heaters monthly,
•
Disinfecting sinks and showers regularly,
•
Flushing unused sinks/showers to reduce stagnation of water,
•
Visually inspecting appliances for signs of biofilm growth (an encased group of microorganisms that can grow on surfaces and protect themselves from the disinfection process),
•
Ensuring that expected water temperatures at fixtures (a fixed or attach structures like a sink and/or shower that delivers water).
Additionally, the policy stated the facility would .establish procedures to execute if control measures are not met .
<Hand Hygiene/Glove Change>
<Resident 3>
Review of the medical records showed they were admitted to the facility on [DATE] with diagnoses including Stage pressure injury (a wound from prolonged pressure to an area of the skin that extends below the skin layers into muscle, tendon or bone) to the sacrum (bottom or lower backside of the body), infection of an indwelling urinary catheter (a flexible tube that is inserted into the bladder to drain urine and is a high risk for infection), and dementia (an impairment of brain function, which causes memory loss, forgetfulness and impaired thinking abilities). The comprehensive assessment, dated 05/21/2024, showed Resident 3 had severe cognitive impairment, frequently incontinent of bowels (no voluntary control over bowel movements), dependent (staff preforms all the effort) on staff for perineal hygiene (care for toileting, cleaning and wiping of private areas of the body) and movement in bed.
Review of Resident 3's care plan dated 05/22/2024 showed the resident had contractures (a permanent tightening of muscles and tendons that cause joint of the body to shorten and stiffen) in bilateral (both sides of the body) lower extremities.
An observation on 08/05/2024 at 1:31 PM showed Staff K, Nursing Assistant (NA), and Staff Z, NA, in Resident 3's room assisting the resident with incontinent care for a bowel movement (BM). Resident 3 was noted to have a contraction (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become stiff, often leading to a deformity) of bilateral lower extremities with abduction (moving inward towards the body) of the legs together, with their urinary catheter squeezed in-between the resident's legs. Resident 3 had a bordered foam (type of wound bandage) dressing on their sacrum and residents BM had soiled the bordered foam dressing along with moving up the resident legs towards their urinary catheter. Staff K and Staff Z did not perform catheter care nor call for a nurse to change Resident 3's solid bordered foam wound dressing.
Continued observation on 08/05/2024 at 1:31 PM, showed Staff Z not changing gloves nor hand hygiene after cleaning the resident's BM. Staff Z then proceeded to assist in turning the resident, applied a clean brief, adjusted the resident's legs, shirt, socks and bed linen while wearing their soiled gloves. Staff Z then took off their gloves and performed hand washing for four seconds after applying soap. Staff K assisted with Resident 3's BM cleaning and clean brief change with the same soiled gloves. Staff K then proceeded to adjust Resident 3's urinary catheter tubing and drained the resident's catheter bag without changing their soiled gloves or performing hand hygiene.
During an interview on 08/12/2024 at 9:27 AM, Staff Z stated the process with Resident 3's brief change was to perform catheter care due to the resident frequent bowel incontinence and if the resident's BM soiled the sacrum wound dressing, they would get the nurse to change it. Staff Z stated the wound dressing was soiled and they should have got a nurse to put on a clean wound dressing. Staff Z stated they forgot to complete catheter care on Resident 3 and their process for hand hygiene was to scrub with soap for 20 seconds.
During an interview on 08/12/2024 at 9:56 AM, Staff K stated they should have changed their gloves and completed hand hygiene after they performed a brief change on Resident 3. Further, that they should have changed their gloves, performed their hand hygiene after they touched the resident's urinary catheter/bag and when moving from a soiled task to a clean task. Staff K stated that urinary catheter care and changing of the resident's sacrum wound dressing should have been completed.
During an interview on 08/12/2024 at 10:48 AM, Staff B, Interim Director of Nursing Services/Infection Preventionist (IDNS/IP) stated that Staff Z and Staff K did not follow the correct infection control process and should have performed urinary catheter care and have Resident 3's nurse change out the soiled sacrum wound dressing. Staff B stated they would expect all staff to have performed a glove change/hand hygiene when moving form a soiled task, to a clean task and hand washing for 20 seconds.
<Resident 23>
Review of the resident's medical record showed they were admitted to the facility with diagnoses to include a fracture to their outer lower left leg and dementia. The 05/26/2024 comprehensive assessment showed Resident 23's cognition was severely impaired.
A concurrent observation and interview on 08/07/2024 at 9:18 AM, showed Staff K and Staff J, NA, provided incontinent care to Resident 23 who had a BM. Staff J and Staff K applied gloves, and Staff J cleansed the BM off of the left hip and leg and Staff K cleansed the BM off of the left buttock and crease with wet wipes. Resident 23 had a soft white splint to the left lower leg and the top edges of the splint had dried brown/black soiled areas on it and newly fresh brown/black soiled areas. Staff K identified the soiled areas as BM and stated the splint was not cleanable to that area because it was a cloth-like material. Staff J and K, with the same soiled gloves, continued cleaning the resident, applying their clean brief, adjusting their pillows, blankets, and bed, without changing gloves, or performing hand hygiene. Staff J removed gloves and performed hand hygiene by applying soap, and then immediately rinsing their hands with water and rinsed for 20 seconds. Staff K did not perform hand hygiene prior to exiting Resident 23's room. Staff J stated their process was to wash hands prior to applying gloves, provide the care, remove the gloves, and wash hands again. Staff K stated they should have changed their gloves and performed hand hygiene in-between dirty and clean tasks and should have lathered their hands with soap for at least 20 seconds prior to rinsing with water.
A concurrent observation and interview on 08/07/2024 at 11:52 AM, showed Staff I, Registered Nurse, and Staff D, Licensed Practical Nurse/Resident Care Manager, providing wound care to Resident 23. Staff I and Staff D donned (to put on) gloves, and Staff I proceeded to removing a dressing from the top of the resident's left foot wound, cleansed the area, applied a wound gel (a substance that creates a moist environment to promote wound healing), and then applied a new dressing over the wound. Then Staff I removed a dressing from the left heel that was saturated with red, and brown drainage, cleansed the wound, applied a wound gel, then covered with a new dressing without removing the gloves or performing hand hygiene in-between the clean and dirty tasks for either of the residents wound dressing changes. Staff I stated they did not feel they needed to perform hand hygiene because they did not touch the inner portion of the dressing that was soiled but recognized they had cleansed the wound with gauze (a thin fabric used for wound care treatments) and cleanser after removing the dressing to both areas. Staff I stated they would normally have completed hand hygiene in-between dirty and clean tasks but did not.
<Water Management Plan>
Record review of facility water management plan program/procedure book, reviewed February 2024 by Staff A, Administrator, Staff B, and Staff G maintenance Director, showed they did not have specific testing protocols in place nor did they identify what procedure would be taken if acceptable ranges for the facility's control measures were not met.
During an interview on 08/06/2024 at 4:41 PM, Staff A, stated they did not conduct any testing related to legionella/water management plan and that testing was not a requirement. When asked how the facility monitored to make sure control measures were met, Staff A stated they were unsure.
During an interview on 08/08/2024 at 4:04 PM, Staff G, stated they had not been testing their water sources and was unsure if testing had been completed before they had started working as the Maintenance Director at the beginning of 2024. Staff G stated they did not know what the facility's testing protocols were or what the procedure would be if their control measures were not within acceptable ranges. Staff G was unsure if monitoring of all control measures was completed and unable to provide documentation of the facility unused sinks/showers and flushing of them nor the inspection of the facility's appliance for signs of biofilm growth.
During an interview on 08/09/2024 at 9:39 AM, when requested documentation regarding the facility testing protocol and procedures they executed when control measures were not within acceptable ranges, Staff A was unaware and stated they would reach out to their corporate office and local health jurisdiction contact on what the facility testing procedures would be required. Staff A was unable to present documentation towards testing protocol/procedures that would be executed if the facility's control measures were not met.
Record review of the facility's water management plans control measure logbook documentation report, showed no testing protocols if control measures were not within acceptable ranges. The records showed the flushing of water heaters were not completed monthly (last done 05/10/2024), no documentation of flushing of facility's unused sinks/showers (except for one eye wash station) or inspection of appliance for signs of biofilm growth (except for one ice machine).
During a follow-up interview on 08/12/2024 at 11:30 AM Staff A had no further information on the facility's water management plan testing protocols for legionella or the corrective actions that would be taken if the facility's control limits were not maintained.
Reference: WAC 388-97-1320 (1)(a,c)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to provide a functional, comfortable and sanitary environment for 1 of 1 laundry rooms (LR1) reviewed for environmental conditions. This failure ...
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Based on observation and interview the facility failed to provide a functional, comfortable and sanitary environment for 1 of 1 laundry rooms (LR1) reviewed for environmental conditions. This failure placed staff and residents at an increased risk for infections related to unsanitary surfaces.
Findings included .
During a concurrent observation and interview on 08/07/2024 at 3:54 PM, with Staff H, Housekeeping/Laundry Director, showed a washing machine with rolled up towels on the laminate (a type of flooring) floor surrounding the base of the washing machine. The towels were soaked with water that had been leaking from the washing machine. Staff H stated that the washing machine had been leaking for a couple of months. When surveyor walked over by the washing machine, the laminate floor squished down, and a grayish sludge (a thick, soft, wet mixture of liquid) oozed out from in-between the laminate flooring.
During an interview on 08/08/2024 at 4:05 PM, in the laundry room, Staff G, Maintenance Director, and Staff H, stated the washing machine had been leaking on/off for months. Staff G stated that Staff H had informed them of the sludge that had come up form the laminate flooring, which was not sanitary, and they would be working to fix the floor and washing machine.
Reference: WAC 388-97-3220 (1)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
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 residents Preadmission Screening and Resident 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 residents Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities are not inappropriately placed in nursing homes for long term care) were correct on admission and had required level II referral if residents had a positive level I PASARR, for 4 of 5 residents (Residents 43, 5, 23, and 34 ) reviewed for PASARR. This failure placed the residents at risk of not receiving the mental health care and services appropriate for their needs.
Findings included .
Review of the Department of Social and Health Services, Dear Nursing Home Administrator Letter, guidance titled, Clarification to the Pre-admission Screening and Resident Review (PASARR or PASRR) Level 1 Screening Process, dated 07/06/2024, showed a positive level I PASARR screen (that would then require a referral for a level II PASARR) was Any of the questions in Section 1A (1, 2, and/or 3) are marked Yes: or Sufficient evidence of SMI is not available, but there is a credible suspicion that a SMI may exist; and the requirements for exempted hospital discharge do not apply . Additionally, nursing facilities will ensure residents with a positive level I PASARR screen have been evaluated by the designated state-authority through the level II PASARR process and approved for admission prior to admitting to the nursing home.
<Resident 43>
Review of the resident medical records showed they were admitted to the facility on [DATE] with diagnoses including multiple heart complications, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (a feeling of worry, nervousness, or unease) and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves, causing shaking movements). The comprehensive assessment dated [DATE] showed the resident had a moderately intact cognition, was able to understand others and make their needs known.
Review of Resident 43's PASARR, dated 07/09/2024 showed SMI indicators, in section 1A, were checked marked for Resident 43's diagnosis of depression and anxiety (a positive level I PASARR). No level II referral was completed and showed .No Level II evaluation indicated .
During an interview on 08/08/2024 at 12:54 PM, Staff M, Social Service Director (SSD), stated their process was to have hospitals complete the level II evaluation prior to the resident being admitted , but that it had not been happening. Staff M stated that Resident 43 should have had a level II PASARR evaluation completed upon admission, due to the resident having a positive level I PASARR.
<Resident 5>
Review of Resident 5's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of anxiety. Review of the comprehensive assessment dated [DATE], showed the resident's cognition was intact.
Review of Resident 5's physician orders showed that the resident had been prescribed Cymbalta ( a brand of medication given for depression and anxiety). Review of Resident 5's July and August 2024 Medication Administration Record (MAR), showed that the resident had been receiving Cymbalta daily as ordered.
Review of Resident 5's PASARR, dated 06/25/2024 showed the SMI indicators, in section 1A, had not been checked for the residents diagnoses of anxiety.
During an interview on 08/08/2024 at 11:01 AM, Staff E, Licensed Practical Nurse/Resident Care Manager, stated that the admissions director worked with the hospital to ensure that residents had their PASARR completed accurately. Staff E stated that they received the information once the resident was admitted , and that medical records scanned the information into the resident's medical record.
In an interview on 08/08/2024 at 11:05 AM, Staff T, Admissions Director, stated they assisted with the PASARR when residents were being admitted to the facility. Staff T stated they contacted the hospital and worked with them to ensure an admitting resident had a PASARR. Staff T stated that they were aware of the change to PASARR process, and they had seen more level II PASARR's. Staff T stated that once a resident admitted to the facility the social services department took over the process.
<Resident 23>
Review of the resident's medical record showed the resident admitted to the facility 05/23/2024 with diagnoses to include depression, anxiety, and insomnia (a sleep disorder that makes it hard to fall asleep or stay asleep). The 05/26/2024 comprehensive assessment, showed the resident's cognition was severely impaired.
Review of Resident 23's August 2024 MAR, showed the resident received psychotropic (any drug that affects behavior, mood, thoughts, or perception) medications as follows; Sertraline (a brand of anti-depressant medication) daily, Trazodone (a brand of anti-depressant medication also used for Insomnia) daily at bedtime, and Alprazolam (a brand of anti-anxiety medication) twice daily.
Review of Resident 23's PASARR, dated 05/23/2024, showed no diagnoses for anxiety or insomnia even though the resident received medications for those SMI disorders.
<Resident 34>
Review of the resident's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of anxiety. Review of the 07/10/2024 comprehensive assessment, showed the resident's cognition was intact.
Review of Resident 34's July 2024, and 08/01/2024 to 08/06/2024 MAR, showed the resident had an order for ativan (a brand of anti-anxiety medication) every six hours as needed for anxiety.
Review of Resident 34's PASARR, dated 07/03/2024, showed no diagnosis for the SMI disorder.
During an interview on 08/08/2024 at 10:00 AM, Staff M stated they, along with the admissions nurse reviewed PASARRs on admission for accuracy, required level IIs if needed to be submitted for an assessment. Staff M stated if PASARRs were not accurate they would ensure they were accurate prior to admission or if after admission, they would correct them.
Reference: WAC 388-97-1915 (1)(2)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 52>
Review of the medical record showed that the resident was admitted to the facility on [DATE] with diagnosis ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 52>
Review of the medical record showed that the resident was admitted to the facility on [DATE] with diagnosis to include heart complications, vascular dementia (Problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain), and anxiety . The comprehensive assessment dated [DATE] showed that Resident 52's cognition was impaired and unable to make sound decisions.
In an interview on 08/06/2024 at 9:46 AM, Resident 52's RR, stated they had not reviewed the BCP with staff 48 hours after admission to the facility.
In an interview on 08/09/2024 at 11:13 AM, Staff E, LPN/RCM, stated that they review the residents' plan of care during the care conferences. Additionally, that they did not discuss the BCP with the residents or provide them a copy of the care plan.
Reference: WAC 388-97-1060 (3)
<Resident 58>
Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include multiple fractures from a motor vehicle accident and Chronic Obstructive Pulmonary Disease (a chronic lung disease that makes breathing difficult and causes cough, mucus and wheezing). The 07/16/2024 comprehensive assessment, showed the resident's cognition was intact. The record further showed no baseline care plan had been developed.
During an interview on 08/05/2024 at 3:01 PM, Resident 58 stated they had not received a BCP summary of their initial goals, medications, dietary instructions, services/treatment that were to be administered by the facility nor the details of their BCP.
During an interview on 08/08/2024 at 9:43 AM, Staff M, Social Services Director, stated they would complete their first assessment, I would assume that is our portion of the baseline care plan on the History/Discharge document for social services within day one to day seven of admission. Staff M further stated they did not give a copy of that to the resident or the Resident Representative (RR).
Review of the 07/16/2024 history/discharge document showed the document had not been started until seven days after admission and not developed within the 48 hours after admission.
During an interview on 08/08/2024 at 10:23 AM, Staff D, Licensed Practical Nurse (LPN)/Resident Care Manager, (RCM) stated they used the [NAME] as the baseline care plan and would go over that with the resident or RR on admission. Staff D stated if the resident or RR had questions regarding their medications then they would print off their physician orders and go over the medications with them. Staff D stated they did not give the resident or RR a copy of the documents unless they asked for one.
Review of Resident 58's 08/12/2024 [NAME], showed a box that was labeled Requirements of Participation: that showed no information for diet, what type of wounds and where, a summary of orders, or treatments, and a signature line for the resident or the RR to sign and acknowledge that they were offered a copy of their plan of care.
Surveyor: [NAME], [NAME] P.
Based on interview and record review the facility failed to develop a baseline care plan (BCP) within 48 hours of admission that included resident specific initial goals and treatment plans, nor provide a summary of the required information from the BCP to the resident for 3 of 6 residents (Residents 7, 58, and 52) reviewed for baseline care plans. This failure placed the residents at risk for a lack of knowledge regarding the initial plan for delivery of care/services and unmet care needs.
Findings included .
<Resident 7>
Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a recent fall with a head laceration (a deep cut or tear in skin) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of the resident's comprehensive assessment dated [DATE], showed Resident 7 required extensive assistance of one caregiver for activities of daily living (ADL's) and was cognitively intact.
During an interview on 08/08/2024 at 10:08 AM, Resident 7 stated they were not provided a BCP within 48 hours of admission that discussed their specific goals or treatment plan while in the facility. Resident 7 stated, I wish they would have so I would have known what the plan was for getting better and being able to go home.
CONCERN
(E)
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** Based on observation, interview and record review, the facility failed to ensure residents were free of unnecessary psychotropic...
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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 residents were free of unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) for 3 of 5 residents (23, 34 and 35) reviewed for unnecessary medications. The facility failed to ensure residents had an appropriate diagnosis for use of psychotropic medications, had person-centered behaviors being monitored to reflect adequate need for the medications or implement non-pharmacological interventions to attempt prior to administering psychotropic medications. Additionally, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS, to assess for the presence and severity of abnormal movements of the face, limbs, and body) prior to beginning the psychotropic medications. These failures placed the residents at an increased risk for receiving medications they no longer needed and/or increased behaviors due to inadequate dosing of medication.
Findings included .
<Resident 23>
Review of the resident's medical record showed they admitted to the facility on [DATE] with diagnoses to include depression (a persistent feeling of sadness and loss of interest), anxiety (a feeling of worry, nervousness, or unease about an imminent event or something with an uncertain outcome), and insomnia (the inability to sleep). The 05/26/2024 comprehensive assessment showed the resident's cognition was severely impaired.
A concurrent observation and interview on 08/09/2024 at 9:05 AM, showed Resident 23 lying in bed, hair uncombed, eating their breakfast. The resident is alert, smiling, pleasant to talk with, and answered questions as appropriate as they were able to.
Review of Resident 23's August 2024 Medication Administration Record (MAR), showed an order on 08/01/2024 for alprazolam (a brand of anti-anxiety medication) 0.25 milligrams (mg, a unit of measure) by mouth two times daily for anxiety, an order on 05/23/2024 for trazodone (a brand of anti-depressant medication) 100 mg by mouth daily at bedtime for depression and insomnia, and an order on 05/24/2024 for sertraline (a brand of anti-depressant medication) 50 mg by mouth daily for depression.
Further review of Resident 23's medical record showed no AIMS assessment had been completed since admission, there were no person-centered behaviors specific to Resident 23 being monitored, and the resident's sleep pattern had not been monitored to ensure effectiveness of the medications.
<Resident 34>
Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include anxiety. Review of the 07/10/2024 comprehensive assessment, showed Resident 23's cognition was intact and received anti-anxiety medication.
During an interview on 08/05/2024 at 3:46 PM, Resident 34 was sitting up in their wheelchair, talkative, alert and answered questions appropriately. Resident 34 stated they were receiving a medication for their anxiousness, but the prescription ran out and they no longer received it. Resident 34 stated the cancer would cause them anxiety and would get in my head.
Review of the July 2024 MAR, showed on 07/03/2024 an order for ativan (a brand of anti-anxiety medication) 0.5 mg every six hours as needed for 14 days for their anxiety and agitation (ended on 07/17/2024). Resident 34 received the medication three times during that period.
Further review of the medical record showed there was no person-centered behavior monitoring specific to Resident 34 nor were there person-centered non-pharmacological interventions attempted prior to administering the ativan. Additionally, no AIMS assessment had been completed prior to the start of a psychotropic medication.
During an interview on 08/08/2024 at 10:10 AM, Staff M, Social Services Director, stated nursing and Social Services were to implement behavior monitoring and non-pharmacological interventions for residents on psychotropic medications. That the interventions were placed on the care plan and the [NAME] so the nursing assistants could document on them. Staff M stated they used standard behaviors and interventions to monitor until they get familiar with the resident. Staff M further stated that if a resident had been receiving an as needed medication or had been in the facility since 05/2024 then they would have experienced some type of behavior, and their care plan should have been updated to reflect the behavior. Staff M stated they were not responsible for completing the AIMS assessments.<Resident 35>
Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a right hip fracture, dementia (the loss of thinking, remembering, and reasoning- to the extent that in interferes with ADL's), severe with other behavioral disturbances, disorientation, and insomnia (a sleep disorder that makes it hard to fall asleep, stay asleep, or get quality sleep). Resident 35's comprehensive assessment dated [DATE], showed they required substantial assistance of 1 to 2 caregivers for activities of daily living (ADLs), cognition was severely impaired.
An observation on 08/05/2024 at 11:24 AM, showed Resident 35 in a wheelchair in the hallway. Resident 35 acknowledged staff by speaking to them, smiling and nodding their head.
An observation on 08/07/2024 at 12:34 PM, showed Resident 35 had wheeled themselves into the dining room. Resident 35 was smiling and stated hello when spoken to.
During an observation and concurrent interview on 08/08/2024 at 10:10 AM, showed Resident 35 being laid down in bed by Staff V, Nursing Assistant (NA). Resident 35 was smiling and compliant with care during the transfer from the wheelchair to the bed and while being provided personal care. Staff stated they had cared for Resident 35 since their admission, and they had always been compliant with all care and had never shown any agitated or aggressive behaviors. Staff V stated Resident 35 was kind and did not speak often.
During an interview on 08/12/2024 at 11:46 AM, Staff W, Registered Nurse (RN), stated they had taken care of Resident 35 since their admission and had never seen them agitated or difficult to care for. Staff W stated Resident 13 was slow to respond to questions however they would answer when given time and was always very kind and easy to care for.
During an interview on 08/12/2024 11:36 AM, Staff C, Registered Nurse, Resident Care Manager (RN/RCM), stated Resident 35 had not shown any type of agitated or combative behavior before. Staff C stated Resident 35 could be impulsive and attempt self-transfers but had always been a gentle, nice person who would communicate with staff appropriately when provided enough time to respond in conversations.
Review of Resident 35's physician orders showed the medication Olanzapine [an antipsychotic (A type of drug used to treat symptoms of psychosis) medication used for mental disorders including Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and bipolar disorder (a brain disorder that causes changes in a person's mood, energy, or ability to function)] was ordered to be administered every evening beginning on 06/25/2024.
Review of Resident 35's MAR for June, July and August 2024 showed, Olanzapine 5 mg tablet was administered every evening.
Review of Resident 35's care plan dated 08/02/2024, showed a problem for behavior monitoring related to the use of Olanzapine. Care plan interventions were to monitor for pinching/scratching/spitting/wandering/threatening behavior/rejection of care/kicking/hitting/grabbing/biting/abuse language and sexually inappropriate behaviors. The care plan further showed if behaviors were exhibited staff were to refer to the system listed interventions and assist Resident 35 to a quiet area, offer snacks, allow them to express concerns, music in room, redirect, and toileting assistance.
Review of Resident 35's June, July and August 2024 MARs showed there was no monitoring for the behaviors that were listed on the care plan related to the use of Olanzapine.
Review of a provider visit note dated 07/05/2024, showed Resident 35 had diagnoses of unspecified dementia severe, unspecified dementia type, unspecified whether behavioral, psychotic, or mood disturbance or anxiety.
Review of a Resident 35's pharmacy review dated July 2024, showed, Resident is receiving Olanzapine an antipsychotic, but behavioral monitoring is not present. Specific behaviors need to be added to the Physician orders.
Reference WAC : 388-97-1060(3)(k)(i)
Jul 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 F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to ensure hemodialysis (a machine that filters wastes, salts and fluids from the blood when the kidneys no longer were working properly) care...
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Based on interviews and record review, the facility failed to ensure hemodialysis (a machine that filters wastes, salts and fluids from the blood when the kidneys no longer were working properly) care and services were consistent with professional standards of practice for 1 of 2 residents (Resident 1) reviewed for dialysis care. The facility failed to remove the pressure dressing applied to the A/V fistula (arteriovenous fistula - surgically created connection between vein and artery to allow direct access to the bloodstream for dialysis) following dialysis treatment, failed to consistently monitor the resident's condition following dialysis and to ensure facility policies and procedures were implemented. This failed practice placed Resident 1 at risk for complications and adverse medical conditions.
Findings included .
Review of the facility policy titled, Hemodialysis Care, last revised on 11/2023, showed staff were to assess bruit (listen for blood flow through the fistula by placing stethoscope on the fistula, any changes in the pitch might indicate a clot or narrowing of the fistula) and thrill (vibration caused by blood flowing through the fistula - can be felt by placing fingers above the incision line) on a daily basis; evaluate fistula site for signs/symptoms of infection, swelling, redness, bleeding, bruising, hematoma (pool of mostly clotted blood) and distention (larger) veins near site; and follow instructions on when to remove dressings to the fistula site. Upon the resident's return from dialysis treatment the post dialysis assessment was to be completed.
Residents who required hemodialysis were provided ongoing assessments and monitoring of the resident's condition before and after dialysis treatments including monitoring for complications and interventions as part of nursing standard of practice.
<Resident 1>
Review of the medical record showed Resident 1 was admitted to the facility with diagnoses which included end stage renal disease (condition in which the kidneys no longer were able to remove waste and balance fluids) and dementia. Review of a comprehensive assessment, dated 05/26/2024, showed Resident 1 had severe cognitive impairment. Review of Resident 1's plan of care, dated 05/23/2024, showed the resident required maximum assistance of one staff for turning in bed, totally dependent on one staff for dressing and toileting, extensive assistance with one staff for grooming and transfers and was unable to walk due to inability to bear weight on the left leg. In addition, Resident 1 received hemodialysis weekly on Tuesdays, Thursdays and Saturdays.
On 07/18/2024 at 8:55 AM, Collateral Contact (CC) A (dialysis Registered Nurse - RN), stated for the past month Resident 1 would return to dialysis with their pressure dressing still in place over the fistula despite instructions provided to the facility to remove it after four hours. Collateral Contact A stated the facility had been notified three times weekly regarding that issue. On 07/18/2024 CC A stated they notified Staff C, Interim Director of Nursing, of the problem. Staff C stated they would have to address the issue with the LN responsible for the removal of the dressing.
On 07/22/2024 at 1:53 PM, CC B (Manager at dialysis center), stated facility staff were not removing Resident 1's pressure dressing from their fistula site and the resident would then return to their next scheduled dialysis treatment with the pressure dressing still in place. Collateral Contact B stated that occurred on every dialysis treatment over the past month. On 07/13/2024 dialysis staff even wrote on the pressure dressing, please change me in four hours. Dialysis staff had called the facility five to six times over the past month to report the problem but nothing changed. Collateral Contact B stated one of the dialysis staff spoke to Staff C, Interim Director of Nursing, on 7/18/2024 regarding the pressure dressing not being removed and yet on 07/20/2024 (next scheduled dialysis treatment) Resident 1 arrived at dialysis with the same pressure dressing that had been placed by dialysis staff on 07/18/2024.
On 07/23/2024 at 11:37 AM, Staff C, stated they had received a telephone call on 07/18/2024 from a staff member at the dialysis center who reported Resident 1 had arrived that day with the pressure dressing still over the fistula since 07/16/2024. Staff C stated they were working on an inservice with Staff D, evening shift Registered Nurse (RN), but did not follow through, thus no education was given.
On 07/22/2024 at 12:45 PM, Staff D, stated they were not sure they removed the pressure dressing from Resident 1's fistula each time following dialysis. Staff D stated they did not really look at the fistula site.
On 07/22/2024 at 12:50 PM, Staff E, day shift RN, stated Resident 1 left for dialysis at approximately 6:30 AM so they rarely even saw the fistula to do an assessment. Staff E stated the evening shift licensed nurses were to check the pressure dressing and remove it.
On 07/22/2024 at 12:58 PM, Staff F, RN, stated facility staff would not be able to assess Resident 1's fistula with the pressure dressing on.
Review of the facility Pre Dialysis Evaluations, dated 06/20/2024, 06/25/2024, 07/16/2024 and 07/18/2024, showed dialysis staff had hand written on the evaluation forms to remove the dressing to Resident 1's left upper arm within four hours. The evaluation forms were then sent with Resident 1 when they returned to the facility. Review of Resident 1's Pre dialysis evaluation form, dated 07/20/2024, showed CC B documented the dressing to the left upper arm was to be removed in four hours. If dressing is not removed w/in [within] 24 hours [Resident 1] runs the risk of [Resident 1's] access clotting and if this happens then [Resident 1] is unable to dialyze and [Resident 1] can die .This access is [Resident 1's] life line.
Review of physician's orders, dated 05/24/2024, showed staff were to evaluate Resident 1's fistula for signs/symptoms of bleeding, bruising, hematoma and infection daily. In addition, review of physician's orders, dated 5/25/2024, showed staff were to complete the Post Dialysis Evaluations every Tuesday, Thursday and Saturday afternoons.
Despite physician's orders and facility policy to complete the Post Dialysis Evaluation forms following each dialysis visit, review of Resident 1's medical record showed they were only completed on 05/25/2024, 06/08/2024 and 07/06/2024.
Reference (WAC) 388-97-1900(1)
May 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
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 interviews and record review the facility failed to timely and thoroughly evaluate and monitor a change of condition fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to timely and thoroughly evaluate and monitor a change of condition for 1 of 3 residents (Resident 1) reviewed for changes in condition. Failure to assess and monitor Resident 1 in a timely manner following a significant change of condition placed the resident at risk for a delay in medical treatment.
Findings included .
<Resident 1>
Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included diabetes, respiratory disease, kidney disease and heart disease. Review of Resident 1's comprehensive assessment, dated 03/12/2024, showed the resident had no cognitive impairments. Review of Resident 1's plan of care, dated 03/05/2024, showed they required maximum assistance with one staff for dressing, bathing, personal hygiene; minimal to moderate assistance with one staff for transfers and walking; stand by assistance by staff for toileting; and was independent with eating.
Review of a PN, dated 04/19/2024 at 1:00 PM, by Staff A, Registered Nurse, stated Resident 1 was more tired today and had a change in mentation (mental activity). Resident 1 had word salad (a jumble of extremely confused/unclear speech) this morning and was a bit more confused from their baseline. The assessment showed slight left sided mouth drooping (unknown if that was Resident 1's baseline), equal hand grips and strength. The Nurse Practitioner (NP) was consulted (unknown time) and orders were received for a urine test to be done. The ordered urine test was negative for infection. The NP advised to send Resident 1 to the emergency room due to a change in mental status.
Review of Progress Notes, dated 04/19/2024 at 1:36 PM, showed Resident 1 was drowsy that morning but easily arousable. Resident 1 had some confusion.
Review of an assessment of Resident 1 by the NP on 04/19/2024 (unknown time), showed the resident was seen urgently due to a change in their mentation and was confused/disoriented since the start of that day. Resident 1 was alert with drowsiness, tremors on both sides, disoriented with impaired memory, vital signs were stable and the urine test performed was negative for infection. The NP recommended to send Resident 1 to the emergency room (ER) for evaluation.
Review of hospital records, dated 04/19/2024, showed Resident 1 was transferred to the ER for left-sided weakness, facial droop, headache, altered mental status and tremors. A magnetic resonance imaging (MRI, a noninvasive medical imaging test that produced detailed images of almost every internal structure in the human body, including the organs, bones, muscles and blood vessels) and computed tomography (CT, imaging test to help detect internal injuries and disease) scan were performed and were negative for stroke. The ER assessment showed Resident 1 had respiratory failure, tremors of both arms and transient ischemic attack (TIA, a short period of symptoms similar to those of a stroke).
On 05/02/2024 at 9:45 AM, Staff B, Nursing Assistant (NA), stated they were Resident 1's primary caregiver on the dayshift of 04/19/2024. Staff B stated at 6:30 AM on 04/19/2024 that when they questioned Resident 1 regarding their breakfast order they made no sense with their verbal responses. Staff B had to feed Resident 1 breakfast that morning, which they usually fed themselves. At 10:00 AM the resident's confusion and the droop to the left side of their mouth got worse. Staff B and Staff C, NA, then attempted to transfer Resident 1 from the bed to their wheelchair. Resident 1 was unable to hold their body up to get out of bed. The sit to stand lift system (designed for residents with some mobility and strength and need some assistance with standing, sitting and toileting) was then attempted, however the resident was again unable to sit up to hold on to the lift. Staff B stated Resident 1 was worse that morning then the day before when Staff B provided care. Normally Resident 1 used a walker and required one staff to assist with transfers. For lunch Staff B had to break up a hamburger in pieces to feed to Resident 1. Staff B stated they had to place a piece of hamburger in the resident's hand five times to get the resident to eat. It took 45 minutes for Resident 1 to eat. The resident's tremors to their arms were bad that day. Staff A had seen Resident 1 at 7:00 AM. At 9:00 AM, Staff A performed a stroke test (testing hand grips and strength, facial symmetry to determine if features were even on both sides, speech and any leaning to the side) on the resident and stated there were no issues. In speaking with Staff D, Director of Nursing, regarding changes in Resident 1's condition, they wanted the NP to be notified. The NP evaluated Resident 1 at 11:00 AM and voiced no concerns. Staff B stated that due to the significant changes in Resident 1's condition the day was getting more frustrating as it went on, as nothing seemed to be done for the resident. Staff B stated they reported the significant changes in Resident 1's condition to Staff A, D and E, Licensed Practical Nurse/Resident Care Manager.
On 05/02/2024 at 9:35 AM, Staff A, stated they only worked at the facility two to three times per month and had not cared for Resident 1 before. Staff A stated on 04/19/2024 at approximately 7:30 AM to 7:45 AM they observed drooping at the left side of the resident's mouth and their verbal responses were word salad. When the NP evaluated Resident 1 later that morning, they stated there was left sided droopiness and an altered mental status. A urine test was performed between 12:00 PM to 12:30 PM and was negative for infection.
On 05/02/2024 at 10:55 AM, Staff E, stated during their initial rounds of their residents the morning of 04/19/2024 they observed Resident 1 seemed a little confused. Staff E stated they spoke with Staff A regarding their observation of Resident 1. Staff E then went to a meeting which lasted 1.5 hours. At approximately 11:30 AM on 4/19/2024 Staff E stated the NAs were getting concerned regarding Resident 1's increased confusion. Staff A then notified the NP who ordered a urine test which was negative. The NP stated because of Resident 1's increased confusion they wanted them sent to the ER for an evaluation. Staff E stated it seemed like it was an obvious TIA.
On 05/02/2024 at 10:45 AM, Staff C, stated the morning of 04/19/2024 they had assisted Staff B with Resident 1. Resident 1 was more confused and had drooping of the left side of their mouth, more than usual. The resident's speech was hard to understand and their left side was slightly weaker. The resident was unable to hold onto the sit to stand lift system and their legs would not hold the resident up. Staff C stated they reported their findings to Staff A.
On 05/02/2024 at 11:15 AM, Emergency Medical Technician (EMT) A, stated upon their assessment on 04/19/2024 Resident 1 could talk but had slurred speech, they were leaning to the left side and had a facial droop on the left side. They stated it looked like a stroke. When the Licensed Nurse (LN) was asked what was going on with Resident 1 they stated the resident was not feeling well. The EMT A stated it seemed like Staff B had more knowledge of Resident 1 than the LN. Staff B stated the changes in the resident's condition had been going on since
7:30 AM that morning and they had been fighting with nursing staff to send Resident 1 to the ER.
On 05/02/2024 at 11:50 AM, EMT B, stated that following their assessment of Resident 1 on 04/19/2024 they called the ER and stated they needed to initiate the stroke protocol upon Resident 1's arrival. The EMT stated Resident 1 was positive on the stroke test due to tremors, fairly significant droop to the left side of their mouth, slurred speech, resident slumped to the left side and confusion. The EMT stated Staff B had made the statement they had been battling with the facility all day to call 911. Transportation from the facility to the ER was emergent, and Resident 1 was immediately taken into the CT lab for testing.
Further review of PNs, dated 04/22/2024 at 11:31 AM, showed Resident 1 was readmitted to the facility following a three day stay at the hospital.
Reference (WAC) 388-97-1060(1)
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0573
(Tag F0573)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide copies of medical records within two working days as requi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide copies of medical records within two working days as required for 1 of 1 resident (Resident 1), reviewed for access to medical records. This failure placed the resident and/or representative at risk of not being fully informed of services and treatments provided, and violated their rights.
Findings included .
Review of Resident 1's medical record showed they were admitted to the facility on [DATE] with diagnoses which included dementia (loss of cognitive functioning - thinking, remembering and reasoning).
A telephone interview on 07/26/2023 at 9:47 AM with Resident 1's representative, showed that on 07/21/2023 at 10:30 AM they requested a copy of parts of Resident 1's medical record and were told only Staff A, Medical Records, could get the form to complete the record request. Staff A was not available at the time of the representative's request. The representative gave their name, phone number, resident's name and date of birth and the specific parts of the medical record they wanted, to an unknown staff member who shared an office with Staff A. That unknown staff member wrote the information on a sticky note and informed the representative that Staff A would call them when they returned to the office. The representative stated they never received a telephone call from Staff A, nor had they received copies of Resident 1's medical record.
Staff B, Licensed Practical Nurse/Resident Care Manager, stated on 07/31/2023 at 3:45 PM, that Resident 1's representative had requested a copy of the resident's record on 07/21/2023, and they were not sure about any form being used by the facility to request records. Staff B stated they wrote the representative's information on a sticky note and placed it on the desk of Staff A on 07/21/2023.
Staff A stated on 07/31/2023 at 9:50 AM that they did not see the sticky note regarding the request for medical records by Resident 1's representative until 07/25/2023. Staff A stated they attempted to call the representative but were unsuccessful, and did not make any further attempts to reach the representative. Staff A stated no copies of Resident 1's medical record had been copied for the representative (10 days following the representative's initial request).
Reference (WAC) 388-97-0300(2)(a)(b)
Jun 2023
6 deficiencies
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 right calf rash was identified, the cause det...
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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 right calf rash was identified, the cause determined, and monitoring occurred in 1 of 1 Residents (Resident 55) reviewed for non-pressure related skin conditions. This failure placed the resident at risk for a delay in identification and treatment of new skin impairments, a delay in preventative measures put in place to prevent worsening, discomfort, and decreased quality of life.
Findings included .
Review of the facility policy titled, Skin at risk/skin breakdown, updated on 09/2020, showed that a full body skin evaluation would be completed upon admission, then weekly by a licensed nurse. The licensed nurse would place monitoring and ordered treatments on the treatment administration record (TAR). The policy further showed that all non-pressure related skin impairments would continue to be monitored weekly during the healing process and were to coincide with weekly skin assessments.
Resident 55. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a left pelvic fracture (a break in one or more bones in the body below the abdomen) and chronic kidney disease (kidneys are damaged and cannot filter blood the way they should.) The 05/29/2023 comprehensive assessment showed the resident was cognitively intact. Further review of the assessment showed no skin issues were documented during the assessment period.
Review of the hospital discharge order summary, dated 05/12/2023, showed that Resident 55 had a right calf erythemal rash (abnormal redness and inflammation of the skin) with orders to apply an anti-bacterial cream (a cream that is used to prevent minor skin injuries from becoming infected) topically (application to areas of the skin) to affected area for seven days.
Review of Resident 55's admission nursing skin assessment, dated 05/12/2023, showed that the resident had a 3.0 centimeter (cm) by 5.0 cm pink, warm, area to the right calf.
Review of the May and June 2023 medication administration record (MAR) and the May and June 2023 TAR showed an order was written on 05/12/2023 for Neomycin-Polymyxin Cream 1 % (an antibacterial cream that is used to prevent minor skin injuries from becoming infected) to be applied to affected areas for seven days. There was no location noted as to where to apply the cream. Further review showed the order was changed on 05/15/2023 to add the location of the cream to the right calf rash for seven days. Further review of the MAR and TAR showed no documentation of monitoring the right calf rash from 05/12/2023 to 06/08/2023.
An observation on 06/07/2023 at 2:53 PM, showed Resident 55's right calf with a quarter size, black scabbed area with slight redness to the edges. There was no drainage noted.
During an interview on 06/07/2023 at 2:25 PM, Resident 55 stated they got the rash at home and thought it was a bug bite, but it had never healed and instead, worsened. The resident further stated, I have told so many people, but I cannot remember their names.
During an interview with Staff U, Registered Nurse (RN) on 06/08/2023 at 8:14 AM, they stated that the process for a skin assessment would be to do a complete head-to-toe assessment of the skin looking for any issues with skin integrity (health of their skin) and to document it on the skin assessment form. Staff U further stated that they did not see any skin issues on 06/06/2023 when they completed a head-to-toe skin assessment on Resident 55.
Record review showed a skin assessment, dated for 06/06/2023, with no skin issues documented.
During an interview with Staff O, RN 06/08/2023 at 10:35 AM, they stated that the skin assessment process would be a head-to-toe skin assessment every week. If they notice any skin issues, they put it on the skin assessment sheet and wrote a description of their findings. They used the wound treatment orders guidelines on how to write a new order for any new skin issues. Staff O further stated that they did not notice any skin issues on Resident 55 when they completed a head-to-toe skin assessment on 05/30/2023.
Record review showed a skin assessment, dated 05/30/2023, with no skin issues documented.
During an interview with Staff R, Licensed Practical Nurse (LPN), on 06/08/23 at 8:36 AM, they stated Resident 55 reported a spider bite on their right calf on the day of admission, 05/12/2023. They further stated that they would normally place an order on the TAR to monitor that area. Staff R stated, There was not an order placed to monitor the right calf. They stated that their expectation would be for the floor nurses to monitor that area for any changes until it was resolved. Staff R stated, We should have put an order on the TAR to monitor for any changes and notify the RCM (Resident Care Manager) for changes. We rely on the nurses on the floor for the weekly skin checks; we would expect our floor nurses to note any changes.
During an interview on 06/08/2023 at 8:32 AM, Staff B, Director of Nursing Services, stated that their expectation for the admitting nurses was to do a full body baseline skin assessment, document any skin issues and place an order for monitoring and treatment.
During an interview on 06/09/2023 at 11:30 AM, Staff C, Medical Director, stated that they were notified about skin issues from the nurses while they were in the building. If they were not in the building, the nurses sent a SBAR ([situation, background, assessment, and recommendation] a form used to notify the physician of a residents change in condition) via fax. Staff C further stated they were not made aware of any skin issues for Resident 55.
Reference: WAC 388-97-1060(3)(b)
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 ensure 1 of 5 residents (Resident 23) reviewed for acc...
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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 1 of 5 residents (Resident 23) reviewed for accidents, was assessed for safe, independent use of a smoking device, after the resident's roommate reported to staff that Resident 23 had been using a vape pen (an electronic cigarette device that simulates tobacco smoking) in their room. This failure placed the residents at risk for preventable accidents and a diminished quality of life.
Findings included .
Review of the undated Resident Orientation Guidebook, showed No Tobacco: Smoking and the use of tobacco products are not allowed anywhere on facility grounds by the residents. Tobacco products, lighters, and matches must be given to family or friends upon admission, or we can assist with disposal.
Review of the No Smoking Policy for Residents, dated 03/2020, showed No smoking or use of smoking materials is allowed on the grounds, including parking lots, except at the following locations: In personal vehicles (vehicles are considered personal property) or off the center premises. Further review showed Residents and family are counseled during pre-admission and at admission about our smoke-free campus for residents .The center will assist with orders for medications, equipment, and other items needed to assist with compliance with the smoking policy.
Resident 23. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including pneumonia, respiratory failure, dementia, and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements). The 04/23/2023 comprehensive assessment showed the resident required extensive assistance of two staff members for activities of daily living (ADLs). The assessment also showed the resident had a severely impaired cognition. Additionally, the assessment showed that the resident had not used tobacco in any form during the seven days of the assessment period.
During an interview with Resident 23's roommate on 06/07/2023 at 9:04 AM, they stated that an unknown staff member found a vape pen in Resident 23's bed and that the resident had been smoking it in their room for the last few weeks. The resident could not recall when the vape pen was found.
During an interview on 06/07/2023 at 10:30 AM, Resident 23 stated that they had been going off-property to use the vape pen and that the nursing staff was keeping it for them when it was not in use.
During an interview on 06/07/2023 at 11:27 AM, Staff M, Nursing Assistant, stated that Resident 23 had a vape pen that was found in their bed, but it was now kept in the medication cart. Staff M stated I do not know if upper management knows about it or not, I have not personally told anyone, but I did take the vape pen away from Resident 23 once before. Staff M further stated that the family brought vape pens to the resident. Staff M could not recall when the vape pen was found in Resident 23's bed.
Review of Resident 23's medical record showed that the facility failed to complete an assessment of the resident's ability to safely handle the vape pen without assistance or supervision. Additionally, the resident's care plan, dated 06/06/2023, had not been revised to include the use of the vape pen.
During an interview on 06/07/2023 at 1:02 PM, Staff A, Administrator, stated that they were unaware of the incident in which a vape pen was found and confiscated from Resident 23.
During an interview on 06/08/2023 at 12:25 PM, Staff A stated that they completed an investigation and found that Staff L, Social Services Assistant, knew the resident had a vape pen, had known about it for about two weeks, and never reported it.
Record review of the 06/07/2023 investigation provided by Staff A, showed that Resident 23 had been hiding the vape pen and stated that they had vaped in the room. Resident 23 stated in the investigation that Staff L came to the room and spoke to them about vaping and that they hadn't used it indoors since. The investigation confirmed that family had brought in multiple pens and the resident wanted to continue to use their pen.
During an interview on 06/08/2023 at 12:32 PM, Staff N, RN, stated that they kept the vape pen in a small bag in the back of a drawer on the medication cart. They stated that it had been in the medication cart for about a week. Staff N opened the drawer and showed a small pink vaping device, about 1.5 inches by 1 inch in a small bag.
During an interview on 06/08/2023 at 1:50 PM, Staff L stated that Resident 23's significant other came to the facility and expressed that they were upset that Resident 23 had a vape pen and that they were using it, adding that the resident's granddaughter brought it in and gave it to the resident. When asked about the resident's safety when using the pen, Staff L stated they could see how it was unsafe for the resident to use the pen due to their cognitive impairment. They further stated that the resident had multiple admissions and discharges to the facility and showed severe cognitive impairment, but that their cognition improved during each stay. Staff L stated that at the current time, they thought the resident was able to go off property alone and safely use the vape pen. Staff L stated that they believed the residents granddaughter took the vape pen when they left, and that they did not know the resident had kept it.
Reference: WAC 388-97-1060(3)(g)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
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 1 of 4 residents (Resident 215) who utilized ad...
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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 1 of 4 residents (Resident 215) who utilized adaptive eating equipment was provided with the necessary adaptive equipment for eating as ordered by Staff S, Occupational Therapist (OT). Resident 215 was not provided with a plate guard (a curved assistive device that helps to keep food from falling off of the plate) for two of three meals observed. This failure placed the resident at risk for increased dependence for eating and the potential for decreased food consumption.
Findings included .
Review of the 02/2019 facility policy titled Assistive Devices, showed that the facility was to provide special eating equipment and utensils for residents that required them. Further review showed the assistive devices were provided to residents at each meal.
Resident 215. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including epilepsy (a brain disorder that causes uncontrolled body movements), severe protein malnutrition, schizoaffective disorder (a mental health disorder that causes symptoms such as hallucinations, delusions [a belief in something that is untrue], and depression), and chronic subdural hemorrhage (an old blood clot on the surface of the brain). The 04/12/2023 comprehensive assessment showed the resident required extensive assistance of one staff member while eating. The assessment also showed they had a severely impaired cognition.
Record review of the 04/08/2023 through 06/06/2023 Occupational Therapy Evaluation and Plan of Treatment, showed goals for the resident included improvement in their ability to perform eating tasks safely and efficiently with standby assist and use of adaptive equipment as needed.
Record review of the 04/07/2023 care plan showed a goal for the resident's weight to remain within acceptable parameters (range) as determined by the Registered Dietician and Interdisciplinary Team (a team of healthcare professionals that work together towards a common goal for the resident). A listed intervention was for the resident to eat in the assisted dining room with one person supervision.
An observation on 06/06/2023 at 11:57 AM, showed the resident was eating lunch in the assisted dining room. They were provided foam handled silverware and a plate guard was applied to their plate. The resident was able to eat more than 75% of their food.
An observation on 06/07/2023 at 8:33 AM, showed the resident was in the assisted dining room with foam handled utensils and no plate guard. Their food was scattered on the table and around the dining plate, as there was no plate guard to prevent the spillage. Further observation showed the resident's food tray card showed they were to have foam handled utensils and a plate guard.
An observation on 06/08/2023 at 8:24 AM, showed the resident in the assisted dining room with foam handled utensils and no plate guard. There was food spillage on their clothing protector and on the table.
During an interview on 06/08/2023 at 8:25 AM, Staff R, Licensed Practical Nurse, stated that the resident's food tray card showed they were to have a plate guard. Staff R stated that the kitchen staff had forgotten to put the plate guard on their tray.
During an interview on 06/08/2023 at 2:28 PM, Staff S, OT, stated that they ordered a plate guard and foam handled utensils for the resident to assist with self-feeding. Staff S stated that the plate guard helped the resident scoop food onto their utensils. Staff S stated that the kitchen staff were responsible for placing the adaptive utensils and plate guard on the resident's tray.
During an interview on 06/09/2023 at 11:49 AM, Staff F, Dietary Manager, stated that the kitchen staff were to place the adaptive utensils and plate guard on the resident's tray during meal service and nursing assistants were to put the plate guard onto the resident's plate. Staff F stated that they were not aware that the plate guard had not been placed on the resident's food tray for breakfast on 06/07/2023 and 06/08/2023.
During an interview on 06/09/2023 at 12:28 PM, Staff B, Director of Nursing Services, stated that the resident had jerky movements and the plate guard assisted with self-feeding. Staff B stated that the assisted dining room was staffed with restorative aides and nursing aides that should help review resident food tray cards and make sure they have the assistive devices they need.
Reference WAC: 388-97-1140(2)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure 1 of 1 kitchen was maintained in a sanitary manner for prevention of cross contamination. The dishwasher was not mainta...
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Based on observation, interview and record review, the facility failed to ensure 1 of 1 kitchen was maintained in a sanitary manner for prevention of cross contamination. The dishwasher was not maintained and repaired as needed, perishable (food that will go bad quickly) food labeling was inconsistent, expired food was observed in the refrigerator, and a staff beverage was located with clean dishware. These failures placed all residents that ate food from the kitchen at risk for food borne illnesses and a diminished quality of life.
Findings included .
Dishwasher
During a concurrent observation and interview on 06/06/2023 at 8:55 AM, Staff F, Dietary Manager (DM), showed a discolored and frayed, eighteen by one inch dish towel, wedged into the vertical edge of the front panel of the dishwasher. The dish towel was wet when exposed to the dishwashing cycles when the dishwasher was operated. Staff F stated that the dish towel was placed there by the Maintenance Director to prevent leaks and water from being sprayed out of the dishwasher.
A concurrent observation and interview on 06/08/2023 at 10:47 AM, showed the dish towel remained in place along the vertical edge of the front panel of the dishwasher. Staff T, Dietary Aide (DA), stated that the dish towel had been there since they were hired one and a half years ago. Staff T stated that the dish towel prevented water from leaking out of the dishwasher. The dish towel was saturated with water when the dishwasher was opened.
During a concurrent observation and interview on 06/08/2023 at 1:45 PM, Staff E, Registered Dietician (RD), stated that they had been employed for six weeks and was not aware of a dish towel wedged into the vertical edge of the front panel of the dishwasher. Staff E observed the dish towel wedged into the dishwasher and stated that the dish towel was exposed to the inside contents and exposed to the outside was not sanitary.
During an interview on 06/08/2023 at 2:51 PM, Staff I, Maintenance Director, stated they placed the dish towel into the edge of the front panel of the dishwasher eight to 10 months ago. Staff I stated the dishwasher was leaking and they stopped the leak by placing the dish towel into the edge of the front panel. Staff I further stated they serviced the dishwasher, completed some repairs, but had not fixed the leak.
During an interview on 06/08/2023 at 2:39 PM, Staff A, Administrator stated that they were unaware of the concern with the dishwasher.
Food Labeling
Review of the 02/2019 facility policy titled, Discard Date, showed that food products would be handled and stored in such a manner as to ensure the freshness of the food product. Food would be dated and prepared for storage to prevent deterioration (to become worse), dehydration (loss of water or fluid), or foodborne illness. All leftover food would be labeled with the discard date to include the month and day. Leftover cooked meat, poultry, and other protein foods would be used within 72 hours. Frozen leftover cooked meat, poultry, and other potentially hazardous food items would be dated with the discard date once they were taken from the freezer, which was 72 hours after being thawed.
A concurrent observation and interview on 06/06/2023 at 8:55 AM, showed the walk-in refrigerator contained a meatloaf, wrapped in plastic wrap, with a handwritten date of 05/23/2023. Staff F stated that the meatloaf was prepared on 05/23/2023 and had been pulled out of the freezer on 06/05/2023 to thaw. Staff F stated that the kitchen staff used a use by dating system and refrigerated foods should only be dated with the use by date. Staff F stated that there was only one date on the meatloaf which could be interpreted as the use by date. Staff F verified there was no indication that the date of 05/23/2023 was not the use by date.
A concurrent observation and interview on 06/08/2023 at 10:47 AM, showed the walk-in refrigerator had a container of spaghetti with a use by date of 06/05/2023 and a package of meatloaf wrapped in plastic wrap dated 06/05/2023. Staff F stated that the spaghetti was expired and should have been discarded. Staff F stated that the meatloaf was removed from the freezer the day before to thaw and the date of 06/05/2023 was the date the meatloaf was prepared. Staff F stated that prepared foods that were kept in the walk-in refrigerator were use by dates and the labeling of the meatloaf was not consistent with the facility dating policy/procedure. Staff F further stated that the meatloaf was expired with a documented date of 06/05/2023.
During an interview on 06/08/2023 at 1:45 PM, Staff E stated that the dietary staff should have used the labeling and dating system and either use the date the item was placed into the walk-in refrigerator or the used by date.
During the initial kitchen inspection with Staff F on 06/06/2023 from 8:55 AM to 9:25 AM, showed there was a plastic disposable cup, three quarters full of an orange-colored beverage, which had a lid and straw, located on the shelf where clean glasses were stored and was directly above a shelf with clean plates. The top of the lid had a one inch in diameter hole where the straw was inserted. Staff F stated personal drinks could be stored anywhere in the kitchen if there was a lid.
During an interview on 06/08/2023 at 1:45 PM, Staff E stated that the staff beverages should be kept in the break room, stored away from food preparation and service areas.
During an interview on 06/09/2023 at 9:13 AM Staff B, Director of Nursing Services, stated that the facility did not have a policy for storage of dietary staff personal beverages.
Reference: WAC 388-97-1100(3)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure standard infection prevention and control preca...
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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 standard infection prevention and control precautions were implemented for 2 of 2 residents (Residents 18 and 163) observed during wound care dressing changes. Additionally, hand hygiene was not performed during personal care (cleaning the private areas of a resident) by 2 of 2 staff (Staff G and Staff H) observed for hand hygiene. These failures placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases.
Findings included .
Review of the Centers for Disease Control and Prevention's January 30, 2020, document Hand Hygiene Guidance, showed that Healthcare personnel should use an alcohol-based hand rub or wash with soap and water:
•
Immediately before touching a resident;
•
Before moving from work on a soiled body site to a clean body site on the same patient;
•
After touching a resident or the resident's immediate environment;
•
After contact with blood, body fluids, or contaminated surfaces;
•
Immediately after glove removal.
Review of the facility policy titled Hand Hygiene Policy and Procedure, revised 04/2019, showed .hand hygiene is the primary means of preventing the transmission of infection . and hand hygiene was required during the following situations:
•
When hands were visibly soiled;
•
Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice);
•
Before and after assisting a resident with personal care;
•
Before and after changing a dressing; after removing gloves and/or before applying gloves.
Wound care
Resident 18. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including aftercare following surgery on their blood vessels and diabetes (a group of diseases that result in too much sugar in the blood). The 05/21/2023 comprehensive assessment showed that the resident required extensive assistance of two staff members for activities of daily living (ADLs). The assessment also showed the resident had a moderately impaired cognition.
An observation on 06/08/2023 at 1:17 PM, showed Staff O, Registered Nurse (RN), and Staff J, Nursing Assistant (NA), prepared to perform wound dressing changes on the resident's seven wounds:
Wound One - Right Toes
An observation on 06/08/2023 at 1:32 PM, showed Staff O cleansed the wound, removed their gloves, and without performing hand hygiene, donned clean gloves. Staff O proceeded to handle wound dressing supplies, then removed their gloves and donned clean gloves without performing hand hygiene. At 1:34 PM, Staff O, with gloved hands, proceeded to apply clean dressings to the wound. Staff J, wearing soiled gloves, assisted by holding the clean 4 inch by 4 inch gauze pads in place while Staff O began the dressing for wound two.
Wound Two - Right Heel
At 1:37 PM, Staff O began the dressing change on the second wound, wearing the same gloves as wound one. Staff O cleansed the wound, removed their gloves, and without performing hand hygiene, donned clean gloves. They obtained a black marker from their pocket and initialed and dated the dressings. They removed their gloves, did not perform hand hygiene, and donned clean gloves. Staff O applied skin protectant around the wound, removed their gloves, did not perform hand hygiene, and donned clean gloves. Staff J continued to hold the gauze in place (with same soiled gloves) while Staff O wrapped the two wounds with gauze. Staff O obtained the same black marker from their pocket, initialed and dated the gauze wrap and placed the marker back in their pocket. Staff O then removed their soiled gloves.
Wound Three - Left Heel
At 1:43 PM, Staff O, without performing hand hygiene, donned clean gloves, and placed a stack of 4 inch by 4 inch gauze pads on a barrier that was used for wound supplies. They cleansed the wound and applied the clean dressings without performing glove changes or hand hygiene between cleaning the wound and applying the new dressings. While wearing the same soiled gloves, Staff O, while wearing the same gloves, removed the black marker from their pocket and initialed and dated the clean dressing and placed the marker back in their pocket. They removed their gloves, did not perform hand hygiene, and donned clean gloves.
Wound Four - Left Groin
At 1:49 PM, Staff J, wearing the same gloves, pulled down the resident's pants, exposing the left and right groin wounds. Staff O, wearing clean gloves, cleansed the left groin wound. Without changing gloves or performing hand hygiene, Staff O applied the clean dressings. They removed their gloves and donned clean gloves, again without performing hand hygiene between glove changes.
Wound Five - Right Groin
At 1:51 PM, Staff O cleansed the wound area. Wearing the same gloves, they applied the new dressings. They did not perform a glove change between cleansing the wound and applying the new dressings.
Wound Six - Tailbone
At 1:53 PM, Staff O removed their gloves, failed to perform hand hygiene, and applied clean gloves. Both Staff O and Staff J rolled the resident onto their right hip to expose their tailbone wound. At that time, the resident required extensive personal care due to having a bowel movement. Staff J cleansed the resident's personal area while Staff O held the resident in place and kept the wound covered with gauze pads. Staff J removed their gloves and, without performing hand hygiene, donned clean gloves and switched places with Staff O, holding the resident on their right side.
At 2:04 PM, Staff O cleansed the area. At that time, the resident had a second bowel movement. While performing personal care, Staff J got a smear of bowel movement on their gloves. Staff J wiped their soiled gloves with a cleansing wipe and, wearing the same gloves, held the resident on their right-side position. Staff O removed their gloves and donned clean gloves without performing hand hygiene between glove changes. They proceeded to apply the clean dressings to the wound.
Wound Seven - Gluteal Crease (horizontal fold where the buttock meets the thigh)
At 2:08 PM, Staff O, wearing the same gloves, removed the soiled dressing from the residents wound. They removed their gloves and donned clean gloves; they did not perform hand hygiene between glove changes. They cleansed the residents wound, removed their soiled gloves, and applied clean gloves without performing hand hygiene between glove changes. They applied the clean dressings to the wound. Staff O then removed their gloves and donned clean gloves (no hand hygiene performed) and obtained a clean brief from the resident's closet. They assisted with additional personal care and redressed the resident.
During an interview on 06/08/2023 at 2:17 PM, Staff O stated that they should have done hand hygiene between each glove change.
Resident 163. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a fractured left hip and kidney injury. The 05/25/2023 admission care plan showed the resident required assistance of two staff members for ADLs. The resident had an intact cognition.
An observation on 06/08/2023 at 1:00 PM, showed Staff U, RN, performed a wound dressing change on the resident's left heel. Staff U applied clean gloves and removed the soiled dressing. They removed their soiled gloves and, without performing hand hygiene, opened the clean dressing material and applied a wound healing gel to the dressing. With bare hands, Staff U touched the resident's wound, and without performing hand hygiene, applied clean gloves. They placed the clean dressing over the wound. Staff U removed their gloves, and without performing hand hygiene, applied clean gloves. Staff U then assessed the residents tailbone wound and applied a barrier cream (used to prevent skin from being irritated from moisture) to the area. Staff U continued to reposition the resident while wearing the same soiled gloves.
During an interview on 06/08/2023 at 1:12 PM, Staff U stated that the purpose of wearing gloves was to create a barrier and that they would not need to do hand hygiene between glove changes. They further stated that they had answered the question wrong and should have changed their gloves more often and performed hand hygiene between the changes.
During an interview on 06/08/2023 at 2:54 PM, Staff B, Director of Nursing Services, stated that the expectation for nursing staff for wound care included removing all of the dressings wearing gloves, then removing the gloves, performing hand hygiene, applying clean gloves, then applying the clean dressings.
Personal Care
Resident 13. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a stroke (damage to the brain caused by an interruption of blood flow to the brain) and heart failure. The 05/03/2023 comprehensive assessment showed the resident required extensive assistance of one to two staff members for ADLs. The assessment also showed the resident had a severely impaired cognition.
An observation on 06/07/2023 at 3:28 PM, showed Staff G, NA, and Staff H, NA, performed personal care on the resident. Staff H, wearing clean gloves, positioned the resident on their left side and held them in position while Staff G pulled a soiled brief from under the resident and placed it on the bare floor. Staff G proceeded to use cleansing wipes to clean the resident's personal area. Staff G then obtained a clean brief from the resident's closet, and without changing gloves and/or performing hand hygiene, placed the clean brief on the resident. Staff G continued to dress and reposition Resident 13 while wearing the same soiled gloves. They picked up the soiled brief from the floor and placed it into the waste basket. Still wearing the same soiled gloves, they placed the package of cleansing wipes into the resident's closet. Staff G and Staff H removed their soiled gloves and exited the room without performing hand hygiene.
During a concurrent interview on 06/08/2023 at 3:39 PM, Staff G stated that they did not follow the correct process from soiled to clean with glove changes or the correct process for hand hygiene. Additionally, Staff H stated that they also did not follow the correct process for hand hygiene.
During an interview on 06/09/2023 at 9:19 AM Staff K, Infection Preventionist, stated that education, training, and monitoring was conducted for proper hand hygiene for all staff.
Reference: WAC 388-97-1320(1)(c)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to ensure the garbage dumpster area was maintained in a manner to prevent the harborage (shelter) of pests during 4 of 4 observations made on th...
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Based on observation and interview, the facility failed to ensure the garbage dumpster area was maintained in a manner to prevent the harborage (shelter) of pests during 4 of 4 observations made on three days of the survey. This failure placed the facility at risk for an unsanitary environment.
Findings included .
An observation on 06/06/2023 at 8:55 AM, showed the outside dumpster was a large metal container with two plastic lids that covered half of the surface area opening. Inside the dumpster were several bags of garbage and cartons of shakes and milk.
An observation on 06/08/2023 at 12:18 PM, showed both dumpster lids were completely open that exposed the garbage. The dumpster had multiple bags of garbage inside.
A concurrent observation and interview on 06/08/2023 at 1:51 PM, showed the dumpster was completely open with multiple bags of garbage inside. Staff E, Registered Dietician (RD), stated that both lids to the dumpster should be closed to prevent contamination.
During an interview on 06/08/2023 at 1:47 PM, Staff F, Dietary Manager, stated that the lids to the dumpster should be kept closed. Staff F stated that Staff I, Maintenance Director, usually closed the lids, and it was important to keep the lids closed so no critters go in there.
During an interview on 06/08/2023 at 2:51 PM, Staff I stated that staff are to close the lids to the dumpster after garbage was placed inside. They stated that the lids for the dumpster were to be kept closed at all times. Staff I stated the Maintenance Department had the overall responsibility for the dumpster area and when the lids were not closed, it resulted in attracting flies and birds.
An observation on 06/09/2023 at 7:55 AM, showed the dumpster lids were closed. There were two large bags of garbage on the pavement next to the dumpster.
During an interview on 06/09/2023 at 12:37 PM, Staff D, Housekeeping Manager, stated that Nursing Assistants and Housekeeping staff emptied the general garbage from the facility. Staff D stated that the dumpster lids should be kept closed, and if staff could not reach the lids, there was a stick at the dumpster area that could be used to close the lids. Staff D further stated that the Maintenance Director closed the lids when they were open, and it was important to keep the lids closed to prevent garbage from blowing out.
Reference: WAC 388-97-1320(4)
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 41% turnover. Below Washington's 48% average. Good staff retention means consistent care.
Concerns
- • 39 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $57,194 in fines. Extremely high, among the most fined facilities in Washington. Major compliance failures.
- • Grade D (45/100). Below average facility with significant concerns.
Bottom line: Trust Score of 45/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Richland Post Acute's CMS Rating?
CMS assigns RICHLAND POST ACUTE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Washington, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Richland Post Acute Staffed?
CMS rates RICHLAND POST ACUTE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 41%, compared to the Washington average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Richland Post Acute?
State health inspectors documented 39 deficiencies at RICHLAND POST ACUTE during 2023 to 2025. These included: 1 that caused actual resident harm and 38 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Richland Post Acute?
RICHLAND POST ACUTE 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 PACS GROUP, a chain that manages multiple nursing homes. With 71 certified beds and approximately 67 residents (about 94% occupancy), it is a smaller facility located in RICHLAND, Washington.
How Does Richland Post Acute Compare to Other Washington Nursing Homes?
Compared to the 100 nursing homes in Washington, RICHLAND POST ACUTE's overall rating (3 stars) is below the state average of 3.2, staff turnover (41%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Richland Post Acute?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Richland Post Acute Safe?
Based on CMS inspection data, RICHLAND POST ACUTE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Washington. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Richland Post Acute Stick Around?
RICHLAND POST ACUTE has a staff turnover rate of 41%, 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 Richland Post Acute Ever Fined?
RICHLAND POST ACUTE has been fined $57,194 across 1 penalty action. This is above the Washington average of $33,651. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Richland Post Acute on Any Federal Watch List?
RICHLAND POST ACUTE 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.