AVAMERE REHABILITATION OF SHORELINE
For profit - Corporation
115 Beds
AVAMERE
Data: November 2025
Trust Grade
58/100
#93 of 190 in WA
Photo by Avamere Rehabilitation of Shoreline
Photo by Brittney Davis
Photo by Avamere Rehabilitation of Shoreline
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Avamere Rehabilitation of Shoreline has a Trust Grade of C, which means it is average and falls in the middle of the pack among nursing homes. It ranks #93 out of 190 facilities in Washington, placing it in the top half, and #20 out of 46 in King County, indicating that only a few local options are better. However, the facility's trend is worsening, with the number of issues identified increasing from 25 in 2024 to 32 in 2025. Staffing is a strength, with a rating of 4 out of 5 stars and a turnover rate of 32%, which is lower than the state average, suggesting that staff are more stable and familiar with residents' needs. On the downside, the facility has been fined $3,250, which is average for the area, but there are concerning incidents, such as expired food not being discarded, which poses a risk of food-borne illness, and failures in ensuring that residents' nutritional needs are met according to established guidelines.
- Trust Score
- C
- In Washington
- #93/190
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 32% turnover. Near Washington's 48% average. Typical for the industry.
- Penalties ✓ Good
- $3,250 in fines. Lower than most Washington facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 46 minutes of Registered Nurse (RN) attention daily — more than average for Washington. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 74 deficiencies on record. Higher than average. Multiple issues found across inspections.
58/100
Top 48%
No red flags
25 → 32 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 25 issues
2025: 32 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (32%)
16 points below Washington average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Washington average (3.2)
Meets federal standards, typical of most facilities
Staff Turnover: 32%
14pts below Washington avg (46%)
Typical for the industry
Federal Fines: $3,250
Below median ($33,413)
Minor penalties assessed
Chain: AVAMERE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 74 deficiencies on record
Jul 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct a thorough investigation and to take appropriate corrective...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct a thorough investigation and to take appropriate corrective action for 1 of 3 residents (Resident 3), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.Findings included .Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, showed, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events .Federal law requires the nursing home to do a thorough investigation of the incident. In order for a facility to provide evidence of the thoroughness of the investigation the information must be recorded. It showed that a thorough investigation may require two phases of fact gathering which included phase one, initial investigation (within the first 24 hours) and phase two, extended investigation (after the first 24 hours). It further showed that interview of witnesses, including caregivers in the immediate area and from work shifts prior to the incident discovery was included in phase one and that interviews of expanded sample of witnesses were included in phase two. Review of the facility's policy titled Abuse and Neglect - Clinical Protocol, revised in March 2018, showed that neglect meant, The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. It further showed that the staff will investigate alleged abuse and neglect to clarify what happened and identify possible causes and that the facility management and that staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Review of electronic health record showed Resident 3 admitted to the facility on [DATE]. Review of the facility's document titled, Online Incident Report Facility/Agency Information, dated 07/08/2025, showed that Staff B, Director of Nursing, received a verbal report via phone call from Resident 3's Collateral Contact 1 regarding an incident on 07/07/2025. The document further showed action taken to prevent a recurrence of the incident was that Staff F, Registered Nurse, was suspended pending investigation.Review of the 07/07/2025 incident investigation summary report provided by Staff B showed that the involved caregivers present during the incident were interviewed. The incident investigation report did not show other potential caregiver witnesses were interviewed. Review of staff time cards showed that Staff F worked in the facility on the following dates:-On 07/09/2025, Staff F worked 1.25 hours.-On 07/10/2025, Staff F worked 10.0 hours.-On 07/11/2025, Staff F worked 9.0 hours. In an interview and joint record review on 07/18/2025 at 1:43 PM, Staff B stated that their process for interviewing witnesses while conducting an incident investigation included interviewing people who are assigned to the resident and if there are any witnesses. Joint record review of the 07/07/2025 incident investigation summary report did not show documentation that caregiver witnesses interviews were conducted. Staff B stated that they interviewed other residents and involved staff only. When asked if they would expect to interview potential witnesses of the incident, Staff B stated that they would check the purple book. Staff B further stated that they completed the investigation on 07/12/2025. Staff B stated that during an investigation, staff suspended for allegations of abuse and neglect would remain suspended until the investigation was completed. Joint record review of Staff F's clock-in/out records on 07/09/2025, on 07/10/2025 and on 07/11/2025 showed that Staff F worked in the facility prior to the completion of the investigation. Staff B stated that Staff F worked at the facility during the data collection phase and prior to the investigation conclusion. Reference: (WAC) 388-97-0640 (6)(a)(b).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet professional standards of practice to ensure a clinical assess...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet professional standards of practice to ensure a clinical assessment was completed timely for a change of condition (a sign that something might be wrong and needs attention) for 1 of 3 residents (Resident 3), reviewed for assessment of care services. This failure placed the resident at risk of receiving delayed care and for potential negative outcomes.Review of the facility's policy titled, admission Assessment and Follow Up: Role of the Nurse, revised in September 2012, showed that The following information should be recorded in the resident's medical record: 1. The date and time of the assessment was performed and showed that reporting included report other information in accordance with facility policy and professional standards of practice.Review of a electronic health record showed Resident 3 admitted to the facility on [DATE]. Review of the facility's document titled, Online Incident Report Facility/Agency Information, dated 07/08/2025, showed that Staff B, Director of Nursing, received a verbal report via phone call from Resident 3's Collateral Contact 1 (CC1) regarding an incident on 07/07/2025. It showed that CC1 alleged that Resident 3 was not assessed for a change of condition and that CC1 reported, I don't think [Staff F, Registered Nurse] assessed [Resident 3]. She said [Resident 3's] oxygen was 92% [pulse oximetry - measurement of oxygen carried in the blood] but yet the EMTs [Emergency Medical Technician - trained professional who show up in ambulances when someone calls 911 for a medical emergency] said [Resident 3's] oxygen was 74%. Review of the facility's document titled Exhibit 359 Follow-Up Investigation Report, submitted on 07/08/2025, showed that the 07/07/2025 incident occurred in the evening hours shortly after dinner. It further showed that at the time of the incident Staff F was called to tend to another resident and that Staff F left a NAC [Nursing Assistant Certified] with [Resident 3].Review of the facility document titled, SBAR [Situation/Background/Appearance/Review] Communication Form, dated 07/07/2025, showed Resident 3's recorded vital signs (basic body measurements that help providers quickly check how healthy someone is) for blood pressure and pulse rate were assessed on 07/07/2025 at 8:38 AM. It further showed that Resident 3's recorded pulse oximetry was assessed on 07/07/2025 at 11:22 PM. It did not show that Resident 3 was assessed for their vital signs at the time of the incident. In an interview on 07/15/2025 at 2:00 PM, Staff C, NAC, stated that on 07/07/2025 after dinner, after 8:00 PM and before 8:30 PM, they were called by Staff F to help interpret for Resident 3 who was non-English speaking. Staff C stated that at the time of the incident, Resident 3 was not able to be understood and that [Resident 3] wasn't [was not] talking, it was so slow, [Resident 3] tried to talk but [Resident 3] could not speak the words. Staff C then stated that they told Staff F that Resident 3 was not responding good at the time and that Staff F should call CC1. Staff C further stated that CC1 arrived at the facility around 8:30 PM or 9 PM. When asked if prior to the incident, Resident 3 could be understood verbally, Staff C stated, Yes, we speak the same language.In an interview on 07/15/2025 at 2:06 PM, Staff D, Licensed Practical Nurse, stated that if a resident had a change of condition, they would assess the resident and then check vital signs to see what's going on. Staff D then stated that they would document an assessment performed using the facility's SBAR Communication Form. Staff D further stated that all licensed nurses could assess a resident having a change of condition.In an interview on 07/15/2025 at 2:11 PM, Staff E, Resident Care Manager, stated that they expected an assessment, including checking the vital signs, would be performed in the event a resident had a change of condition. Staff E stated that they expected a resident would be assessed immediately for a change in condition and that their vital signs will be changed [differ from usual vital signs]. When asked if license nurses could delegate assessment of a resident to another staff member, Staff E stated, Yes, if a nurse is busy with another resident, and anytime there's [there is] a change of condition. Staff E stated that, It's the duty of all nurses to do something and that nurses should not walk away until another nurse takes over. In an interview and joint record review on 07/18/2025 at 1:43 PM, Staff B, Director of Nursing, stated that they expected nursing staff would assess a resident for a change of condition, including checking the vital signs. Staff B stated that they considered a change in level of alertness and in the ability to communicate as a change of condition. Staff B then stated that they expected documentation of an assessment performed would be recorded in the facility's SBAR Communication Form and that nurses had the ability to manually enter data onto the form. When asked when the 07/07/2025 incident occur, Staff B stated, It happened in the evening shift between 8:00 PM and 9:00 PM and that they suspected Resident 3 was transferred to the hospital from the facility on 07/07/2025 between 8:00 PM and 9:00 PM. Joint record review of the 07/07/2025 SBAR Communication Form, showed Resident 3's recorded Vital signs for blood pressure and pulse rate were assessed on 07/07/2025 at 8:38 AM and Resident 3's recorded pulse oximetry was assessed on 07/07/2025 at 11:22 PM. Staff B stated that according to the documentation presented Staff F did not perform a clinical assessment to include updated vital signs of Resident 3 at the time of the incident. Staff B stated that Staff F had left Resident 3 with a NAC at the time of the incident. When asked if nurses could delegate observation or care of a resident who had a change of condition to a NAC, Staff B stated No. Staff B further stated that upon identification of a change of condition, I expect them to stay with the resident and ask for additional assistance as needed. Reference: (WAC) 388-97-1620 (2)(b)(i)(ii).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
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 therapeutic diet was provided as ordered for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a therapeutic diet was provided as ordered for 2 of 3 residents (Residents 1 & 2), reviewed for therapeutic diets. This failure had the potential to cause unwanted weight gain, a decline in medical conditions, and a diminished quality of life. Findings included.Review of the facility's policy titled, Diets Available on the Menu, Revised June 2019 showed, Prescribed diets are provided to deliver nutrition for residents in the facility. In order to define and standardized, diet orders will be interpreted as follows to comply with the [facility name] approved diet manual and/or to enhance choices & quality of life while meeting the current resident nutrition needs.RESIDENT 1Review of Resident 1's Electronic Health Record (EHR) printed on 07/18/2025 showed Resident 1 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes (A disease that occurs when your body cannot use insulin - is a hormone that helps your body use sugar properly). It further showed that Resident 1 was prescribed a Carbohydrate [diabetic] diet and received scheduled insulin.Review of Resident 1's dietary card on their lunch tray dated 07/15/2025 showed Resident 1 was on a diabetic diet.Observation on 07/15/2025 at 12:00 PM showed Resident 1's lunch tray consisted of honey mustard chicken, cheesy broccoli rice floret, cornbread, baked apple with pear slices, and a non-sugary drink. Further observation showed Resident 1 consumed the entire meal.RESIDENT 2Review of EHR showed Resident 2 was admitted to the facility on [DATE] and had a diagnosis of Type 2 Diabetes, and received scheduled insulin.Review of Resident 2's dietary card on their lunch tray dated 07/15/2025 showed a diabetic diet.Observation and interview on 07/15/2025 at 12:23 PM, showed Resident 2's lunch meal tray consisted of honey mustard chicken, cheesy broccoli rice floret, cornbread, baked apple with pear slices, non-sugary drink, and one serving of whole milk. Resident 2 stated that they were diabetic and were supposed to be on a diabetic diet. Observation showed that Resident 2 consumed three quarters of the meal served.In a joint observation and interview on 07/15/2025 at 1:45PM with Staff G, Registered Dietician, Resident 2 had consumed all of their cornbread, and three quarters of their meal served. Staff G stated that they followed the prescribed diet and used a dietary spreadsheet to ensure residents received the right diet. Staff G stated that Resident 2 was not supposed to be served cornbread since they were diabetic.In a joint record review of the dietary spreadsheet on 07/15/2025 at 2:00PM with staff G, showed that cornbread was marked No for residents on a diabetic diet. Staff G further clarified that No meant that resident on a diabetic diet was not supposed be served with Cornbread.A joint record review and interview on 07/18/2025 at 11:06 AM with Staff H, Kitchen Cook, showed Resident 1's dietary card listed a diabetic diet on 07/15/2025. When asked if Resident 1 should have received cornbread for lunch on 07/15/2025 and Staff H said, No. Staff H further stated that they followed the prescribed diet and dietary spreadsheets when serving food. In an interview and joint record review on 07/18/2025 at 1:57PM, Staff B, Director of Nursing, stated that they expected staff would follow the prescribed therapeutic diet. Staff B further stated that Resident 1 and 2 should not have received the cornbread serving since they were on a diabetic diet. Reference (WAC): 388-97-1200(1)
May 2025
28 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure residents on urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) were provided with priva...
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Based on observation, interview, and record review, the facility failed to ensure residents on urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) were provided with privacy for 2 of 6 residents (Residents 30 & 8), reviewed for dignity. This failure placed the residents at risk for decreased self-worth and a diminished quality of life
Findings included .
Review of the facility's policy titled, Dignity, revised in February 2021, showed that each resident would be cared for in a manner that promoted and enhanced their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The document further showed that residents were to be treated with dignity and respect.
Review of the facility's policy titled, [Urinary] Catheter Care, revised in August 2022, showed that the purpose of this procedure is to prevent urinary catheter-associated complications, including bladder infections. The document further showed that catheter tubing and drainage bag were to be kept off the floor.
RESIDENT 30
Observation on 05/13/2025 at 4:25 PM and on 05/14/2025 at 1:30 PM showed Resident 30's urinary catheter bag was not covered by a privacy bag and visible from the hallway.
A joint observation and interview on 05/14/2025 at 1:55 PM with Staff M, Licensed Practical Nurse, showed Resident 30's urinary catheter bag was not covered with a privacy bag. Staff M stated that Resident 30's catheter bag should have been inside the privacy bag.
In an interview on 05/17/2025 at 1:17 PM, Staff E, Resident Care Manager, stated that Resident 30's urinary catheter should have been covered with a privacy bag.
In an interview on 05/17/2025 at 4:15 PM, Staff B, Director of Nursing, stated they expected urinary catheter bags to be covered, and that Resident 30's urinary catheter bag should have been covered with a privacy bag.
RESDIENT 8
Review of Resident 8's urinary care plan revised on 12/05/2024, showed, Drainage bag to remain covered.
Observations on 05/13/2025 at 11:58 AM and on 05/15/2025 at 7:52 AM, showed Resident 8's urinary catheter bag was not covered with a privacy bag, and it was visible from the hallway.
In an interview and joint observation on 05/15/2025 at 8:02 AM, Staff H, Certified Nursing Assistant, stated that catheter drainage bags should be covered with a privacy bag. A joint observation showed Resident 8's urinary catheter drainage bag was not covered with a privacy bag. Staff H stated that Resident 8's catheter bag could be seen from the hallway and should be covered with privacy bag for dignity.
In an interview on 05/16/2025 at 11:54 AM, Staff E stated that Resident 8's catheter drainage bags should be covered.
In an interview on 05/17/2025 at 10:42 AM, Staff B stated they expected catheter drainage bags to be covered with a privacy bag.
Reference: WAC 388-97-0180 (2)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an updated guardianship letter was readily available in medi...
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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 an updated guardianship letter was readily available in medical records and accessible to staff for 1 of 4 residents (Resident 29), reviewed for Advanced Directives (a written instruction, such as a living will or durable power of attorney for health care). This failure placed the resident and/or their representative at risk of losing their right to have their preferences honored to receive care according to their choice.
Findings included .
Review of Resident 29's guardianship letter signed/dated on [DATE] showed it was effective until [DATE]. Further review showed no documentation that the facility attempted to have an updated guardianship letter in Resident 29's Electronic Health Record (EHR).
In an interview and joint record review on [DATE] at 2:36 PM, Staff A, Administrator, stated that if a resident had a guardianship, the facility would ask for documentation and it would be uploaded into the resident's EHR. Staff A stated that guardianships expired, and they would need to contact the guardian if it needed to be renewed. A joint record review of Resident 29's guardianship letter showed that it was signed on [DATE] and expired on [DATE]. Staff A stated, it should not be expired. A joint record review of Resident 29's EHR showed no discussion of guardianship. Staff A stated, I need to reach out to the guardian for new paperwork and there should be new paperwork in the chart [EHR] for [Resident 29].
Reference: (WAC) 388-97-0280 (3)(a)(d)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to issue Notification of Medicare Non-Coverage (NOMNC- a required form notifying the resident that their skilled services coverage was ending ...
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Based on interview and record review, the facility failed to issue Notification of Medicare Non-Coverage (NOMNC- a required form notifying the resident that their skilled services coverage was ending and would no longer be covered by their Medicare A benefits) at least two calendar days before the Medicare coverage ended for 1 of 3 residents (Resident 56), reviewed for beneficiary notification. This failure placed the resident and/or their representative at risk for not being fully informed and losing their right to an appeals process.
Findings included .
Review of the facility's policy titled, NOMNC Policy, revised on 09/12/2024, showed that A NOMNC will be issued at least 2 days, but not greater than 4 days, prior to the last covered day, to beneficiaries where it has been determined that Medicare A, B, or C covered services are no longer required.
Review of Resident 56's NOMNC showed a last day of Medicare A coverage of 04/11/2025 and signed on 04/10/2025, one day before the end of Medicare A coverage.
In an interview and joint record review on 05/16/2025 at 3:23 PM, Staff G, Social Services Director, stated that the NOMNC must be provided no less than 2 days prior to last coverage day of their skilled stay. A joint record review of Resident 56's NOMNC showed that Resident 56's last coverage day was 04/11/2025 and the NOMNC was provided on 04/10/2025. Staff G stated, it was not given two days before the last coverage day and it should have been given on 04/09/2025.
In an interview on 05/17/2025 at 11:50 AM, Staff A, Administrator, stated that the NOMNC should be given to residents two days prior to the last day of Medicare A coverage.
Reference: (WAC) 388-97-0300 (1)(e)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
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 non-pharmacological interventions were in place for psychotr...
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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 non-pharmacological interventions were in place for psychotropic (drugs that affects how the brain works, and causes changes in mood, awareness, thoughts, feelings or behavior) medication management for 2 of 5 residents (Residents 64 & 57), reviewed for unnecessary medications. This failure placed the residents at risk for unmet care needs, adverse side effects, and a diminished quality of life.
Findings included .
Review of the facility policy titled, Psychotropic Medication Use, revised in July 2022, showed, A psychotropic medication is any mediation that affects brain activity associated with mental processes and behavior . non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible.
RESIDENT 64
Review of a face sheet printed on 05/13/2025 showed Resident 64 admitted to the facility on [DATE] with diagnosis that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).
Review of physician's orders printed on 05/14/2025 showed that Resident 64 had an order for quetiapine (an antipsychotic-medication that treats psychosis [mental disorder caused by abnormal thinking and perception]) 50 milligrams (mg- a unit of measurement) at bedtime and quetiapine 50 mg as needed per day. Further review of Resident 64's physician's orders did not show documentation for non-pharmacological interventions related to quetiapine use.
RESIDENT 57
Review of a face sheet printed on 05/13/2025 showed Resident 57 admitted to the facility on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Alzheimer's disease (a brain condition that slowly damages your memory, thinking, learning and organizing skills).
Review of physician's orders printed on 05/14/2025 showed Resident 57 had an order for quetiapine 25 mg at bedtime. Further review of Resident 57's physician's orders did not show documentation for non-pharmacological interventions related to quetiapine use.
In an interview and joint record review on 05/16/2025 at 11:54 AM, Staff E, Resident Care Manager, stated that psychotropic medications should have non-pharmacologic interventions in place. A joint record review of Resident 64 and Resident 57 physician's orders showed they had orders for psychotropic medication. It further showed that non-pharmacological interventions related to the use of psychotropic medication were not in place for Resident 64 and Resident 57. Staff E stated that they expected non-pharmacological interventions would be in place when residents were started on psychotropic medication.
In an interview and joint record review on 05/17/2025 at 10:42 AM, Staff B, Director of Nursing, stated that they expected residents who were prescribed psychotropic medication would have an order for non-pharmacological interventions. A joint record review of physician orders for Resident 64 and Resident 57 did not show non-pharmacological interventions related to quetiapine use. Staff B further stated that Resident 64 and Resident 57 should have had an order for non-pharmacological interventions related to psychotropic medication use.
Reference: (WAC) 388-97-1060 (3)(k)(i)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
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 a Significant Change in Status Assessment (SCSA) Minimum Dat...
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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 a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed timely for 1 of 2 residents (Resident 2), reviewed for SCSA. This failure placed the resident at risk for delayed care planning, unmet care needs, and a diminished quality of life.
Findings included .
Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed that a SCSA is required to be performed when a terminally ill resident enrolls in a hospice (compassionate care provided to individuals who are in the final stages of a terminal illness) program or changes hospice providers and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election. The RAI manual further showed that the assessment should be completed no later than 14 days after the determination was made (determination date plus 14 calendar days).
Review of a document titled, Hospice Plan of Care, dated 03/02/2025, showed that Resident 2 started hospice services on 03/02/2025.
Review of the SCSA MDS dated [DATE] showed it was completed on 03/26/2025, 10 days late.
In an interview and joint record review on 05/16/2025 at 5:35 PM, Staff F, MDS Coordinator, stated that they followed the RAI manual for completion of MDS assessments. A joint record review of the hospice plan of care showed Resident 2 admitted to hospice on 03/02/2025. A joint record review of Resident 2's SCSA MDS dated [DATE] showed it was completed on 03/26/2025. Staff F stated that Resident 2 was admitted to hospice on 03/02/2025 and that they opened an SCSA MDS for 03/12/2025. Staff F stated that Resident 2's MDS was completed 14 days after the ARD. Staff F further stated that Resident 2's MDS was completed late and that it should have been completed by 03/16/2025.
On 05/17/2025 at 3:15 PM, Staff B, Director of Nursing, stated they expected that MDS assessments were completed timely. Staff B further stated that Resident 2's MDS should have been completed by 03/16/2025.
Reference: (WAC) 388-97-1000 (3)(b)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
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 coordinate the Preadmission Screen and Resident Review (PASARR) for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate the Preadmission Screen and Resident Review (PASARR) for Level II services (a process to determine what mental health services residents required after a Level I PASARR determined mental health services were necessary) for 1 of 2 residents (Resident 26), reviewed for PASARR. This failure placed the resident at risk of not receiving the necessary mental health services and a diminished quality of life.
Findings included .
Review of the facility's policy titled, PASRR, revised in July 2024, showed, Social services will review the completed PASRR [Level] II screening for any recommendations and will ensure that the patient [resident] receives the necessary services and that interventions are care planned . Care Planning for Level II PASRR Residents who have screened positive for Level II during the PASRR evaluation are required to have this reflected clearly in the care plan, and any recommendations made by the evaluator are to be included as the resident specific interventions.
Review of a face sheet printed on 05/13/2025 showed Resident 26 was admitted to the facility on [DATE].
Review of the Level II PASRR Initial Psychiatric Evaluation Summary, dated 04/09/2019, showed Resident 30 had diagnoses of conversion disorder (a mental health condition that disrupts how the brain works causing real, physical symptoms that a person cannot control), schizophrenia (a chronic mental disorder with symptoms such as hallucinations [experience involving the apparent perception of something not present], delusions [a false belief, judgment, or perception], and cognitive challenges [affects the ability to think, learn, and process information), and anxiety (excessive, persistent and uncontrollable worry and fear about everyday situations). Further review of the Level II PASRR form showed specific interventions recommended for the nursing facility regarding Resident 26's care.
Review of the PASARR care plan dated 03/01/2021 showed no recommendations from Resident 26's Level II PASARR were included in their care plan.
In an interview on 05/16/2025 at 4:59 PM, Staff G, Social Services Director, stated that when a resident had a Level II PASARR, the recommendations from the Level II PASARR were included in the residents' care plan. A joint record review and interview showed Resident 26 had a Level II PASARR dated 04/09/2019 and that the document listed interventions for Resident 26. Staff G stated that Resident 26 was a Level II PASARR positive (appropriate level of care and necessary behavioral services and support to maintain the highest practicable level of health) and that their Level II PASARR had recommendations for their care. A joint record review of the PASARR care plan dated 03/01/2021 did not show the recommendations from Resident 26's Level II PASARR form were included. Staff G stated that Resident 26 had a general care plan, it should be personalized just for [Resident 26], the care plan should have been updated with the information and recommendations word for word from their Level II PASARR.
On 05/17/2025 at 4:11 PM, Staff A, Administrator, stated that they expected recommendations from Resident 26's Level II PASARR form were included in their assessments and care plans.
Reference: (WAC) 388-97-1915 (4)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR-an assess...
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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 Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or related conditions are not inappropriately placed in nursing homes for long-term care) Level I form was completed accurately and Level II PASARR referrals were made for 1 of 6 residents (Resident 36), reviewed for PASARR screening. In addition, the facility failed to complete Level I PASARR screening form for an exempted hospital discharge resident who remained in the facility for more than 30 days for 1 of 2 residents (Resident 57). These failures placed the residents at risk of not receiving the appropriate care and services for their needs and/or lacking access to specialized services for individuals with identified mental health diagnoses or disabilities.
Findings included .
Review of the facility's policy titled, PASRR Policy, revised in July 2024, showed Level II PASRR evaluations are required for all nursing facility residents identified to have indicators of SMI/ID during the Level I screening or at any time during residency in the nursing facility, and for any resident with confirmed SMI or ID who presents with significant changes in their cognitive or physical conditions .In certain limited circumstances, an individual may be admitted to a NF (nursing facility) without first having a PASRR Level II assessment, known as an Exempted Hospital Discharge. This is the only situation that exempts a person with SMI/ID from having a Level II PASRR completed before NF admission .(C) Whose attending physician has certified before admission to the facility that the individual is likely to require less than 30 days nursing facility services.
RESIDENT 36
Review of a face sheet printed on 05/13/2025 showed Resident 36 admitted to the facility on [DATE] with diagnosis that included depression (feeling of loneliness, sadness) and anxiety disorder (having excessive/persistent worry and fear).
Review of Resident 36's Level I PASARR dated 04/28/2025, showed the diagnosis of depression and anxiety disorder were not marked in Section IA (SMI). Further review showed that Section IV (4- Service Needs and Assessor Data) was marked for No level II evaluation indicated.
A joint record review and interview on 05/16/2025 at 4:59 PM with Staff G, Social Services Director, showed Resident 36 had diagnoses of depression and anxiety disorder on their face sheet. An additional joint record review showed that depression and anxiety disorder were not marked in Resident 36's Level I PASARR in Section IA. Staff G stated that Resident 36's Level l PASARR was not accurate and that they should have included their diagnoses of depression and anxiety disorder. Staff G further stated that a Level II PASARR referral should have been sent to the PASARR coordinator for Resident 36.
RESIDENT 57
Review of Resident 57's Level I PASARR dated 04/03/2025, showed that Section IV was marked for No Level II evaluation indicated at this time due to exempted hospital discharge: Level II must be completed if scheduled discharge does not occur.
Review of a face sheet printed on 05/13/2025 showed that Resident 57 was admitted to the facility on [DATE].
A joint record review and interview on 05/16/2025 at 4:59 PM with Staff G, showed Resident 57's Level I PASARR was marked for no level II evaluation indicated at this time due to exempted hospital discharge: Level II must be completed if scheduled discharge does not occur. Further joint record review of Resident 57's face sheet showed that they admitted on [DATE]. Staff G stated they should have reviewed Resident 57's Level I PASARR and that a Level II PASARR referral should have been made.
In an interview on 05/17/2025 at 10:42 AM, Staff B, Director of Nursing, stated that they expected PASARR forms to be completed accurately and that Level II PASARR referral would be sent to the PASARR coordinator if residents had a SMI diagnosis.
In an interview on 05/17/2025 at 10:58 AM, Staff A, Administrator, stated that they expected the PASARR form to be accurate and Level II PASARR referrals would be sent out when required.
Reference: (WAC) 388-97-1975(1)(5)
.
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 provide care and services in accordance with professi...
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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 care and services in accordance with professional standards of practice for 2 of 4 residents (Residents 51 & 39), reviewed for quality of care. The failure to consistently conduct skin evaluations to include care planning, monitoring and necessary treatment for Resident 51, and the failure to consistently monitor and manage constipation (passing fewer than three stools a week or having a difficult time passing stool) for Resident 39, placed the residents and other residents at risk for unmet care needs, pain/discomfort, and related complications.
Findings included .
Review of the facility's policy titled, Wound Management Guidelines, revised on 03/31/2025, showed that skin checks were completed by the Licensed nurse weekly . CNA [Certified Nursing Assistant/NAC [Nursing assistant Certified]/Shower aides will report any alterations in skin identified during routine care .If a Resident is identified to have a new skin alteration the Licensed Nurse will document in the resident record the evaluation of the wound, provider notification and obtain treatment orders. The resident and/or representative will be notified of [the] change in treatment plan . Skin documentation of wounds or pressure injury [sores that happen on areas of the skin that are under pressure] identification is completed in the resident's record. An assessment will be completed for each area. Areas include . diabetic/neuropathic ulcers [slow-healing wounds that commonly appear on the feet - complication of diabetes (a group of diseases that results in too much sugar in the blood) due to lack of sensation or blood flow.]
Review of the facility's policy titled, Foot Care, revised in October 2022, showed that residents would receive appropriate care and treatment to maintain mobility and foot health. The policy showed that residents would be provided with foot care and treatment in accordance with professional standards of practice. The policy further showed that foot care would include the care and treatment of medical conditions to prevent complications on the feet from these conditions such as diabetes.
RESIDENT 51
Review of the face sheet printed on 05/14/2025 showed Resident 51 readmitted to the facility on [DATE]. Further review of the face sheet showed Resident 51 had diagnoses that included type 2 diabetes mellitus (chronic condition characterized by insulin [hormone that regulates blood sugar in the blood] resistance and high blood sugar levels), polyneuropathy (nerve damage that affects peripheral [outside brain and spinal cord] nerves that can lead to weakness, numbness and burning pain typically in hand and feet and potentially progressing to other areas of the body), and protein-calorie malnutrition (clinical condition resulting in mild to severe undernutrition).
Review of the comprehensive care plan printed on 05/13/2025 did not show Resident 51's had a wound on their feet. Review of the diabetes care plan showed that Resident 51 would have nail care done by a licensed nurse.
Review of the Medication Administration Record (MAR)/Treatment Administration Record (TAR) from January 2025 to May 2025 showed Resident 51 had one skin evaluation on 01/23/2025. Further review showed no documentation that nail care for residents with diabetes was conducted.
Review of the quarterly Minimum Data Set (MDS - an assessment tool) dated 04/22/2025 showed Resident 51 required maximal assistance with repositioning. Further review of the MDS show Resident 51 had no foot wounds.
In an interview on 05/15/2025 at 2:50 PM, Resident 51 stated, I have sores on the bottom of my [right] feet and they pointed at their right middle ear and stated, it hurts.
A joint observation and interview on 05/15/2025 at 2:54 PM with Staff N, Registered Nurse, showed Resident 51 had a wound on the bottom of their right foot. Staff N stated Resident 51 had a scab (a dry, rough protective crust that forms over a cut or wound) on their right foot and that they did not see that wound before.
Another joint observation and interview on 05/15/2025 at 3:05 PM with Staff N and Staff E, Resident Care Manager, showed Resident 51 had a wound on bottom of their right foot that measured 1.0 centimeters (cm- a unit of measurement) by 0.5 cm with dark discoloration and redness around the wound. It further showed that Resident 51 had a small wound on their right ear. The right ear was observed with yellowish crust in Resident's right middle ear. Staff E instructed Staff N to do a complete skin assessment.
In an interview on 05/17/2025 at 9:19 AM, Staff H, Certified Nurse Assistant, stated that Resident 51 required maximum to total assist with their care. Staff H stated that Resident 51 had a wound on the bottom of their right foot, it has been there for a long time, maybe two months. Staff H further stated that they had notified an unknown nurse about Resident 51's wound when they first saw it.
In an interview and joint record review on 05/17/2025 at 11:37 AM, Staff Q, Licensed Practical Nurse, stated that Resident 51 required assistance with everything [activities of daily living]. Staff Q stated that weekly skin checks were conducted for all residents. Staff Q stated they did not know that Resident 51 had wounds on their right foot and right ear. A joint record review of the skin evaluations from January 2025 to May 2025 showed Resident 51's weekly skin assessments were not conducted except for 01/23/2025 and 05/15/2025. Staff Q stated that Resident 51 should have had a weekly skin assessment done every Thursday. Staff Q stated that nail care for residents with diabetes was done weekly by a licensed nurse. A joint record review of the diabetes care plan showed Resident 51 had an intervention listed for diabetic nail care by LN [licensed nurse]. A joint review of May 2025 MAR showed no documentation that Resident 51 was provided nail care. Staff Q stated that Resident 51 should have had orders for weekly diabetic nail care in place.
A joint record review and interview on 05/17/2025 at 12:07 PM with Staff E, showed Resident 51 had their weekly skin evaluation completed on 01/23/2025 and one on 05/15/2025. Staff E stated that Resident 51 should have had weekly skin evaluations conducted and that if there was a new skin issue, Staff E expected a skin evaluation to be completed.
In an interview and joint record review on 05/17/2025 at 3:18 PM, Staff B, Director of Nursing, stated that they expected staff to report to their direct supervisor when a new wound was found on a resident, and that staff completed a skin evaluation. Staff B stated that residents would have weekly skin evaluations conducted. A joint record review of the clinical records did not show Resident 51 had weekly skin evaluations [except for 01/23/2025 and 05/15/2025] and/or weekly diabetic nail care since their readmission to the facility. Staff B stated that there were no weekly skin evaluations done from February 2025 to May 2025, and that there should have been done weekly. Staff B stated that Resident 51 should have orders for weekly skin evaluations and weekly diabetic nail care in place. Staff B further stated that Resident 51's wounds on their right foot and ear could have been identified during scheduled weekly skin evaluations and wound treatments could have been started.
RESIDENT 39
Review of the face sheet printed on 05/13/2025 showed Resident 39 was admitted to the facility on [DATE].
Review of the Resident 39's April 2025 bowel documentation task from 04/06/2025 through 04/10/2025 showed Resident 39 did not have any bowel movement.
Review of the April 2025 physician orders showed that Resident 39 had orders for Senna (medication to treat constipation) 17.2 milligrams (a unit of measurement) as needed and Polyethylene (medication to treat constipation) 17 gram (a unit of measurement) as needed for constipation.
Review of the April 2025 MAR showed that Resident 39 did not receive bowel management medications from 04/06/2025 through 04/10/2025.
Review of the nursing progress notes for April 2025 showed no documentation that addressed Resident 39's constipation and/or if bowel management medications were given or refused by Resident 39.
In an interview and joint record review on 05/16/2025 at 11:54 AM, Staff E stated that if residents did not have a bowel movement for three days that they would follow the facility bowel protocol. A joint record review of Resident 39's April bowel documentation task from 04/06/2025 through 04/10/2025 showed Resident 39 did not have a bowel movement. Further joint record review of the April 2025 MAR showed Resident 39 did not receive bowel management medications from 04/06/2025 through 04/10/2025. Staff E stated that staff should have given Resident 39 bowel management medication.
In an interview on 05/17/2025 at 10:42 AM, Staff B stated that they expected nurses to follow the facility bowel protocol.
Reference: (WAC) 388-97-1060 (1)(3)(b)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
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 podiatry (the treatment of feet and their ailm...
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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 podiatry (the treatment of feet and their ailments) care and services were provided for 1 of 3 residents (Resident 10), reviewed for foot care. This failure placed the resident at risk for further skin impairment, discomfort, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Foot Care, revised in October 2022, showed, Residents are provided with foot care and treatment in accordance with professional standards of practice . Residents are assisted in making appointments and with transportation to and from specialists (podiatrist) . Trained staff may provide routine foot care (e.g., toenail clipping) within professional standards of practice for residents without complicating disease processes.
Review of Resident 10's quarterly Minimum Data Set (MDS - an assessment tool) dated 04/22/2025, showed Resident 10 was cognitively intact and required substantial/maximal assistance (helper does more than half effort) with personal hygiene.
Review of Resident 10's care plan printed on 05/12/2025, showed Resident 10 requires full assistance with personal hygiene.
Review of the January 2025 to May 2025 Electronic Health Record (EHR-nursing progress notes and under the miscellaneous tab), showed Resident 10 was scheduled for podiatrist visit on 03/28/2025. It showed Resident 10 was in the hospital on [DATE] and was not seen by the podiatrist as scheduled. It further showed no subsequent podiatrist visits occurred or were scheduled after Resident 10 returned to the facility.
Multiple observations and interview on 05/12/2025 at 2:09 PM, on 05/13/2025 at 8:00 AM, and on 05/14/2025 at 1:07 PM, showed that Resident 10's toenails on both feet were long, thick, and untrimmed with the right great toenail starting to curve into the skin. Resident 10 stated they had not seen the podiatrist and that their toenails had not been trimmed.
In an interview and joint observation on 05/14/2025 at 1:32 PM, Staff X, Certified Nursing Assistant (CNA), stated the CNAs and shower aids would do nail care, unless it was for a resident with diabetes (a group of diseases that results in too much sugar in the blood), then the nurse would do the nail care. A joint observation of Resident 10's toenails showed they were long and thick. Staff X stated Resident 10's toenails needed to be trimmed.
A joint observation and interview on 05/14/2025 at 1:51 PM with Staff Y, CNA, showed Resident 10's toenails were long, thick, and curved into the skin. Staff Y stated that Resident 10's toenails were long, thick, and curved into the skin and that they needed to be trimmed.
In an interview and joint record review on 05/16/2025 at 5:20 PM, Staff E, Resident Care Manager, stated that the podiatrist would come monthly and that they would make a list of residents to be seen on the next visit. A joint record review of the EHR with Staff E showed Resident 10 was scheduled to see the podiatrist on 03/28/2025 but was not seen due to Resident 10 was in the hospital. Staff E stated Resident 10 had not been seen by the podiatrist since returning from the hospital on [DATE] and that Resident 10 should have been seen.
In an interview on 05/17/2025 at 1:10 PM, Staff B, Director of Nursing, stated that Resident 10 should have been seen by the podiatrist after returning from the hospital.
Reference: (WAC) 388-97-1060 (3)(j)(viii)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 services were consistently provided to increas...
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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 services were consistently provided to increase and/or to prevent decrease Range of Motion (ROM) for 2 of 3 residents (Residents 32 & 34), reviewed for restorative services. This failure placed the residents at risk for a decline in ROM, unmet care needs, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Restorative Services, revised on 11/11/2005, showed, It is the policy of the facility to provide its residents the restorative services in an effort to maintain the residents highest level of self-care and independence, physically and psychosocially.
RESIDENT 32
Review of the annual Minimum Data Set (MDS-an assessment tool), dated 04/05/2025, showed Resident 32 admitted to the facility on [DATE] with diagnosis that included cerebral palsy (a group of conditions that affect movement and posture). It further showed that Resident 32 had ROM impairment in their upper and lower extremities.
Review of Resident 32's Cerebral Palsy care plan, revised on 04/12/2025, showed an intervention to maintain good body alignment to prevent contractures [a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff]. Use braces and splints as ordered. It further showed interventions for Occupational Therapy (OT) and Physical Therapy (PT) to monitor/document and treat as indicated.
Review of Resident 32's Pain care plan, revised on 10/02/2024, showed that Resident 32 had contractures.
Review of a medical provider progress note dated 05/01/2024, showed that Resident 32 had moderate risk for developing contractures .if not receiving adequate therapy.
Observation and interview on 05/12/2025 at 9:31 AM, showed Resident 32's left hand in a fist. Further observation showed Resident 32 could move their thumb and pointer finger and could not move the other three fingers. When asked if anyone did exercises with them, Resident 32 stated, no.
Observation and interview on 05/13/2025 at 3:09 PM, showed Resident 32's left hand in a fist. Resident 32 stated that no one did any exercises with them today. When asked if they could open their left hand that was in a fist, Resident 32 stated, ow and could not open their fist.
In an interview and joint observation on 05/15/2025 at 2:08 PM, Staff O, Licensed Practical Nurse, stated that Resident 32 had limited ROM in their left hand. A joint observation of Resident 32's left hand, showed they could not move three fingers on their left hand. Staff O stated, they're contracted.
In an interview on 05/16/2025 at 10:44 AM, Staff AA, Restorative Aide, stated that Resident 32 was not on a restorative program and did not use any splints.
In an interview and joint observation on 05/16/2025 at 11:07 AM, Staff D, Resident Care Manager, stated they expected that residents with contractures should be monitored for any worsening and should have range of motion and positioning. Staff D stated that Resident 32 had lower body and upper body contractures and I'm thinking he should be on restorative but he's not. A joint observation of Resident 32's left hand showed Staff D helping Resident 32 to open their fist. Staff D stated, it's not locked. Staff D further stated that Resident 32 could benefit from interventions to prevent worsening of Resident 32's left hand and they need to work on the fingers.
In an interview on 05/16/2025 at 12:15 PM, Staff EE, MDS Coordinator, stated they oversaw the restorative program. Staff EE stated that Resident 32 was not on a restorative program. When asked how to care for a resident with contractures, Staff EE stated that residents should move around daily and depending on where they are at should have active range of motion or passive range of motion.
In an interview on 05/17/2025 at 1:42 PM, Staff B, Director of Nursing, stated they expected residents with contractures to be on some kind of exercise program to prevent further contractures.
RESIDENT 34
Review of the quarterly MDS dated [DATE], showed Resident 34 had ROM impairment on one side of their upper extremity.
Review of Resident 34's Mobility care plan revised on 04/28/2025, showed that Resident 34 was on a restorative nursing program 6-7 days a week, 10-20 minutes a day.
Review of the facility's document titled, Task: Nursing Rehab: Active ROM Restorative Nursing Program, from the dates 04/13/2025 through 05/13/2025, showed one day (04/25/2025) where it was documented that the program was carried out. No other day showed documentation that the restorative nursing program was carried out.
In an interview on 05/12/2025 at 12:30 PM, Resident 34 stated that their left arm doesn't work that well and no one [was] doing exercises with them.
In an interview on 05/14/2025 at 10:20 AM, Resident 34 stated, not yet when asked if anyone had done exercises with them that day. Resident 34 further stated, I would certainly like to do something with my arms.
In an interview and joint record review on 05/16/2025 at 10:44 AM, Staff AA stated that they were responsible for carrying out the restorative program for residents. Staff AA stated that they would document in the resident's Electronic Health Record (EHR) after working with a resident who was on a restorative program. Staff AA further stated that Resident 34 was on a restorative program. A joint record review of Resident 34's EHR showed no documentation that the restorative program was being done for Resident 34. Staff AA stated, this is the only place I document.
In an interview on 05/16/2025 at 12:15 PM, Staff EE stated that they expected there to be documentation when the restorative aide carried out a restorative program for a resident. Staff EE stated that Resident 34 was started on a restorative program on 04/03/2025 and that it [the restorative nursing program] was entered wrong in the EHR, so there was no prompt for Staff AA to document when they had worked with Resident 34. Staff EE stated that there was probably a month of services without documentation. Staff EE stated that they expected Staff AA to put in the chart somewhere that it [restorative nursing program] was done and no there was no documentation that it had been done for Resident 34.
In an interview on 05/17/2025 at 1:42 PM, Staff B stated that they expected documentation when restorative nursing programs were carried out.
Reference: (WAC) 388-97-1060 (3)(d)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure residents with urinary catheters (a flexible tube inserted into the bladder to drain urine) received appropriate care ...
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Based on observation, interview, and record review, the facility failed to ensure residents with urinary catheters (a flexible tube inserted into the bladder to drain urine) received appropriate care and services for 2 of 8 residents (Residents 4 & 39), reviewed for catheter care. The failure to empty urinary catheter bag and/or ensure other urinary catheter care were provided placed the residents at risk for infections, related complications, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, [Urinary] Catheter Care, revised in August 2022, showed that the purpose of this procedure is to prevent urinary catheter-associated complications, including bladder infections. The document further showed that catheter tubing and drainage bag (collects urine from the catheter) were to be kept off the floor.
RESIDENT 4
Review of Resident 4's admission minimum data set (an assessment tool) dated 02/03/2025, showed Resident 4 had a urinary catheter.
Review of a provider note date 04/25/2025, showed that Resident 4 had informed, [that] sometimes her urine bag is not getting emptied when it is full, it is overflowing, informed RCM [Resident Care Manager] to put orders to empty urine bag twice a shift.
Review of Resident 4's April 2025 and May 2025 physician orders showed an order to check [the urinary] drainage bag twice a shift and empty drainage [bag] when ½ [half] full started on 04/25/2025.
Review of Resident 4's [Urinary] Catheter care plan, revised on 04/25/2025, showed an intervention to check [the] drainage bag twice per shift, and empty if about or at ½ level.
In an interview on 05/13/2025 at 9:29 AM, Resident 4 stated that they had a urinary tract infection (infection of the bladder) three weeks ago. Nobody checked my bag [catheter drainage bag] and it backed up.
In a joint observation and interview on 05/13/2025 at 4:37 PM with Staff W, Certified Nursing Assistant, showed Resident 4's catheter drainage bag was more than half full. Staff W stated, looks full. A joint observation showed Staff W emptied the drainage bag into a urinal (a plastic container that collects urine) two times with a total amount of 1400 milliliters (unit of measurement).
In an interview and joint record review on 05/17/2025 at 12:54 PM, Staff P, Licensed Practical Nurse, stated that they were checking twice a shift to empty Resident 4's catheter drainage bag. A joint record review of Resident 4's physician orders showed to empty the catheter drainage bag twice a shift and empty it when it was half full. Staff P stated, I don't want to see it more than half full.
In an interview and joint record review on 05/17/2025 at 1:30 PM, Staff D, RCM, stated that they expected staff to follow the care plan. A joint record review of Resident 4's catheter care plan showed the catheter drainage bag should be emptied when it was about half full. Staff D stated they expected the drainage bag to not be full, so nothing in the tubing. When told that Resident 4's catheter drainage bag had been observed to be full, Staff D stated, my expectation is it should not be full.
In an interview on 05/17/2025 at 1:42 PM, Staff B, Director of Nursing, stated that they expected staff to follow orders for catheter care and if there was an order to empty the catheter drainage bag when it was half full then it should be emptied.
RESIDENT 39
Review of the physician orders printed on 05/13/2025, showed Resident 39 had an order for Document Foley [urinary catheter] output [amount of urine] q [every] shift, dated 02/03/2025. Further review of the physician orders did not show documentation for catheter care to include how often to change the urinary catheter, the resident's catheter size, when to change the urinary catheter bag, and/or instructions when to empty the catheter bag.
Observation on 05/12/2025 at 9:30 AM showed Resident 39 had a urinary catheter hanging on the left side of the bed.
A joint record review and interview on 05/16/2025 at 12:51 PM with Staff E, RCM, showed Resident 39's physicians order did not have an order for urinary catheter. Staff E stated, did she [have] catheter? A joint observation with Staff E showed Resident 39 had a urinary catheter, and the urinary catheter bag was hanging on the left side of bed. Staff E further stated Resident 39 should have had orders for urinary catheter care.
In an interview on 05/17/2025 at 10:42 AM, Staff B stated they expected Resident 39 to have a standing order for catheter use including catheter size and catheter care.
Reference WAC 388-97-1060(3)(c)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0691
(Tag F0691)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure resident who require ostomy (a surgical procedure creating an opening in the body for the discharge of body waste into...
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Based on observation, interview, and record review, the facility failed to ensure resident who require ostomy (a surgical procedure creating an opening in the body for the discharge of body waste into a collection bag) care received services consistent with professional standards for 1 of 1 resident (Resident 17), reviewed for ostomy care. This failure placed the resident at risk for unmet care needs, skin breakdown, related complications, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Evaluation Guidelines for Managing Ostomy Care, revised in October 2015, showed Task completed should be documented via the Treatment Administration Record (TAR) .A physician's order should be obtained to match the required task(s) being performed.
Review of the comprehensive care plan printed 05/13/2025 showed Resident 17 had a colostomy (type of ostomy).
Review of Resident 17's physician orders printed on 05/13/2025 showed no orders related to colostomy.
Review of Resident 17's Medication Administration Record (MAR) and/or TAR printed on 05/13/2025 showed no colostomy care directives.
Observation on 05/13/2025 at 10:03 AM, showed Resident 17 had a colostomy bag connected to their left abdomen.
In an interview on 05/14/2025 at 1:40 PM, Staff X, Certified Nursing Assistant (CNA), stated that CNAs and nurses could empty the colostomy bag, and that the nurse would change the colostomy bag and appliance.
In an interview and joint record review on 05/15/2025 at 9:50 AM, Staff O, Licensed Practical Nurse, stated they would do colostomy care by checking the colostomy site and skin around the colostomy, check the colostomy bag and empty it, and change the bag and change the appliance per the physician orders. Staff O stated they would document those in the MAR and/or TAR. A joint record review of the May 2025 physician orders with Staff O, showed no colostomy care directives. Staff O stated, it's [order] not here, and that there were no colostomy orders for care, bag change, appliance change, or to monitor bag and site. Staff O further stated that there should have been colostomy care orders in place.
In an interview and joint record review on 05/16/2025 at 6:15 PM, Staff D, Resident Care Manager, stated they have an order set for residents with a colostomy that includes colostomy care, change colostomy appliance, and change colostomy bag. A joint record review of the May 2025 physician orders with Staff D showed no colostomy care directives. Staff D stated, I have to add it [colostomy order]. It's not there. I don't know what happened. Staff D stated there should have been orders for Resident 17's colostomy care, change colostomy appliance, and change colostomy bag.
In an interview on 05/17/2025 at 1:10 PM, Staff B, Director of Nursing, stated there should be orders for colostomy care, appliance change, bag change, and monitoring of colostomy, site, and skin. Staff B further stated they expected there to be colostomy care orders for Resident 17.
Reference: (WAC) 388-97-1060 (3)(j)(iii)
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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 interview and record review, the facility failed to ensure residents who were trauma survivors and diagnosed with Post ...
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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 residents who were trauma survivors and diagnosed with Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event that was either experienced or witnessed) received trauma informed care, trigger assessment, and trauma-informed care assessment in accordance with professional standards of practice for 1 of 1 resident (Resident 48), reviewed for mood/behavior. This failure placed the resident at risk for unidentified triggers, re-traumatization, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Trauma Informed Care and Culturally Competent Care, revised in August 2022, showed that it was the policy of the facility to guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice and to address the needs of trauma survivors by minimizing triggers (cause [an event or situation] to happen or exist) and/or re-traumatization. The policy showed staff would perform universal screening of residents that may include trauma history. The policy further showed an assessment would be done that involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers.
Review of Resident 48's face sheet printed on 05/12/2025 showed Resident 48 was admitted to the facility on [DATE] with a diagnosis that included PTSD.
Review of Resident 48's Electronic Health Record (EHR-under the evaluation tab and miscellaneous tab) from June 2024 through May 2025, showed no Trauma Informed Care assessment.
In an interview and joint record review on 05/16/2025 at 3:40 PM, Staff G, Social Services Director, stated they would check the resident's diagnosis and record for information related to trauma and history of, then would do an assessment and record it in the resident's EHR. A joint record review of Resident 48's EHR with Staff G, showed no trauma informed care assessment. Staff G stated there was no trauma informed care assessment for Resident 48 in their EHR and there should have been.
In an interview on 05/16/2025 at 3:58 PM, Staff A, Administrator, stated they expected to be a trauma informed assessment completed for Resident 48.
Reference: (WAC) 388-97-1060(3)(e)
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 34
Review of Resident 34's Electronic Health Record (EHR- evaluation tab, miscellaneous tab, nursing progress notes fro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 34
Review of Resident 34's Electronic Health Record (EHR- evaluation tab, miscellaneous tab, nursing progress notes from 05/12/2024 to 05/13/2025, and May 2025 physician orders), showed no documentation that Resident 34 had an assessment for self-administration of medication.
Observation on 05/14/2025 at 10:22 AM, showed three bottles of multi-collagen [a supplement to provide structure, strength and support throughout the body] supplements on Resident 34's bedside table.
Observation on 05/14/2025 at 12:41 PM, showed three bottles of multi-collagen supplements on Resident 34's bedside table. Resident 34 stated, I take [them] every day.
A joint record review and interview on 05/14/2025 at 1:38 PM with Staff V, Licensed Practical Nurse (LPN), showed no documentation or assessment for self-administration of medications for Resident 34. Staff V stated there should be an order to self-administer medications.
A joint observation and interview on 05/14/2025 at 2:07 PM with Staff V, showed three bottles of multi-collagen on Resident 34's bedside table. Resident 34 also showed that they had another bottle of multi-collagen and a bottle of probiotics [microorganisms that provide health benefits] in the drawer of their nightstand. Resident 34 stated that they were taking both medications every day. Staff V stated, I'll take these [medications] until I get an order from the doctor to keep at the bedside and to self-administer [the medications].
RESIDENT 38
Review of Resident 38's physician orders, printed on 05/12/2025, showed an order for Albuterol Sulfate with the instructions, two puffs inhale orally every four hours as needed for shortness of breath. It showed no documentation for self-administration of medication.
Review of Resident 38's EHR (nursing progress notes from 05/14/2024 to 05/15/2025), showed no documentation that Resident 38 had an assessment for self-administration of medication.
Observation on 05/13/2025 at 8:55 AM, showed Resident 38 took out an inhaler from the top drawer of their nightstand and inhaled two puffs. Resident 38 stated they [the facility] know I have it. Resident 38 stated they had not been assessed for self-administration of medications and I've been using it [the inhaler] for years.
Additional observation on 05/14/2025 at 1:01 PM, showed one albuterol sulfate inhaler stored in Resident 38's nightstand drawer. Resident 38 stated, it's my rescue one [inhaler] that came from my doctor.
In an interview and joint record review on 05/14/2025 at 1:38 PM, Staff V stated that residents may not have medications at their bedside and may not self-administer medications unless they have an order. Staff V stated that Resident 38 had not had an assessment done for self-administration of medications. A joint record review of Resident 38's physician orders showed no documentation for self-administration of medication. Staff V stated, I don't see anything [an order]. A joint observation of Resident 38's room showed Staff V asked Resident 38 if they had any medications in their nightstand table. Resident 38 stated, yes, my albuterol inhaler and showed Staff V their inhaler. Staff V stated it should not be there.
In an interview on 05/14/2025 at 1:57 PM, Staff D, RCM, stated that Resident 38 should have an order for self-administration of medications and he doesn't have one.
In an interview on 05/17/2025 at 1:42 PM, Staff B stated that medications should not be at the bedside unless there is a self-administration assessment. Staff B stated that they expected a doctor's order and a self-administration assessment to be done prior to a resident being able to self-administer medications. When asked if they expected Resident 38's inhaler or Resident 34's medications to be at the bedside without a self-administration assessment, Staff B stated, no that's not the practice and no, would not expect that.
Based on observation, interview, and record review, the facility failed to ensure the residents were evaluated and assessed, and/or physician orders were obtained for safe administration of medication for 5 of 19 residents (Residents 30, 34, 38, 10 & 5), reviewed for self-medication administration. This failure placed the residents at risk for inaccurate and unsafe medication administration, adverse side effects, medical complications, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Self-Administration of Medications, revised in September 2004, showed that the facility would allow residents to self-administer medications if they choose. If the resident wishes to self-administer their medications, the Resident Care Manager (RCM) will evaluate potential by using the self-medication review form. If the RCM determines the resident can carry out this task in a safe and prudent manner, the physician will be notified, an order obtained, and the resident will be placed in a self-administration program. The RCM must establish a care plan. Drugs may be kept in a locked drawer at the bedside or if the resident desires, the medication may also be stored by the nursing staff. Residents who self-administer medications will be reviewed at least quarterly and with any significant change. The residents may continue the self-administration of medication programs as long as the residents remain competent and accountable.
RESIDENT 30
Review of Resident 30's self-administration of medication evaluation assessment dated [DATE] showed it was incomplete, no answers were filled in the form, it was blank.
Review of the physician orders printed on 05/12/2025 showed Resident 30 had orders for Flonase (medication that treats nasal congestion) nasal (into the nose) spray, two sprays in both nostrils (nasal passages) one time a day, Incruse Ellipta (Umeclidinium Bromide - brand name) inhaler [portable device for administering a drug which is to be breathed in] one puff inhale orally one time a day for Chronic Obstructive Pulmonary Disease (COPD - an ongoing lung condition caused by damage to lungs); and Albuterol Sulfate (an inhaler used to open the airways to increase air flow to the lungs) inhaler - two puffs orally every six hours as needed for COPD. Further review of the physician orders did not indicate that Resident 30 would self-administer and/or would keep the medications at bedside.
Observation on 05/12/2025 at 2:05 PM, showed that Resident 30 had an albuterol inhaler, a bottle of Flonase nasal spray, and an Arnuity Ellipta (fluticasone furoate- [brand name], a steroid [anti-inflammatory drugs that help treat breathing disorders]) inhaler on their bedside table. Resident 30 stated they administered the medications themselves. Resident 30 further stated that they get the albuterol inhaler once at night, the nasal spray once a day and the Arnuity Ellipta inhaler twice a day after breakfast and after lunch.
Observation on 05/13/2025 at 3:23 PM, showed that Resident 30 had an albuterol inhaler, a bottle of fluticasone nasal spray, and an Arnuity Ellipta inhaler on top of the side table within Resident 30's reach.
In an interview and joint observation on 05/13/2025 at 4:16 PM, Staff E, RCM, stated that when residents request to self-administer their medications, staff would complete a self-administration medication assessment and orders would be obtained. A joint observation and interview with Staff E showed Resident 30 had one albuterol inhaler, one bottle of fluticasone nasal spray, and one Arnuity Ellipta inhaler on top of their side table. Resident 30 stated that they kept their medications at bedside and that they use their medication every day. Staff E stated that Resident 30's medications should have been kept in a locked box.
A joint record review and interview on 05/13/2025 at 4:31 PM with Staff E, showed Resident 30's May 2025 physician orders showed they had orders for Flonase nasal, albuterol inhaler, and Incruse Ellipta inhaler. Further review of Resident 30's physician orders did not show documentation for self-administration of medication. Staff E stated that Resident 30 should have had orders for self-administration of the three medications that were in Resident 30's room. A joint record review of the self-administration of medication evaluation dated 07/09/2024 showed it was incomplete. Staff E stated that the self-administration of medication evaluation should have been completed, and that Resident 30's medications should have been stored in a locked box.
In an interview on 05/17/2025 at 3:55 PM, Staff B, Director of Nursing Services, stated that Resident 30 should have had a self-administration of medication evaluation for the three medications they were self-administering, orders for self-administering of medications, a care plan in place, and that Resident 30's medications should have been kept in a locked box.
RESIDENT 10
Review of Resident 10's face sheet printed on 05/12/2025, showed they were admitted to the facility on [DATE] with a diagnosis that included COPD and dyspnea (difficulty breathing).
Review of Resident 10's physician orders printed on 05/12/2025, showed Resident 10 was prescribed Albuterol Sulfate inhaler as needed. The physician orders further showed no documentation for self-administration of medication.
Review of Resident 10's EHR under assessment tab and miscellaneous tab from January 2025 to May 2025, showed no documentation that Resident 10 had an assessment for self-administration of medication.
Observations on 05/12/2025 at 2:09 PM and on 05/13/2025 at 8:00 AM, showed Resident 10 had one Albuterol Sulfate inhaler lying on top of their bedside table. Resident 10 stated they used the inhaler when they feel short of breath, especially at night.
In an interview and joint observation on 05/13/2025 at 8:08 AM, Staff J, LPN, stated that Resident 10 did not have an order for self-administration and did not have a self-administration assessment. A joint observation showed Resident 10 had an Albuterol Sulfate inhaler lying on top of their bedside table. Staff J stated the inhaler should not be on Resident 10's bedside table and that they should have had a self-administration order.
In an interview and joint record review on 05/16/2025 at 5:50 PM, Staff E stated that when a resident wishes to self-administer their medications, they would do an assessment, verify with the physician and get an order, then update their care plan. A joint record review of Resident 10's EHR showed no assessment or documentation for self-administration of medication, Staff E stated Resident 10 did not have an order or an assessment for self-administration of medications and that there should have been.
In an interview on 05/17/2025 at 1:10 PM, Staff B stated they expected that there should have been a self-administration of medications assessment and order for Resident 10.
RESIDENT 5
Review of the face sheet printed on 05/13/2025 showed Resident 5 was admitted to the facility on [DATE].
Observations on 05/12/2025 at 9:35 AM and on 05/13/2025 at 8:20 AM showed Resident 5 had one bottle of Centrum (brand name) vitamins and one bottle of Fish oil on top of the nightstand.
Review of Resident 5's physician orders printed on 05/13/2025, did not show documentation for self-administration of medication.
Review of Resident 5's April 2025 and May 2025 EHR under the assessment tab and miscellaneous tab, did not show an assessment for self-administration of medication was done.
Review of Resident 5's comprehensive care plan printed on 05/13/2025, did not show documentation that Resident 5 could safely self-administer or independently store medication.
A joint observation and interview on 05/13/2025 at 8:25 AM with Staff J, showed that Resident 5 had two bottles of supplement on top of their nightstand. Staff J stated that they [Resident 5] should not have medication on the bedside. Staff J further stated that Resident 5 was not on self-administration of medication program.
In an interview on 05/16/2025 at 11:54 AM, Staff E stated medications should not be kept by the bedside before self-administration of medication assessment was completed.
In an interview on 05/17/2025 at 10:42 AM, Staff B stated they expected staff to have been assessed Resident 5 to be able to safely self-administer medication and complete the documentation.
Reference: (WAC) 388-97-0440, 1060(3)(l)
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure resident rooms were maintained for 4 of 19 residents (Residents 29, 13, 269 & 31), reviewed for environment. The failur...
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Based on observation, interview and record review, the facility failed to ensure resident rooms were maintained for 4 of 19 residents (Residents 29, 13, 269 & 31), reviewed for environment. The failure to ensure resident rooms were free from broken light switches and soiled privacy curtains placed residents at risk for a less than homelike environment and a diminished quality of life.
Findings included .
RESIDENT 29
Observations on 05/13/2025 at 2:57 PM and on 05/15/2025 at 11:01 AM, showed the privacy curtains for Resident 29's room were dirty with a brown material on them. It further showed a broken pull cord above Resident 29's bed and plastic bags tied together being used as the pullcord.
In an interview and joint observation on 05/15/2025 at 11:16 AM, Staff BB, Certified Nursing Assistant, stated that if they noticed something in disrepair in a resident's room, they would report to the nurse first, tell maintenance. A joint observation of Resident 29's room showed a broken pull cord above Resident 29's bed and plastic bags tied together being used as the pull cord. Staff BB stated, I don't know why it's like that. It further showed brown material on Resident 29's privacy curtains and Staff BB stated, looks dirty.
In an interview and joint observation on 05/15/2025 at 11:24 AM, Staff I, Maintenance Director, stated that they checked resident rooms every single day, I have an assistant who helps. Staff I stated that housekeeping lets us know if privacy curtains needed to be cleaned and we also check them when we check the rooms. A joint observation of Resident 29's room showed plastic bags tied together for the pullcord for the light above Resident 29's bed. Staff I stated, that needs to be taken down, plastic shouldn't be there. I have something else that we can use. It further showed that the privacy curtain had a brown material on it. Staff I stated, it's not clean, I have clean ones downstairs.
In an interview on 05/17/2025 at 11:55 AM, Staff A, Administrator, stated that they expected staff to report any maintenance issues, and they were not expecting the plastic bags to be used as a pullcord for the light above resident's beds. Staff A further stated that they expected the privacy curtains in resident rooms to be in good repair and clean.
RESIDENT 13
Observations on 05/12/2025 at 10:18 AM and on 05/15/2025 at 11:22 AM showed Resident 13's overhead lighting pull cord was extended by plastic bags.
RESDIENT 269
Observations on 05/13/2025 at 9:21 AM and on 05/15/2025 at 11:20 AM showed Resident 269's overhead lighting pull cord was extended by a green piece of fabric strip.
RESIDENT 31
Observations on 05/13/2025 at 9:21 AM and on 05/15/2025 at 11:20 AM showed Resident 31's overhead lighting pull cord was extended by a night gown strip.
A joint observation and interview on 05/15/2025 at 11:24 AM with Staff I showed Resident 13, Resident 269, and Resident 31's overhead lighting pull cord were not home like. Staff I stated, I don't [do not] know [why] it looks like this, it should not look like this.
In an interview on 05/17/2025 at 10:42 AM, Staff B stated resident's rooms should provide a home like environment.
Reference: WAC 388-97-0880 (1)
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
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 transmit the resident Minimum Data Set (MDS - an assessment tool) 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 transmit the resident Minimum Data Set (MDS - an assessment tool) to the Centers for Medicare & Medicaid Service (CMS) within the required timeframe for 4 of 6 residents (Residents 53, 25, 42 & 59), reviewed for transmitting MDS assessments. This failure placed the residents at risk for unmet care needs and diminished quality of life.
Findings included .
Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.11, revised in October 2024, showed all Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES). After completion of the required assessment and/or tracking records, each provider must create electronic transmission files that meet the requirements detailed in the current MDS 3.0 Data Submission Specifications. For submission, the MDS data must be in record and file formats that conform to standard record layouts and data dictionaries, and pass standardized edits defined by CMS and the State. Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date.
RESIDENT 53
Review of the face sheet printed on 05/13/2025, showed Resident 53 admitted to the facility on [DATE] and discharged on 02/19/2025.
Review of Resident 53's discharge MDS dated [DATE] showed it was completed on 04/09/2025, 35 days late. Further review of the MDS showed it was not transmitted/submitted to CMS' iQIES.
In an interview and record review on 05/16/2025 at 5:35 PM, Staff F, MDS Coordinator, stated they followed the RAI manual for completion of MDSs, that discharge MDS would be completed no later than 14 days from the ARD, and then transmitted to CMS. A joint record review showed Resident 53's MDS dated [DATE] was completed on 04/09/2025. Staff F stated, it was completed late. Further review of the MDS showed it was not transmitted/submitted to CMS. Staff F stated that Resident 53's MDS should have been transmitted to CMS.
On 05/17/2025 at 3:59 PM, Staff B, Director of Nursing, stated they expected MDS to be completed and transmitted in a timely manner. Staff B further stated that Resident 53's MDS should have been transmitted after it was completed.
RESIDENT 25
Review of Resident 25's discharge MDS dated [DATE] showed it was completed on 05/08/2025, 26 days late.
A joint record review and interview on 05/16/2025 at 5:52 PM with Staff F showed that Resident 25's discharge MDS dated [DATE] was completed on 05/08/2025. Staff F stated that Resident 25's MDS was late and that it should have been completed within the required timeframe.
On 05/17/2025 at 4:04 PM, Staff B stated that Resident 25's MDS should have been completed and transmitted in a timely manner.
RESIDENT 42
Review of the discharge MDS dated [DATE] showed Resident 42 admitted to the facility on [DATE] and discharged on 04/01/2025. Further review of the MDS showed it was completed on 04/09/2025 and it was not transmitted/submitted to CMS.
A joint record review and interview on 05/16/2025 at 5:54 PM with Staff F showed Resident 42's discharge MDS dated [DATE] was completed and it was not transmitted/submitted to CMS. Staff F stated that Resident 42's MDS was not transmitted to CMS, and it should have been.
On 05/17/2025 at 4:07 PM, Staff B stated that Resident 42's MDS should have been completed and submitted to CMS timely.
RESIDENT 59
Review of Resident 59's discharge MDS dated [DATE] showed it was completed on 04/08/2025 and it was not transmitted/submitted to CMS.
A joint record review and interview on 05/16/2025 at 5:55 PM with Staff F showed Resident 59's MDS dated [DATE] was completed on 04/08/2025 and it was not submitted to CMS. Staff F stated that Resident 59's MDS should have been completed timely and submitted/transmitted to CMS.
On 05/17/2025 at 3:59 PM, Staff B stated that Resident 59's discharge MDS should have been completed and submitted to CMS in a timely manner.
Reference: (WAC) 388-97-1000(5)(a)(e) (i-iii)
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
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 accurately assess 8 of 21 residents (Residents 26, 65, 51, 30, 21, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess 8 of 21 residents (Residents 26, 65, 51, 30, 21, 2, 48 & 39), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments were coded on the MDS regarding Preadmission Screening and Resident Review (PASARR- an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], intellectual/developmental disabilities [ID/DD]), discharge status, bowel (gut) continence, oxygen, medication, urinary catheter (a flexible tube inserted into the bladder to drain urine), and bowel patterns, placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.
Findings included .
According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. It further showed that always incontinent of bowel would be coded if during the 7-day look-back period, the resident was incontinent of bowel for all bowel movements and had no continent bowel movements. Constipation was defined as If the resident has two or fewer bowel movements during the 7-day look-back period.
The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period).
PASARR
RESIDENT 26
Review of the Level II PASARR Initial Evaluation Summary, dated 04/09/2019, showed Resident 26 had a Level II PASARR with diagnosis of conversion disorder (a mental health condition that disrupts how the brain works causing real, physical symptoms that a person cannot control), schizophrenia (a chronic mental disorder with symptoms such as hallucinations [experience involving the apparent perception of something not present], delusions [a false belief, judgment, or perception], and cognitive challenges [affects the ability to think, learn, and process information), and anxiety (excessive, persistent and uncontrollable worry and fear about everyday situations).
Review of the annual MDS dated [DATE] showed that Resident 26 was admitted to the facility on [DATE]. Further review of the MDS showed Section A1500 (PASARR) was coded 0. [No conditions related to SMI/ID/DD status]. Section A1500 should have been coded 1. [Yes, as the Resident 26 had SMI].
In an interview and joint record review on 05/16/2025 at 4:53 PM with Staff F, MDS Coordinator, stated they followed the RAI manual for completion of MDSs. A joint record review showed Resident 26 had a PASARR Level II dated 04/09/2019 that included diagnoses of conversion disorder, schizophrenia, and anxiety. Staff F stated that Resident 26 had a PASARR Level II and had SMIs. A joint record review showed Resident 26's annual MDS dated [DATE] was not marked for Level II PASARR and/or SMI in Section A. Staff F stated that Resident 26's MDS should have been coded for PASARR Level II and for Level II SMI.
In an interview on 05/17/2025 at 3:33 PM, Staff B, Director of Nursing, stated that Resident 26's annual MDS should have been accurate.
DISCHARGE STATUS
RESIDENT 65
Review of a face sheet printed on 05/14/2025 showed Resident 65 was readmitted to the facility on [DATE] and was discharged on 02/19/2025.
Review of the progress notes printed on 05/14/2025 showed Resident 65 was discharged to home on [DATE].
Review of the discharge MDS dated [DATE] showed Resident 65 was marked discharged to the hospital in Section A2105 (Discharge Status). Section A2105 should be marked discharge to community/home.
A joint record review and interview on 05/16/2025 at 5:40 PM with Staff F showed that Resident 65's MDS dated [DATE] was marked discharged to the hospital. Staff F stated that Resident 65 was discharged to the hospital. A joint record review of Resident 65's progress notes dated 02/19/2025, showed Resident 65 was discharged home. Staff F stated that Resident 65 discharged home and that their MDS was inaccurate.
In an interview on 05/17/2025 at 3:36 PM, Staff B stated that Resident 65's MDS should have been coded to have discharged home and that their MDS was inaccurate.
BOWEL CONTINENCE
RESIDENT 51
Review of the April 2025 task for bowel documentation showed Resident 51 was incontinent of bowel every day during the look-back-period (04/16/2025 to 04/22/2025).
Review of the quarterly MDS dated [DATE] showed Resident 51 was coded as always continent of bowel in H0400 (Bowel Continence). Section H0400 should be marked always incontinent, as the bowel task documentation showed Resident 51 was incontinent during the look back period.
A joint record review and interview on 05/16/2025 at 6:14 PM with Staff F showed Resident 51's MDS dated [DATE] was coded for always continent. Staff F stated, it was coded that [Resident 51] was always continent. A joint record review of the April 2025 task for bowel function showed Resident 51 was incontinent of bowel every day during the look-back-period. Staff F stated that Resident 51 was incontinent of bowel, that their MDS should have been coded as always incontinent, and that Resident 51's MDS was inaccurate.
In an interview on 05/17/2025 at 3:36 PM, Staff B stated they expected Resident 51's MDS to be completed accurately.
OXYGEN USE
RESIDENT 30
Review of Resident 30's annual MDS dated [DATE] did not show oxygen was marked in Section O (Special Treatments).
Review of the nursing progress notes dated 04/23/2025 showed that Resident 30 was on continuous oxygen at two liters (unit of measurement) per minute.
A joint record review and interview on 05/16/2025 at 6:11 PM with Staff F, showed that Resident 30's MDS dated [DATE] was not marked for oxygen use. Staff F stated that oxygen was not marked. A joint record review of the progress notes dated 04/23/2025 showed that Resident 30 was on continuous oxygen at two liters per minute. Staff F stated that Resident 30 received oxygen during the look-back-period and that their MDS was inaccurate.
In an interview on 05/17/2025 at 3:50 PM, Staff B stated that Resident 30's MDS should have been accurate.
MEDICATION USE
RESIDENT 21
Review of Resident 21's quarterly MDS dated [DATE] showed, 7 [seven] injections (N0300) and 7 insulin (a medication to manage blood sugar) injections (N0350A) were marked in Section N (Medications).
Review of the April 2025 and March 2025 Medication Administration Record (MAR) did not show Resident 21 received injections and/or insulin injections during the look-back-period (03/26/2025 to 04/01/2025).
A joint record review and interview on 05/16/2025 at 5:46 PM with Staff F showed Resident 21's MDS dated [DATE] was marked for seven injections and seven insulin injections in Section N. Staff F stated that Resident 21's MDS was coded for injections and insulin injections. A joint record review of Resident 21's March 2025 MAR and April 2025 MAR showed Resident 21 did not receive insulin injections during the look-back-period. Staff F stated that Resident 21's MDS should not have been coded for injections and/or insulin injections and that their MDS was inaccurate.
In an interview on 05/17/2025 at 4:02 PM, Staff B stated that Resident 21's MDS was inaccurate.
RESIDENT 2
Review of Resident 2's Significant Change in Status Assessment (SCSA) MDS dated [DATE] showed Section N0415F (1. Is taking an antibiotic [medication that treats infection] and 2. Indication noted) were marked. Further review of the MDS showed Section N0415H (opioid [narcotic pain medication]) use was not marked.
Review of the March 2025 MAR showed Resident 2 was not receiving antibiotics during the look-back- period (03/06/2025 to 03/12/2025). Further review of the MAR showed Resident 2 received oxycodone (an opioid pain medication) on 03/07/2025 and 03/10/2025.
A joint record review and interview on 05/16/2025 at 5:58 PM with Staff F showed that Resident 2's MDS dated [DATE] was marked for antibiotic use in Section N. Staff F stated that Resident 2 received antibiotics according to the MDS. A joint record review of the March 2025 MAR did not show Resident 2 received antibiotics during the look-back-period and that Resident 2 received opioids on 03/07/2025 and 03/10/2025. Staff F stated that Resident 2's MDS should have not been marked for antibiotics as they did not receive any antibiotics, and that opioids should have been coded in the MDS. Staff F further stated that Resident 2's MDS was inaccurate.
In an interview on 05/17/2025 at 3:49 PM, Staff B stated they expected MDS to be accurate and that Resident 2's MDS was inaccurate.
RESIDENT 48
Review of Resident 48's quarterly MDS dated [DATE] showed Section N0415B (use of antianxiety [medication for anxiety]) were marked: 1. Is taking [receiving an antianxiety medication], and 2. Indication noted [reason for taking the medication] during the look-back-period (02/25/2025 to 03/03/2025).
Review of February 2025 and March 2025 MAR showed Resident 48 did not receive an antianxiety medication during the look-back-period.
Review of the physician orders printed on 05/12/2025, showed Resident 48 was not prescribed an antianxiety medication.
In an interview and joint record review on 05/16/2025 at 6:38 PM, Staff F stated they would follow the RAI Manual for MDS coding accuracy. A joint record review of Resident 48's February 2025 and March 2025 MAR showed Resident 48 did not receive an antianxiety medication. Further joint record review of Resident 48's quarterly MDS dated [DATE], showed that Section N was marked for use of antianxiety medication. Staff F stated Resident 48 did not receive an antianxiety and that their MDS coding was not accurate.
In an interview on 05/17/2025 at 1:10 PM, Staff B stated that they expected the MDS to be completed accurately for Resident 48.
URINARY CATHETER USE AND BOWEL PATTERNS
RESIDENT 39
Review of a physician orders printed on 05/13/2025, showed Resident 39 had an order for Document Foley [urinary catheter] output [amount of urine] q [every] shift, dated 02/03/2025.
Review of the April 2025 bowel documentation task from 04/04/2025 through 04/10/2025 showed Resident 39 had two bowel movements in the seven-day look-back-period.
Review of the SCSA MDS assessment dated [DATE], showed Resident 39 was not marked for urinary catheter use under Section H0100 (Appliances). Further review showed constipation (Section H0600) was not marked, indicating Resident 39 did not have constipation.
A joint record review and interview on 05/16/2025 at 5:35 PM with Staff F showed Resident 39 had an order for Document Foley output q shift. Further joint record review of Resident 39's April 2025 bowel documentation task from 04/04/2025 through 04/10/2025 showed Resident 39 had two bowel movements in the seven-day look-back-period. Staff F stated Resident 39's MDS should have been coded for urinary catheter use and constipation, and that Resident 39's MDS was coded inaccurately.
In an interview on 05/17/2025 at 10:42 AM, Staff B stated that they expected Resident 39's MDS to be completed accurately.
Reference: (WAC) 388-97-1000 (1)(b)
.
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 care plans for 5 of 15 resid...
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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 care plans for 5 of 15 residents (Residents 3, 4, 29, 51 & 39), reviewed for comprehensive care plans. The failure to develop/implement care plans for Activities of Daily Living (ADL) and urinary catheter (a flexible tube inserted into the bladder to drain urine) care placed the residents at risk for unmet care needs and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised in March 2022, showed that the comprehensive care plan includes measurable objectives and time frames .describes the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being.
RESIDENT 3
Review of Resident 3's quarterly Minimum Data Set (MDS-an assessment tool), dated 02/11/2025, showed that Resident 3 needed substantial/maximal assistance (helper does more than half the effort) for personal hygiene. It further showed that Resident 3 had diabetes (a group of diseases that result in too much sugar in the blood) diagnosis.
Review of Resident 3's ADL care plan, revised on 04/13/2025, showed Resident 3 required total assistance with personal hygiene care. Review of Resident 3's Diabetes care plan, revised on 04/13/2025, showed an intervention for Diabetic nail care by LN [Licensed Nurse].
Observation on 05/12/2025 at 10:07 AM, showed Resident 3 with long fingernails on both hands and the right thumb had brown matter underneath the nail. Resident 3 stated, I need them [fingernails] to be trimmed. Resident 3 further stated, I'm diabetic.
Observation on 05/14/2025 at 10:28 AM, showed Resident 3 with long fingernails. Resident 3 stated, I had a bed bath yesterday. I've asked them twice in the past two days [to trim fingernails] and I asked an aide to ask the nurse. I'm diabetic so a nurse needs to do it.
In an interview and joint observation on 05/14/2025 at 11:14 AM, Staff GG, Certified Nursing Assistant (CNA), stated that they helped dependent residents with personal hygiene and if a resident had diabetes they would let a nurse know if the nails needed to be trimmed. A joint observation of Resident 3's fingernails showed they were long on both hands. Staff GG stated, it's too long on both hands, the nurse has to cut and I will tell the nurse.
In an interview and joint observation on 05/14/2025 at 11:26 AM, Staff V, Licensed Practical Nurse, stated that CNA's were responsible for personal hygiene for dependent residents including nail care and that if a resident had diabetes, the nurses would trim the nails. Staff V stated that Resident 3 had diabetes and the nurses would be doing the trimming. A joint observation showed Resident 3 had long fingernails on both hands. Staff V stated that Resident 3's nails were pretty long, need them trimmed.
In an interview and joint record review on 05/16/2025 at 11:44 AM, Staff D, Resident Care Manager (RCM), stated that Resident 3 gets help with his nails. A joint record review of Resident 3's Diabetes care plan showed an intervention for nail care by LN. Staff D stated that the care plan should be followed.
RESIDENT 4
Review of Resident 4's admission MDS dated [DATE], showed Resident 4 had a urinary catheter.
Review of a provider note dated 04/25/2025, showed Resident 4 informed, sometimes [that] her urine bag is not getting emptied when it is full, it is overflowing, informed RCM to put orders to empty urine bag twice a shift.
Review of Resident 4's physician orders showed an order to check [the] drainage bag twice a shift and empty drainage when ½ [half] full, started on 04/25/2025.
Review of Resident 4's [Urinary] Catheter care plan, revised on 04/25/2025, showed the intervention to check [the] drainage bag twice per shift, and empty if about or at ½ level.
In an interview on 05/13/2025 at 9:29 AM, Resident 4 stated that they had a urinary tract infection (infection of the bladder) three weeks ago. Nobody checked my bag [catheter drainage bag] and it backed up.
A joint observation and interview on 05/13/2025 at 4:37 PM with Staff W, CNA, showed Resident 4's catheter drainage bag was more than half full. Staff W stated, looks full. A joint observation showed Staff W emptied the drainage bag into a urinal (a plastic container that collects urine) two times with a total amount of 1400 milliliters (unit of measurement).
In an interview and joint record review on 05/17/2025 at 1:30 PM, Staff D stated that they expected staff to follow the care plan. A joint record review of Resident 4's catheter care plan showed the catheter drainage bag should be emptied when it was about half full. Staff D stated they expected the drainage bag to not be full, so nothing in the tubing. When told that it was observed to be full, Staff D stated, my expectation is it should not be full.
RESIDENT 29
Review of Resident 29's ADL self-care care plan revised on 05/06/2025, showed that Resident 29 need one-person extensive assistance (requiring a large amount of effort from the helper) for personal hygiene.
Observations on 05/12/2025 at 10:59 AM, on 05/12/2025 at 2:00 PM, on 05/13/2025 at 3:00 PM, and on 05/14/2025 at 10:25 AM, showed Resident 29's left-hand fingernails had dark brown matter underneath them.
In an interview and joint observation on 05/14/2025 at 11:32 AM, Staff HH, CNA, stated that cleaning nails was included in personal hygiene. A joint observation of Resident 29's left-hand fingernails had dark brown matter underneath them. Staff HH stated that Resident 29's fingernails need to trim and [it was] not clean.
In an interview and joint record review on 05/16/2025 at 11:07 AM, Staff D stated that they expected staff to help them [residents] if they can't do it, when asked how staff should provide ADL care to dependent residents. Staff D stated, aides should clean under the nails. When asked how much help Resident 29 needed with nail care, Staff D stated, he needs someone to trim nails and that their nails should be clean. A joint record review of Resident 29's self-care care plan showed Resident 29 need one-person extensive assistance for personal hygiene. Staff D stated that Resident 29 needed help with cleaning their hands and we need to clean after each meal.
In an interview on 05/17/2025 at 1:42 PM, Staff B, Director of Nursing, stated that they expected resident care plans to be followed.
RESIDENT 51
Review of the quarterly MDS dated [DATE] showed Resident 51 required partial to moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with personal hygiene [for washing/drying face and hands].
Review of the ADLs care plan printed on 05/13/2025 showed that Resident 51 required staff assistance with personal hygiene care.
Observations on 05/13/2025 at 8:52 AM and at 9:14 AM, showed Resident 51's eyelids were covered with yellowish crusty matter. Resident 51 stated they have crusty eyes all the time in the mornings, staff does not clean [their eyes].
Observation on 05/14/2025 at 9:35 AM showed Resident 51's eyes were covered with yellowish crusty matter. Resident 51 stated, it is hard to open my eyes, it hurts and also itches. Resident 51 stated that staff did not clean their eyes and that they [staff] should, they see me every day. I cannot do it. I am blind on my left eye; my eyes are dry.
Observation on 05/15/2025 at 2:34 PM, showed Resident 51's eyelids were covered with yellowish crusty matter. Resident 51 stated they wished they could get a wet towel to clean my eyes. Further observation showed Resident 51's right eye had a scratch on the corner of their right eyelid with a reddish-brownish crusty matter and their left eyelid was covered with yellowish crusty matter. Resident 51 stated I need help from staff to do that [clean their eyes].
In an interview and joint observation on 05/15/2025 at 3:05 PM, Staff E, RCM, stated, the aides [CNAs] should be doing the [Resident 51's] eye wash daily. Resident 51 stated, nobody seems to do anything about it, they see it there. Staff E stated that Resident 51 had a slight redness [scratch] on their eyes and that staff should have been cleaning Resident 51's eyes.
In an interview and joint record review on 05/17/2025 at 12:02 PM, Staff E stated that Resident 51 required assistance with their ADLs, pretty much total care. Staff E stated that Resident 51 needed assistance with personal hygiene, brushing hair, and washing their face. A joint record review of Resident 51's ADLs care plan and Kardex (care plan for CNAs) showed that Resident 51 required staff assistance with personal hygiene. Staff E stated that CNAs should have been cleaning Resident 51's crust from their eyes, it is part of personal hygiene. Staff E further stated that Resident 51's care plan should have been followed.
In an interview on 05/17/2025 at 3:07 PM, Staff B stated that they expected staff to follow residents care plans. Staff B stated that Resident 51 required moderate assist with personal hygiene and that staff should have been cleaning Resident 51's crust from their eyes. Staff B further stated that Resident 51's care plan should have been followed.
RESIDENT 39
Review of a face sheet printed on 05/13/2025 showed Resident 39 admitted to the facility on [DATE].
Observation on 05/12/2025 at 9:30 AM showed Resident 39 had a urinary catheter hanging on the left side of the bed.
Review of the physician orders printed on 05/13/2025, showed Resident 39 had an order for Document Foley [urinary catheter] output [amount of urine] q [every] shift, dated 02/03/2025.
Review of Resident 39's comprehensive care plan printed on 05/13/2025, showed no care plan for urinary catheter use.
A joint record review and observation on 05/16/2025 at 12:51 PM with Staff E, showed Resident 39 did not have a care plan for urinary catheter use. Staff E stated, did she has catheter? A joint observation with Staff E showed Resident 39's urinary catheter was hanging on the left side of the bed. Staff E stated Resident 39 should have had a care plan for urinary catheter.
In an interview on 05/17/2025 at 10:42 AM, Staff B stated that they expected the care plan to be updated and current. Staff B further stated that Resident 39 should have a care plan for urinary catheter.
Reference: (WAC) 388-97-1020 (1)(2)(a)
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RANGE OF MOTION EXERCISES
RESIDENT 32
Review of Resident 32's Cerebral Palsy [a group of conditions that affect movement and pos...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RANGE OF MOTION EXERCISES
RESIDENT 32
Review of Resident 32's Cerebral Palsy [a group of conditions that affect movement and posture] care plan, revised on 04/12/2025, showed an intervention to maintain good body alignment to prevent contractures [a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff]. Use braces and splints as ordered. It further showed interventions for Occupational Therapy (OT) and Physical Therapy (PT) to monitor/document and treat as indicated.
In an interview and joint observation on 05/15/2025 at 2:08 PM, Staff O, LPN, stated that Resident 32 had limited range of motion in their left hand. A joint observation of Resident 32's left hand, showed they could not move three fingers on their left hand. Staff O stated, they're contracted.
In an interview on 05/16/2025 at 10:44 AM, Staff AA, Restorative Aide, stated that Resident 32 was not on a restorative program and did not use any splints.
In an interview and joint record review on 05/16/2025 at 11:07 AM, Staff D, RCM, stated they expected that residents with contractures were monitored for any worsening and should have range of motion and positioning. Staff D stated that Resident 32 had lower body and upper body contractures and I'm thinking he should be on restorative but he's not. A joint record review of Resident 32's Cerebral Palsy care plan showed interventions for OT and PT to monitor/document and treat as indicated. Staff D stated he's not on PT or OT. This [care plan] needs to be updated. Staff D further stated, there's no written range of motion exercises in the care plan and there should be and I need to follow up.
In an interview on 05/17/2025 at 1:42 PM, Staff B stated that a resident's care plan should be revised when there was a change in condition, quarterly, or whenever needs to be.
Reference: (WAC) 388-97-1020 (5)(b)
Based on observation, interview, and record review, the facility failed to revise comprehensive care plans for 4 of 9 residents (Residents 26, 2, 30 & 32), reviewed for care plan revision. The failure to revise the care plan that included interventions for Level II Preadmission Screen and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or related conditions), use of opioid (narcotic pain medication), self-administration of medication, oxygen use, and range of motion, placed the residents at risk for unmet care needs and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised in March 2022, showed that a comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. Further review showed that the care plan described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including any specialized services to be provided as a result of PASARR recommendations. The policy further showed that the interdisciplinary team reviewed and updated the care plan, when there has been a significant change in the resident's condition . when the desired outcome is not met .when the resident has been readmitted to the facility from a hospital stay . and at least quarterly, in conjunction with the required quarterly MDS assessment.
Review of the facility's policy titled, Medications with Boxed Warning, revised in January 2023, showed that nursing should include appropriate monitoring parameters on the resident specific care plan as appropriate. Monitoring for adverse consequences involving ongoing vigilance and may periodically involve evaluations.
PASARR
RESIDENT 26
Review of a face sheet printed on 05/13/2025 showed Resident 26 was admitted to the facility on [DATE].
Review of the Level II PASRR Initial Psychiatric Evaluation Summary, dated 04/09/2019, showed Resident 26 had diagnoses of conversion disorder (a mental health condition that disrupts how the brain works causing real, physical symptoms that a person cannot control), schizophrenia (a chronic mental disorder with symptoms such as hallucinations [experience involving the apparent perception of something not present], delusions [a false belief, judgment, or perception], and cognitive challenges [affects the ability to think, learn, and process information), and anxiety (excessive, persistent and uncontrollable worry and fear about everyday situations). Further review of the Level II PASRR form showed specific interventions were recommended for the nursing facility regarding Resident 26's care.
Review of the PASARR care plan dated 03/01/2021 showed that the interventions from Resident 26's Level II PASARR recommendations were not included in their care plan.
In an interview and joint record review on 05/16/2025 at 4:59 PM, Staff G, Social Services Director, stated that when a resident had a Level II PASARR, the recommendations from the Level II PASARR were included in the resident's care plan. A joint record review showed Resident 26 had a Level II PASARR dated 04/09/2019 with listed interventions for Resident 26. Staff G stated that Resident 26's [NAME] II PASARR had recommendations for their care. A joint record review of the PASARR care plan dated 03/01/2021 did not show the interventions listed from Resident 26's Level II PASARR form. Staff G stated that Resident 26 had a general care plan, it should be personalized just for [Resident 26], the care plan should have been updated with the information and recommendations word for word from their Level II PASARR.
In an interview on 05/17/2025 at 4:11 PM, Staff A, Administrator, stated that they expected care plans to be reviewed and updated at least quarterly. Staff A further stated that Resident 26's PASARR care plan should have been updated with the recommendations from Resident 26's Level II PASARR form.
PAIN MEDICATION
RESIDENT 2
Review of the February 2025 to May 2025 Medication Administration Record (MAR) showed Resident 2 had orders for oxycodone (an opioid medication). Further review of the MAR showed no documentation that Resident 2 was being monitored for adverse side effects related to oxycodone use and/or non-pharmacological interventions were provided prior to administering the oxycodone.
Review of Resident 2's pain care plan printed on 05/13/2025 did not show that opioid medication use, monitoring for adverse side effects to the medication, and/or non-pharmacological interventions were included.
A join record review and interview on 05/17/2025 at 12:56 PM with Staff E, Resident Care Manager (RCM), showed Resident 2's pain care plan did not indicate opioid medication use, monitoring for adverse side effects, and non-pharmacological interventions prior to administering pain medication. Staff E stated that Resident 2's pain care plan should have been updated and personalized to include opioid use, monitoring of adverse side effects, and non-pharmacological interventions.
In an interview on 05/17/2025 at 3:37 PM, Staff B, Director of Nursing, stated that Resident 2's pain care plan should have been revised to include opioid use, monitoring for adverse side effects and non-pharmacological interventions for pain.
SELF-ADMINISTRATION OF MEDICATION
RESIDENT 30
Review of the physician orders printed on 05/12/2025 showed Resident 30 had orders for Flonase (medication that treats nasal congestion) nasal (into the nose) spray, Incruse Ellipta (brand name - inhaler [portable device for administering a drug which is to be breathed in] used to open the airways to increase air flow to the lungs) inhaler, and Albuterol Sulfate (used to open the airways to increase air flow to the lungs) inhaler. Further review of the physician orders did not indicate Resident 30 could self-administer and/or keep the medications at bedside.
Observations on 05/12/2025 at 2:05 PM and on 05/13/2025 at 3:23 PM showed that Resident 30 had an albuterol inhaler, a bottle of Flonase nasal spray, and an Arnuity Ellipta (brand name - inhaler used to open the airways to increase air flow to the lungs) inhaler on their bedside table. Resident 30 stated they administered the medications themselves.
In an interview on 05/13/2025 at 4:16 PM, Staff E stated that residents on self-administration of medication program would an evaluation, order for medications to be self-administered, a locked box to store the medications, and a care plan for it. Staff E further stated that Resident 30's care plan should have been updated for self-administration of medication.
In an interview on 05/17/2025 at 3:55 PM, Staff B stated that Resident 30's care plan should have been revised to include self-administration of medication.
OXYGEN USE
Review of the physician's progress notes dated 04/23/2025 documented that Resident 30 was on continuous oxygen at two liters (unit of measurement) per minute.
Observation on 05/12/2025 at 7:15 AM showed Resident 30 was receiving three liters per minute of oxygen via nasal cannula (flexible tubing that sits inside the nostrils and delivers oxygen) that was connected to an oxygen concentrator (a device that delivers oxygen).
Observation on 05/12/2025 at 1:24 PM and on 05/14/2025 at 1:30 PM showed Resident 30 was receiving two liters per minute of oxygen via nasal cannula. Resident 30 stated that they used oxygen at all times.
A joint observation and interview on 05/14/2025 at 1:51 PM with Staff M, Licensed Practical Nurse (LPN), showed Resident 30 was receiving two liters per minute of oxygen via nasal cannula. Staff M stated that Resident 30 was on two liters per minute of oxygen continuously.
In an interview on 05/17/2025 at 1:06 PM, Staff E stated that Resident 30's care plan should have been updated to include oxygen use.
In an interview on 05/17/2025 at 3:50 PM, Staff B stated that Resident 30's care plan should include the oxygen use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary assistance with Activities of Daily...
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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 necessary assistance with Activities of Daily Living (ADL) for 3 of 4 residents (Residents 3, 29 & 51), reviewed for ADLs. The failure to provide residents who were dependent on staff for assistance with personal hygiene placed the residents at risk for unmet care needs and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised in March 2018, showed that Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
RESIDENT 3
Review of Resident 3's quarterly Minimum Data Set (MDS-an assessment tool), dated 02/11/2025, showed Resident 3 needed substantial/maximal assistance (helper does more than half the effort) for personal hygiene. It further showed that Resident 3 had diabetes (a group of diseases that result in too much sugar in the blood) diagnosis.
Review of Resident 3's Diabetes care plan, revised on 04/13/2025, showed an intervention for Diabetic nail care by LN [Licensed Nurse].
Observation on 05/12/2025 at 10:07 AM, showed Resident 3 with long fingernails on both hands and showed the right thumb had brown material underneath the nail. Resident 3 stated, I need them [fingernails] to be trimmed. Resident 3 further stated, I'm diabetic.
Observation on 05/14/2025 at 10:28 AM, showed Resident 3 with long fingernails. Resident 3 stated, I had a bed bath yesterday. I've asked them twice in the past two days [to trim my fingernails] and I asked an aide to ask the nurse. I'm diabetic so a nurse needs to do it.
In an interview and joint observation on 05/14/2025 at 11:14 AM, Staff GG, Certified Nursing Assistant (CNA), stated that they helped dependent residents with personal hygiene and if a resident had diabetes, they would let a nurse know if the nails needed to be trimmed. A joint observation of Resident 3's nails showed they were long on both hands. Staff GG stated, it's too long on both hands, the nurse has to cut and I will tell the nurse.
In an interview and joint observation on 05/14/2025 at 11:26 AM, Staff V, Licensed Practical Nurse, stated that CNAs were responsible for personal hygiene for dependent residents including nail care and that if a resident had diabetes and the nurses have to do the clipping [of] the nails. A joint observation showed that Resident 3 had long fingernails on both hands. Staff V stated that Resident 3's nails were pretty long, need them trimmed.
In an interview and record review on 05/16/2025 at 11:44 AM, Staff D, Resident Care Manager (RCM), stated that Resident 3 gets help with his nails. A joint record review of Resident 3's physician orders showed an order for diabetes nail care weekly. Staff D stated that Resident 3 had an order for nail care.
RESIDENT 29
Review of a quarterly MDS dated [DATE], showed that Resident 29 needed substantial/maximal assistance for personal hygiene.
Review of a self-care care plan, revised on 05/06/2025, showed that Resident 29 needed one-person extensive assistance (requiring a large amount of effort from the helper) for personal hygiene.
Observations on 05/12/2025 at 10:59 AM, on 05/12/2025 at 2:00 PM, on 05/13/2025 at 3:00 PM, and on 05/14/2025 at 10:25 AM, showed Resident 29 with dark brown matter under their left-hand fingernails.
In an interview and joint observation on 05/14/2025 at 11:32 AM, Staff HH, CNA, stated that cleaning nails was included in personal hygiene. A joint observation of Resident 29's hands showed dark brown matter under their left hand's fingernails. Staff HH stated Resident 29's fingernails were not clean and that they needed to be trimmed.
In an interview on 05/16/2025 at 11:07 AM, Staff D stated that they expected staff to help them [dependent residents] if they can't do it. Staff D stated, aides should clean under the nails. When asked how much help Resident 29 needed with nail care, Staff D stated, Resident 29 needed help with trimming their nails and that they should be clean.
In an interview on 05/17/2025 at 1:42 PM, Staff B, Director of Nursing, stated they expected nail care for dependent residents to be done and that nails should be trimmed as needed and clean. Staff B further stated that if a resident had diabetes, the nurse should do the nail care.
RESIDENT 51
Review of the quarterly MDS dated [DATE] showed Resident 51 required moderate assist (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for personal hygiene that included washing/drying face and hands.
Observations on 05/13/2025 at 8:52 AM and at 9:14 AM, showed Resident 51's eyelids had yellowish crusty matter. Resident 51 stated they have crusty eyes all the time in the mornings, staff does not clean [their eyes].
Observation on 05/14/2025 at 9:35 AM showed Resident 51 had yellowish crusty matter on their eyelids. Resident 51stated, it is hard to open my eyes, it hurts and also itches. Resident 51 further stated that staff did not clean their eyes, they should, they see me every day. I cannot do it. I am blind on my left eye; my eyes are dry.
Observation on 05/15/2025 at 2:34 PM, showed Resident 51 had crusty matter on their eyelids. Resident 51 stated they wished they could get a wet towel to clean my eyes. Further observation showed Resident 51's right eye had a scratch on the corner of their right eyelid with a reddish-brownish crusty matter and their left eye had yellowish crusty matter. Resident 51 stated, I need help from staff to do that [clean their eyes].
In an interview and joint observation on 05/15/2025 at 3:05 PM, Staff E, RCM, stated, the aides [CNAs] should be doing the [resident's] eye wash daily. Resident 51 stated, nobody seems to do anything about it, they see it there. Staff E stated that Resident 51 had a slight redness on their eyes and that staff should have been cleaning them.
In an interview on 05/17/2025 at 3:07 PM, Staff B stated that Resident 51 required moderate assist with personal hygiene and that staff should have been cleaning the crust from their eyes.
Reference: (WAC) 388-97-1060(2)(c)
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 38
Review of the oxygen care plan revised on 04/25/2025, showed Resident 38 used oxygen.
Review of Resident 38's May 20...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 38
Review of the oxygen care plan revised on 04/25/2025, showed Resident 38 used oxygen.
Review of Resident 38's May 2025 physician orders, printed on 05/12/2025 showed an order that oxygen tubing should be changed when visibly soiled and labeled [with] current date.
Observations on 05/12/2025 at 6:30 AM and at 12:24 PM and on 05/13/2025 at 7:58 AM, showed Resident 38's oxygen concentrator (a device to deliver oxygen) was in use and the oxygen tubing was not labeled/dated.
Additional observations on 05/14/2025 at 10:49 AM and at 12:59 PM, showed an unsecured portable oxygen tank set on top of a stool in Resident 38's room.
In an interview and joint record review on 05/13/2025 at 8:33 AM, Staff V, LPN, stated the nurses were responsible for caring for oxygen equipment and that oxygen tubing should be dated. A joint record review of Resident 38's physician orders showed that oxygen tubing should be labeled with the current date. A joint observation showed Resident 38's oxygen tubing was not dated. Staff V stated that it absolutely should be [labeled with a date].
An interview and joint observation on 05/14/2025 at 1:39 PM, Staff V stated that portable oxygen tanks should be secured and set on a dolly [a wheeled cart specifically designed to safely transport oxygen tanks], that fits oxygen tanks. A joint observation showed a free standing, unsecured portable oxygen tank on top of a stool in Resident 38's room. Staff V stated it should not be stored like that. It's not secured.
In an interview on 05/17/2025 at 1:42 PM, Staff B stated that they expected oxygen tubing to be changed when visibly soiled and staff should date it when it was changed. Staff B further stated that portable oxygen tanks should be upright, in a stand and secured.
RESIDENT 30
Review of a face sheet printed on 05/13/2025 showed that Resident 30 was admitted to the facility on [DATE] with diagnoses that included COPD.
Review of the May 2025 MAR showed no documentation that Resident 30 was receiving oxygen.
Observation on 05/12/2025 at 7:15 AM showed Resident 30 was receiving three liters (unit of measurement) per minute of oxygen via nasal cannula (flexible tubing that sits inside the nostrils and delivers oxygen) that was connected to an oxygen concentrator.
Observation and interview on 05/12/2025 at 1:24 PM showed Resident 30 was receiving two liters per minute of oxygen via nasal cannula that was connected to an oxygen concentrator. Resident 30 stated that they used oxygen at all times.
Another observation on 05/14/2025 at 1:30 PM showed Resident 30 was receiving two liters of oxygen per minute via nasal cannula.
A joint observation and interview on 05/14/2025 at 1:51 PM with Staff M, LPN, showed Resident 30 was in their room and using their oxygen via nasal cannula at two liters per minute from an oxygen concentrator. Staff M stated that Resident 30 was on two liters per minute of oxygen via nasal cannula continuously.
A joint record review and interview on 05/14/2025 at 1:58 PM with Staff M, showed Resident 30's May 2025 MAR showed no oxygen orders. Staff M stated, I do not see it [oxygen use orders] here. Staff M further stated that Resident 30 should have had orders for oxygen use to include the oxygen liters per minute, changing oxygen tubing, changing the concentrator filter, and/or to check the oxygen saturation (a measurement of how much oxygen is in the blood) level.
In an interview on 05/17/2025 at 1:06 PM, Staff E stated they expected that residents receiving oxygen should have standing orders for oxygen. Staff E further stated that Resident 30 should have had orders and care plan for oxygen use.
In an interview on 05/17/2025 at 3:50 PM, Staff B stated that Resident 30 should have had orders for oxygen.
In an interview on 05/17/2025 at 1:06 PM, Staff E stated they expected that residents receiving oxygen would have orders for oxygen with the number of liters per minute, orders for changing oxygen tubing, orders for cleaning or changing the oxygen concentrator filter, and for checking oxygen saturation every shift. Staff E further stated that Resident 30 should have had orders and care plan for oxygen use.
In an interview on 05/17/2025 at 3:50 PM, Staff B stated that Resident 30 should have had orders for oxygen.
Based on observation, interview, and record review, the facility failed to provide respiratory care in accordance with accepted professional standards of practice for 4 of 5 residents (Residents 10, 38, 30 & 271), reviewed for respiratory care. The failure to label/date oxygen tubing, properly store oxygen tank, and obtain oxygen orders placed the residents at risk of respiratory infections, and related complications.
Findings included .
Review of the facility's policy titled, Oxygen Administration, revised in October 2010, showed, staff verify that there is a physician's order .Review the physician's orders or facility protocol for oxygen administration.
RESIDENT 10
Review of Resident 10's face sheet printed on 05/12/2025, showed they were admitted to the facility on [DATE] with a diagnosis that included Chronic Obstructive Pulmonary disease (COPD - an ongoing lung condition caused by damage to lungs) and dyspnea (difficulty breathing).
Review of the May 2025 physician orders printed on 05/12/2025, showed Resident 10 had oxygen orders that included, Oxygen tubing is to be changed when it becomes visibly soiled. Labeled w/ [with] current date .every night shift Tue [Tuesday].
Observations on 05/12/2025 at 2:09 PM and on 05/13/2025 at 7:58 AM, showed Resident 10's oxygen tubing was unlabeled/undated.
During a joint record review and interview on 05/13/2025 at 8:08 AM with Staff J, Licensed Practical Nurse (LPN), showed Resident 10 had orders for oxygen. Staff J stated, Oxygen tubing is to be changed when it becomes visibly soiled. Labeled with current date. Joint observation showed Resident 10's oxygen tubing was undated. Staff J stated the oxygen tubing was not labeled or dated and that there should have been a label with the date of when it was last changed.
In an interview and joint record review on 05/16/2025 at 6:05 PM, Staff E, Resident Care Manager (RCM), stated Resident 10's order showed to change oxygen tubing when it becomes visibly soiled and to label with the current date. Staff E further stated they expected staff (nurses) to follow the physician order to label and date oxygen tubing for Resident 10.
In an interview on 05/17/2025 at 1:10 PM, Staff B, Director of Nursing, stated they expected the oxygen tubing to be labeled and dated for Resident 10.
RESIDENT 271
Review of a face sheet printed on 05/13/2025 showed Resident 271 admitted to the facility on [DATE] with diagnosis that included pneumonia (an infection that causes inflammation in the lungs).
Observation on 05/13/2025 at 7:59 AM, showed Resident 271's was receiving oxygen and their oxygen tubing was not dated.
Review of the May 2025 MAR printed on 05/13/2025, showed Oxygen tubing is to be changed when it becomes visibly soiled. Labeled [with] current date, oxygen concentrator filter to be cleaned every week Tuesdays Noc [night shift].
A joint observation and interview on 05/13/2025 at 8:25 AM with Staff J, showed Resident 271's oxygen tubing had no date when it was last changed. Staff J stated Resident 271's oxygen tube should have been dated.
In an interview on 05/16/2025 at 11:54 AM, Staff E stated that Resident 271's oxygen tubing should have been dated.
In an interview on 05/17/2025 at 10:42 AM, Staff B stated that staff should have followed the oxygen order and Resident 271's oxygen tubing should have been labeled when it was last changed.
Reference: (WAC) 388-97-1060 (3)(j)(vi)
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed with the census, actual number of staff, and the hours worked f...
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Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed with the census, actual number of staff, and the hours worked for each shift for 4 of 4 days (05/12/2025, 05/13/2025, 05/14/2025 & 05/16/2025), reviewed for posted nurse staffing information. The failure to post a complete and accurate form daily prevented the residents, family members, and visitors from exercising their rights to know the actual nursing staff hours worked in the facility.
Findings included .
Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, revised in August 2006, showed that Within two hours of the beginning of each shift, the number of licensed nurses and the number of unlicensed nurses directly responsible for resident care is posted in a prominent location and in a clear and readable format .The information recorded should include the actual time worked during that shift for each category and type of nursing staff and total number of licensed and non-licensed nursing staff working for the posted shift. The policy further showed that within two (2) hours of the beginning of each shift, the charge nurse or designee computes the number of direct care staff and completes the Nurse Staffing Information form.
Observations on 05/12/2025 at 6:41 AM at the main entrance and at the nurse's station, showed the Daily Nursing Staff posting that day had the staffing information from 05/11/2025.
Observations on 05/13/2025 at 9:50 AM at the main entrance and at 8:14 AM at the nurse's station, showed the Daily Nursing Staff posting that day had the staffing information from 05/12/2025.
Observations on 05/14/2025 at 10:46 AM and at 2:56 PM at the main entrance and at the nurse's station, showed the Daily Nursing Staff posting that day had the staffing information from 05/13/2025.
Observations on 05/16/2025 at 9:59 AM and at 2:57 PM at the main entrance and at the nurse's station, showed the Daily Nursing Staff posting that day had the staffing information from 05/15/2025.
In an interview on 05/16/2025 at 3:36 PM with Staff K, Human Resource, stated that their process for filling out the Daily Nursing Staff posting was based on the prior day of residents' census and staff working hours.
In an interview on 05/17/2025 at 10:42 AM, Staff B, Director of Nursing, stated that the nurse staffing post should show the current date, census, and update the staff working hours per shift.
In an interview on 05/17/2025 at 10:58 AM, Staff A, Administrator, stated that the nurse staffing post should be current and updated per shift.
No associated WAC
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
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 pharmacy services were provided in accordance ...
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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 pharmacy services were provided in accordance with professional standards of practice to meet the needs of 4 of 6 residents (Resident 4, 30, 21 & 38), reviewed for medication management. The failure to follow physicians order and medication instruction placed the residents at risk for medication errors, negative outcomes, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Administering Medications, revised in April 2019, showed, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.
Review of the facility's policy titled, Oral Inhaler [portable device for administering a drug which is to be breathed in], revised in January 2023, showed that the facility would allow for safe, accurate, and effective administration of medication using oral inhaler. Further review showed that a cup of water would be provided for the resident to rinse their mouth after steroid inhaler (anti-inflammatory drugs that help treat breathing disorders, such as asthma [chronic respiratory disease that affects the airways in the lungs, making it difficult to breathe] and chronic obstructive pulmonary disease [COPD - an ongoing lung condition caused by damage to lungs]) medication.
RESIDENT 4
Review of Resident 4's physician orders, printed on 05/13/2025, showed an order for Ondansetron (medication to treat nausea) eight milligram to give one tablet via G-tube (a small flexible tube surgically inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications).
Observation on 05/13/2025 at 3:39 PM, showed Staff V, Licensed Practical Nurse (LPN), preparing to give Resident 4 their medications, including the ondansetron.
In an interview and joint record review on 05/13/2025 at 3:45 PM, Staff V stated that Resident 4 had a G-tube but she takes Zofran [brand name for ondansetron] sublingual [under the tongue]. A joint record review of Resident 4's physician orders showed an order for Ondansetron to be given every eight hours via G-tube and with the directions to give 1 tab [tablet] by mouth. When asked how they knew to give the ondansetron by mouth, Staff V stated, per the directions. I will call the doctor to change. The way it's written, it's not supposed to be like that. Observation showed Staff V gave the Ondansetron to Resident 4 by mouth.
In an interview on 05/17/2025 at 1:42 PM, Staff B, Director of Nursing, stated that if a medication order showed two routes for administration, they expected staff to call the provider to clarify and change it [the medication order]. Staff B stated, if there's a discrepancy [with the medication order], don't give, call the provider to clarify.
RESIDENT 30
Review of the facility's pharmacy Nursing Drug Handbook, dated 2024, indicated that Arnuity Ellipta (fluticasone furoate [brand name], a steroid [anti-inflammatory drugs that help treat breathing disorders] inhaler, used for COPD]). Further review of drug handbook showed an instruction to rinse mouth with water after use of the Arnuity Ellipta inhaler.
Review of the physician orders printed on 05/12/2025 showed Resident 30 had orders for Incruse Ellipta (Umeclidinium Bromide [brand name]-inhaler used for COPD) inhaler 1 puff a day for COPD. Further review of the physician orders did not indicate that Resident 30 was on self-medication administration program.
Multiple observations on 05/12/2025 at 2:05 PM and on 05/13/2025 at 3:23 PM, showed Resident 30 had an Arnuity Ellipta inhaler on their bedside table. Resident 30 stated they administered the medication themselves and that they used the Arnuity Ellipta inhaler twice a day, after breakfast and after lunch. Resident 30 further stated they did not rinse their mouth after self-administering the inhaler, I do not have to do that.
In an interview and joint observation on 05/13/2025 at 4:16 PM, Staff E, Resident Care Manager, stated that if a resident had orders for a steroid inhaler, staff would have the resident rinse their mouth and spit after using the inhaler. A joint observation showed Resident 30 had an Arnuity Ellipta inhaler on top of their bedside table. Resident 30 stated that they kept their medications at bedside and that they used their medication every day. Staff E stated that Resident 30's medications should have been kept in a locked box.
A joint record review and interview on 05/17/2025 at 1:27 PM with Staff E showed Resident 30's March 2025 to May 2025 Medication Administration Record did not show orders for Arnuity Ellipta inhaler. Staff E stated that Resident 30 had orders for Incruse Ellipta inhaler. Staff E further stated that Resident 30 should have had orders for the Arnuity Ellipta inhaler.
Another joint record review and interview on 05/17/2025 at 1:29 PM with Staff E showed the facility's pharmacy Nursing Drug Handbook showed an instruction to rinse the mouth with water and spit after using the Arnuity Ellipta inhaler. Staff E stated that Resident 30 should be instructed and to rinse their mouth with water after using the Arnuity Ellipta inhaler.
In an interview on 05/17/2025 at 4:26 PM, Staff B stated that Resident 30 should have had orders for Arnuity Ellipta inhaler and should be rinsing their mouth after using Arnuity Ellipta.
RESIDENT 21
Review of a face sheet printed on 05/15/2025 showed Resident 21 admitted to the facility on [DATE] with diagnosis that included asthma.
Review of April 2025 physician orders printed on 05/15/2025 showed Resident 21 had an order for fluticasone-salmeterol (a steroid inhaler for asthma) 500-50 microgram (a unit of measurement) inhaler give one puff two times a day. Further review of the physician orders did not show instruction to rinse mouth after using the inhaler.
Observation on 05/15/2025 at 8:20 AM, showed Staff R, LPN, administered the Fluticasone-Salmeterol to Resident 21. Further observation showed Staff R did not help Resident 21 rinse their mouth with water after using the inhaler.
A joint record review and interview on 05/15/2025 at 8:28 AM with Staff R showed Fluticasone-Salmeterol manufacturer instructions to Step 5 Rinse your mouth. Rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow it. Staff R stated the physician orders should have had an instruction to rinse the mouth after using inhaler and that Resident 21 should be reminded/assisted to rinse their mouth after using the inhaler.
RESIDENT 38
Review of a face sheet printed on 05/15/2025 showed Resident 38 admitted to the facility on [DATE] with diagnosis that included type 2 diabetes mellitus (a group of diseases that result in too much sugar in the blood).
An observation and interview on 05/15/2025 at 12:10 PM, showed Staff O, LPN, was preparing the insulin pen (an injection device to deliver insulin) for Resident 38. Staff O removed the insulin pen cap, turned the dose to seven units, and injected the insulin to Resident 38's left upper thigh without priming (removing the air from the needle and to get the full dose) the insulin pen. Staff O stated they should have primed the insulin pen before administering the insulin to Resident 38.
In an interview on 05/16/2025 at 11:54 AM, Staff E stated that the Fluticasone-Salmeterol was one of the inhalers that need to rinse mouth after use, and they expected staff to follow the instructions on the inhaler box. Staff E further stated they expected staff to prime the insulin pen before each use.
In an interview on 05/17/2025 at 10:42 AM, Staff B stated that they expected staff to help Resident 21 rinse their mouth after using an inhaler. Staff B further stated that Staff O should have primed two units on the insulin pen before they administered it to Resident 38.
Reference: (WAC) 388-97- 1300 (1)(b)(i)(3)(a)
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure medications with adverse side effects were adequately monitored and/or non-pharmacological interventions were provided prior to admi...
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Based on interview and record review, the facility failed to ensure medications with adverse side effects were adequately monitored and/or non-pharmacological interventions were provided prior to administering pain medications for 3 of 5 residents (Residents 2, 39 & 271), reviewed for unnecessary medications. This failure placed the residents at risk for unmet care needs, related complications, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Medications with Boxed Warning, revised in January 2023, showed, nursing should include appropriate monitoring parameters on the resident specific care plan as appropriate. Monitoring for adverse consequences involving ongoing vigilance and may periodically involve evaluations.
RESIDENT 2
Review of the February 2025 to May 2025 Medication Administration Record (MAR) showed that Resident 2 had orders for oxycodone (opioid - narcotic pain medication). Further review of the MAR showed no documentation that Resident 2 was being monitored for adverse side effects related to oxycodone use and/or non-pharmacological interventions were provided prior to administering the oxycodone.
Review of Resident 2's pain care plan printed on 05/13/2025 showed opioid use was not included in the care plan, monitoring of its adverse side effects and non-pharmacological interventions were also not included in the care plan.
In an interview and joint record review on 05/17/2025 at 12:36 PM, Staff E, Resident Care Manager, stated that residents using opioid medications would have orders for monitoring of adverse side effects and non-pharmacological interventions. A joint record review of the May 2025 physician orders and February 2025 through May 2025 MAR did not show monitoring of adverse side effects and non-pharmacological interventions for opioid use. Staff E stated Resident 2 started opioids on 02/25/2025. Staff E further stated that Resident 2 should have been monitored for adverse side effects for opioid use and non-pharmacological interventions should be offered prior to administering it.
A join record review and interview on 05/17/2025 at 12:56 PM with Staff E, showed Resident 2's pain care plan did not include opioid medication use, monitoring for adverse side effects, and/or non-pharmacological interventions prior to administering the opioid medication. Staff E stated that Resident 2's pain care plan should have been personalized to include opioid use, monitoring of adverse side effects, and non-pharmacological interventions.
In an interview on 05/17/2025 at 3:37 PM, Staff B, Director of Nursing, stated that Resident 2 started on oxycodone on 02/25/2025, monitoring of adverse side effects and non-pharmacological interventions should have been included in their care plan.
RESIDENT 271
Review of Resident 271's May 2025 MAR printed on 05/13/2025, showed orders for insulin (a medication to manage blood sugar) Glargine (brand name- a type insulin) administer 45 units (unit of measurement) subcutaneously (under the skin) once a day, Lispro (brand name-a type of insulin) administer 10 units before meals. Further review of Resident 271's MAR did not show monitoring for hypoglycemia (blood sugar level is lower than the standard range) and/or hyperglycemia (blood sugar level is higher than the standard range).
Review of the May 2025 Treatment Administration Record (TAR) printed on 05/13/2025, did not show Resident 271 was being monitored for hypoglycemia and/or hyperglycemia.
Review of Resident 271's care plan for diabetes (a group of diseases that result in too much sugar in the blood), revised in 05/11/2025, showed interventions to Monitor/document for side effects and effectiveness.
RESIDENT 39
Review of Resident 39's May 2025 MAR printed on 05/13/2025, showed an order for hydromorphone (an opioid medication used to manage moderate to severe pain) two milligrams (a unit of measurement) one time a day. Further review of the MAR did not show Resident 39 was monitored for side effects of hydromorphone.
Review of the May 2025 TAR printed on 05/13/2025, did not show Resident 39 was monitored for side effects of hydromorphone use.
In an interview and joint record review on 05/16/2025 at 11:54 AM, Staff E stated that residents who got insulin for diabetes should have had an order for monitoring signs and symptoms of hypoglycemia and hyperglycemia in the physician order. A joint record review of Resident 271's May 2025 MAR and TAR did not show documentation that Resident 271 was being monitored for signs and symptoms of hypoglycemia or hyperglycemia. Staff E stated that they did not see an order in Resident 271's MAR and TAR and that there should have been.
Another joint record review and interview on 05/16/2025 at 12:38 PM with Staff E, showed Resident 39's May 2025 MAR had no monitoring for side effects of hydromorphone use. Staff E stated that Resident 39 should have had side effects monitoring for hydromorphone use.
In an interview on 05/17/2025 at 10:42 AM, Staff B stated that Resident 271 should have had an order for monitor signs and symptoms hypoglycemia and hyperglycemia. Staff B further stated that Resident 39 should have had an order for monitoring side effects of hydromorphone use.
Reference: (WAC) 388-97-1060 (3)(k)(i)(4)
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 38
Review of Resident 38's physician orders, printed on 05/12/2025, showed an order for Albuterol Sulfate inhaler. Furt...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 38
Review of Resident 38's physician orders, printed on 05/12/2025, showed an order for Albuterol Sulfate inhaler. Further review of the physician orders did not show instructions if Resident 38 could self-administer their medication.
Review of Resident 38's Electronic Health Records (EHR-nursing progress notes from 05/14/2024 to 05/15/2025), showed no documentation that Resident 38 had an assessment for self-administration of medication.
Observation and interview on 05/13/2025 at 8:55 AM, showed Resident 38 took an inhaler out of the top drawer of their nightstand and inhaled two puffs. Resident 38 stated they [the facility] know I have it. Resident 38 further stated they had not been assessed for self-administration of medications and I've been using it [the inhaler] for years.
Observation on 05/14/2025 at 1:01 PM, showed an albuterol sulfate inhaler stored in Resident 38's unlocked nightstand drawer. Resident 38 stated, it's my rescue one [inhaler] that came from my doctor.
In an interview and joint record review on 05/14/2025 1:38 PM, Staff V, LPN, stated that residents may not have medications at their bedside and may not self-administer medications unless they have an order. Staff V stated that Resident 38 had not had an assessment done for self-administration of medications. A joint record review of Resident 38's physician orders showed no self-administration of medication order. Staff V stated, I don't see anything [an order]. Staff V was observed asking Resident 38 if they had any medications in their nightstand table. Resident 38 stated, yes, my albuterol inhaler. Staff V was asked if the inhaler should be in Resident 38's room, Staff V stated, no, only if we can get a doctor order for it.
RESIDENT 34
Review of Resident 34's EHR (evaluation tab, miscellaneous tab, nursing progress notes from 05/12/2024 to 05/13/2025, and May 2025 physician orders), showed no documentation that Resident 34 had an assessment or an instruction in the physician order for self-administration of medication.
Observation on 05/14/2025 at 10:22 AM, showed three bottles of multi-collagen [a supplement to provide structure, strength and support throughout the body] supplements on Resident 34's bedside table.
Observation on 05/14/2025 at 12:41 PM, showed three bottles of multi-collagen supplements on Resident 34's bedside table. Resident 34 stated, I take them every day.
A joint record review and interview on 05/14/2025 at 1:38 PM with Staff V, showed no self-administration of medications instruction in the physician orders. Staff V stated there should be an order to self-administer medication and also an order to keep medication at the bedside.
A joint observation and interview on 05/14/2025 at 2:07 PM with Staff V, showed three bottles of multi collagen on Resident 34's bedside table. Resident 34 also showed Staff V that they had another bottle of multi-collagen and a bottle of probiotics [microorganisms that provide health benefits] in their unlocked nightstand drawer. Resident 34 stated that they were taking both medications. Staff V further stated that medications should not be stored at bedside unless she [the resident] has an order.
In an interview on 05/17/2025 at 1:42 PM, Staff B stated that medications should be stored in the medication cart and should not be at bedside unless there is a self-administration assessment. When asked about keeping Resident 38's inhaler and Resident 34's medications at their bedside, Staff B stated, no, that's not the practice and no, would not expect that.
Based on observation, interview, and record review, the facility failed to ensure expired medications and biologicals were discarded for 1 of 1 medication room (Medication Room) and for 2 of 2 crash carts (300 Hall & 400 Hall Crash Carts), reviewed for medication storage and labeling. In addition, the facility failed to properly store medications for 5 of 19 residents (Residents 30, 38, 34, 10 & 5). These failures placed the residents at risk for receiving compromised and/or ineffective biological and medical supplies.
Findings included .
Review of the facility's policy titled, Storage of Medications, revised in April 2020, showed that the facility stored all drugs and biologicals in a safe, secure, and orderly manner. The policy further showed that discontinued, outdated, or deteriorated medications or biologicals would be returned to the dispensing pharmacy or destroyed.
Review of the facility's policy titled, Self-Administration of Medications, revised in September 2004, showed that medications may be kept in a locked drawer at the bedside if the resident was determined to be appropriate for the self-administration of medication program.
MEDICATION ROOM - SMALL REFRIGERATOR
A joint observation and interview on 05/15/2025 at 11:05 AM with Staff E, Resident Care Manager, showed the small refrigerator had one undated multiuse vial of tuberculin (a combination of proteins that are used in the diagnosis of tuberculosis [TB- a bacterial infection that mainly affects the lungs]). Staff E stated that a tuberculin vial could be used for 30 days from when it was first opened. Staff E further stated that the tuberculin vial should have been dated when first opened.
MEDICATION ROOM - MEDICATION REFRIGERATOR
A joint observation and interview on 05/15/2025 at 11:12 AM with Staff E, showed an opened bottle of vanilla Med Plus 2.0 (nutritional supplement) with use-by-date of 04/25/2025, an opened bottle of vanilla Med Plus with use-by-date of 05/14/2025, an opened bottle of vanilla Med Plus with use-by-date of 04/11/2025, and three unopened bottles of vanilla Med Plus with best by date of 12/30/2024. Staff E stated that the Med Plus bottles should have been discarded by the use-by-date and/or by best-by-date.
300 HALL CRASH CART
Observation on 05/16/2025 at 12:03 PM showed the 300 Hall Crash Cart had four bottles of five milliliter (ml - a unit of measurement) sodium chloride (normal saline - sterile salt water) with an expiration date of March 2025.
A joint observation and interview on 05/16/2025 at 12:18 PM with Staff O, Licensed Practical Nurse (LPN), showed the 300 Hall Crash Cart had four five ml bottles of sodium chloride with an expiration date of March 2025. Staff O stated, they expired in March 2025. Staff O further stated that the expired normal saline bottles should not have been in the 300 Hall crash cart.
400 HALL CRASH CART
Observation on 05/16/2025 at 12:23 PM, showed the 400 Hall Crash Cart had a Peripherally Inserted Central Catheter (PICC-a long, flexible tube that is inserted into a vein in the arm) line dressing change tray kit with an expiration date of 05/31/2023, a bottle of 340 ml sterile water with an expiration date of November 2015, and a [NAME] (brand name) humidifier (a device that adds moisture to the air) adaptor with expiration date of September 2016.
A joint observation and interview on 05/16/2025 at 12:42 PM with Staff P, LPN, showed a PICC line kit with an expiration date of 05/31 2023, a bottle of sterile water with an expiration date of November 2015, and a humidifier adaptor with an expiration date of September 2016. Staff P stated the items were expired and they should not have been in the 400 Hall crash cart.
On 05/16/2025 at 1:15 PM, Staff E stated that the four normal saline bottles from the 300 Hall crash cart should have been discarded. Staff E further stated that the expired PICC line dressing kit, sterile water bottle, and the humidifier adaptor should not have been in the 400 Hall crash cart.
On 05/16/2025 at 3:35 PM, Staff B, Director of Nursing, stated that they expected the crash carts to be checked nightly and that expired items should be discarded. Staff B stated that expired items in the 300 Hall and 400 Hall crash carts should have been discarded. Staff B stated that the tuberculin vial should have been dated when it was first opened. Staff B further stated that the opened and unopened bottles of Med Plus should have been discarded by the use-by-date or the best-by-date.
MEDICATION STORAGE
RESIDENT 30
Review of Resident 30's self-administration of medication evaluation assessment dated [DATE] showed it was incomplete, no answers were filled in the form, it was blank.
Review of the physician orders printed on 05/12/2025 showed Resident 30 had orders for Flonase (medication that treats nasal congestion) nasal (into the nose) spray - two spray in both nostrils (into the nose) one time a day, Incruse Ellipta (Umeclidinium Bromide- a brand) inhaler [portable device for administering a drug which is to be breathed in]- one puff inhale orally one time a day for Chronic Obstructive Pulmonary Disease (COPD - an ongoing lung condition caused by damage to lungs), and Albuterol Sulfate (medication used to open the airways to increase air flow to the lungs) inhaler - two puffs orally every six hours as needed for COPD. Further review of the physician orders did not show instructions if Resident 30 could self-administer and/or keep their inhalers at bedside.
Observations on 05/12/2025 at 2:05 PM and on 05/13/2025 at 3:23 PM showed that Resident 30 had an albuterol inhaler, a bottle of Flonase nasal spray, and an Arnuity Ellipta (fluticasone furoate- [brand name], a steroid [anti-inflammatory drugs that help treat breathing disorders]) inhaler on their bedside table within the resident's reach. Resident 30 stated they administer the medications themselves and that they used albuterol inhaler once at night, the nasal spray once a day, and the Arnuity Ellipta inhaler twice a day after breakfast and after lunch.
In an interview and joint observation on 05/13/2025 at 4:16 PM, Staff E stated that when residents request to self-administer their medications, staff would complete a self-administration medication assessment, obtain orders for the medication the resident would self-administer and to keep medication at bedside. A joint observation and interview with Staff E showed Resident 30 had an albuterol inhaler, a bottle of fluticasone nasal spray, and an Arnuity Ellipta inhaler on top of their bedside table. Resident 30 stated that they kept their medications at bedside and that they used them every day. Staff E stated that Resident 30's medications should have been kept in a locked box.
In an interview on 05/17/2025 at 3:55 PM, Staff B stated that Resident 30 should have had an evaluation and orders for self-administration of medications, and medications should have been stored in a locked box.
RESIDENT 10
Review of the physician orders printed on 05/12/2025, showed Resident 10 was prescribed Albuterol Sulfate inhaler. It further showed no instructions for self-administration of medication in the physician orders.
Observations on 05/12/2025 at 2:09 PM and on 05/13/2025 at 8:00 AM, showed Resident 10 had an Albuterol Sulfate inhaler lying on top of their bedside table. Resident 10 stated they used their inhaler when they felt short of breath.
A joint observation and interview on 05/13/2025 at 8:08 AM, Staff J, LPN, showed Resident 10 with an Albuterol Sulfate inhaler lying on top of their bedside table. Staff J stated the inhaler should not have been on Resident 10's bedside table since they did not have a self-administration order.
In an interview and joint record review on 05/16/2025 at 5:50 PM, Staff E stated that Resident 10 did not have an order for self-administration and did not have a self-administration assessment. Staff E further stated that Resident 10's inhaler should have been kept in a locked box if they were on a self-administration program.
In an interview on 05/17/2025 at 1:10 PM, Staff B stated that they expected Resident 10's inhaler to be kept locked.RESIDENT 5
Review of the face sheet printed on 05/13/2025 showed Resident 5 was admitted to the facility on [DATE].
Review of Resident 5's April 2025 and May 2025 EHR under the assessment tab and miscellaneous tab, did not show an assessment for self-administration of medication was done.
Review of Resident 5's physician orders, printed on 05/13/2025, did not show an instruction for self-administration of medication.
Review of Resident 5's comprehensive care plan printed on 05/13/2025, did not show documentation that Resident 5 could independently store medication.
Observations on 05/12/2025 at 9:35 AM and on 05/13/2025 at 8:20 AM showed Resident 5 had a bottle of Centrum (brand name) vitamins and a bottle of Fish oil (supplement) on top of their nightstand.
A joint observation and interview on 05/13/2025 at 8:25 AM with Staff J showed that Resident 5 had two bottles of supplements [Centrum and Fish Oil] on top of their nightstand. Staff J stated that medications should not be kept at their bedside.
In an interview on 05/16/2025 at 11:54 AM, Staff E stated medications should not be kept at the resident's bedside and should be locked in the drawer or a locked box.
In an interview on 05/17/2025 at 10:42 AM, Staff B stated medications should be locked in the drawer.
Reference: (WAC) 388-97-1300(2)
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 25
Review of the face sheet printed on 05/14/2025 showed Resident 25 was admitted to the facility on [DATE] and dischar...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 25
Review of the face sheet printed on 05/14/2025 showed Resident 25 was admitted to the facility on [DATE] and discharged on 03/30/2025.
Review of the nursing progress notes dated 03/29/2025 showed Resident 25 discharged home that day.
A joint record review and interview on 05/16/2025 at 5:52 PM with Staff F, Minimum Data Set (an assessment tool) Coordinator, showed Resident 25's face sheet indicated they discharged on 03/30/2025. Staff F stated that Resident 25 was discharged from the facility on 03/30/2025. A joint record review of the progress note dated 03/29/2025 showed Resident 25 discharged from the facility on 03/29/2025. Staff F stated that Resident 25 was discharged on 03/29/2025 and that the discharge date on their face sheet should have matched the discharge date documented in the progress notes.
In an interview on 05/17/2025 at 4:04 PM, Staff B stated that Resident 25 discharge date on their face sheet should have been 03/29/2025.
RESIDENT 2
Review of Resident 2's Hospice [compassionate care provided to individuals who are in the final stages of a terminal illness] admission Plan of Care, dated 03/02/2025 showed Resident admitted to hospice services on 03/02/2025.
Review of the clinical records titled, Hospice Routine admission Orders, Hospice, and Certification of Terminal Illness, in Resident 2's clinical records under miscellaneous tab showed three documents (three hospice documents: Hospice Routine admission Orders, Hospice and Certification of Terminal Illness) belonged to Resident 169's clinical records.
A joint record review and interview on 05/16/2025 at 6:08 PM with Staff F showed the three documents titled, Hospice Routine admission Orders, Hospice, and Certification of Terminal Illness, in Resident 2's miscellaneous tab belonged to Resident 169. Staff F stated that the three hospice documents were not Resident 2's clinical records and should not have been there.
In an interview on 05/17/2025 at 3:37 PM, Staff B stated that Resident 169's documents should not have been in Resident 2's clinical records.
RESIDENT 30
Review of the face sheet printed on 05/13/2025 showed Resident 30 was admitted to the facility on [DATE].
Review of Resident 30's document titled, Self-Administration of Medication Evaluation, dated 07/09/2024 was not filled out, it was blank.
A joint record review and interview on 05/17/2025 at 1:29 PM with Staff E showed Resident 30's Self-Administration of Medication Evaluation, dated 07/09/2024 was blank. Staff E stated that the document was bank and that it should have been completed after assessing Resident 30 for self-administration of medication.
In an interview on 05/17/2025 at 3:57 PM, Staff B stated that Resident 30's self-administration of medication evaluation dated 07/09/2024 should have been completed.
Reference: (WAC) 388-97-1720 (1)(a)(i)(ii)
Based on interview and record review, the facility failed to ensure clinical records were properly completed for 4 of 7 residents (Residents 36, 25, 2 & 30), reviewed for resident records. The failure to fill out resident forms accurately placed the residents at risk for unmet care needs and a diminished quality of life.
Findings included .
RESIDENT 36
Review of a face sheet printed on 05/13/2025 showed Resident 36 was admitted to the facility on [DATE] with diagnoses that included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (having excessive/persistent worry and fear).
Review of Resident 36's Level I Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or related conditions are not inappropriately placed in nursing homes for long-term care) dated 04/28/2025, did not show depression and anxiety disorder were documented in Section IA (SMI).
A joint record review and interview on 05/16/2025 at 4:59 PM with Staff G, Social Services Director, showed Resident 36 had diagnoses of depression and anxiety disorder on their face sheet. Further joint record review showed that depression and anxiety disorder were not marked in Resident 36's Level I PASARR in Section IA. Staff G stated that Resident 36's Level l PASARR was not accurate and that they should have included their diagnoses of depression and anxiety disorder.
In an interview on 05/17/2025 at 10:42 AM, Staff B, Director of Nursing, stated that they expected PASARR forms to be completed accurately.
In an interview on 05/17/2025 at 10:58 AM, Staff A, Administrator, stated that they expected the PASARR form information should be accurate.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
RESIDENT 7
Observation on 05/13/2025 at 3:03 PM, showed Staff L, CNA, entered Resident 7's room, Staff L helped Resident 7 to sit up on the edge of the bed, then left the room with Resident 7's lunch ...
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RESIDENT 7
Observation on 05/13/2025 at 3:03 PM, showed Staff L, CNA, entered Resident 7's room, Staff L helped Resident 7 to sit up on the edge of the bed, then left the room with Resident 7's lunch tray. Staff L did not perform hand hygiene before entering and/or after leaving Resident 7's room.
Observation on 05/13/2025 at 3:09 PM, showed Staff L entered Resident 7's room with their lunch tray, put on a pair of gloves and assisted Resident 7 to the bathroom. Staff L went to the nurse's station to get a cup of coffee for Resident 7. Staff L did not perform hand hygiene before putting on new gloves, between tasks, and/or after leaving Resident 7's room.
Observation on 05/13/2025 at 3:16 PM, showed Staff L entered Resident 7's room with a cup of coffee and placed it on the lunch tray. Staff L then moved the bedside table in front of Resident 7. Staff L did not perform hand hygiene before entering and/or after leaving Resident 7's room.
RESIDENT 23
Observation on 05/13/2025 at 3:18 PM, showed Staff L entered Resident 23's room, donned gloves, cleaned Resident 23's bedside table, removed their soiled gloves and left Resident 23's room. Staff L did not perform hand hygiene before putting their gloves on, between tasks and/or after leaving Resident 23's room.
In an interview on 05/13/2025 at 3:51 PM, Staff L stated they should have done hand hygiene before putting their clean gloves on, after removing their soiled gloves, and/or after leaving the rooms of Resident 7 and Resident 23.
In an interview on 05/16/2025 at 11:54 AM, Staff E, RCM, stated Staff L should have performed hand hygiene before entering Resident 23's room, between tasks, and/or after leaving the resident's room.
In an interview on 05/16/2025 at 3:05 PM, Staff C stated they expected all staff to do hand hygiene before entering and/or after leaving the residents' room, before donning and after removing their soiled gloves.
In an interview on 05/16/2025 at 3:25 PM, Staff B stated, staff should be doing hand hygiene between care, before touching food and when needed. Staff B further stated, gloves cannot replace hand hygiene.
Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases by:
1. Not ensuring the Infection Prevention and Control Program (IPCP) policies and procedures were reviewed annually, as required.
2. Not monitoring the expiration for eyewash station solutions for 3 of 4 eyewash stations (300 Hall Nurse's Station, 500 Hall Resident Care Manager [RCM] Office, Laundry Room), reviewed for water management.
3. Not ensuring Enhanced Barrier Precautions (EBP - precautions to protect the spread of infectious organisms) were followed for 1 of 9 residents (Residents 1).
4. Not performing hand hygiene during care and treatments for 4 of 11 residents (Residents 4, 7, 23 & 38).
5. Not appropriately handling soiled linen during transport for 2 of 2 residents (Residents 2 & 19), reviewed for infection control.
These failures placed the residents, visitors, and staff at an increased risk of acquiring infections, related complications, and personal injury.
Findings included .
Review of facility's policy titled, Infection Prevention and Control Program, revised in December 2023, showed the infection prevention and control committee, medical director, director of nursing services, and other key clinical and administrative staff review the infection control policies at least annually.
Review of the facility's policy titled, Water Management Plan, revised on 04/22/2025, showed that eyewash stations are inspected weekly and if bottles of saline [sterile salted water] are used instead, check the expiration date on the bottles and replace as necessary.
Review of the facility's policy titled, Enhanced Barrier Precautions, revised on 03/21/2024, showed that in addition to Standard Precautions (minimum infection prevention practices that apply to all resident care, regardless of suspected or confirmed infection status), the facility will implement EBP for residents with indwelling medical devices for the duration of the stay or the indwelling device is discontinued. The policy further stated that indwelling medical devices includes urinary catheters (a device that drains urine from the bladder into a collection bag outside of the body). The policy further showed that Personal Protective Equipment (PPE - gloves, gown, and surgical mask) for EBP was necessary when performing high-contact care activities.
Review of facility's policy titled Handwashing/Hand Hygiene, revised in October 2023, showed 1. Hand hygiene is indicated: a. immediately before touching a resident; c. after contact with blood, body fluids, or contaminated surfaces; d. after touching resident; after touching the resident's environment; f. before moving from work on a soiled body site to clean body site on the same resident; and g. immediately after glove removal . 5. the use if gloves does not replace hand washing/hand hygiene.
INFECTION PREVENTION AND CONTROL PROGRAM-ANNUAL REVIEW
Review of the IPCP including standards, policies, and procedures showed that the policies and procedures have not been reviewed at least annually. The following policies were last reviewed and/or dated below:
1. The IPCP policies - December 2023
2. The Surveillance of Infections - September 2017
3. Antibiotic Stewardship policy - December 2016
4. Influenza vaccine policy - March 2022
5. Pneumococcal Vaccine policy - October 2023
6. COVID-19 (a highly transmissible infectious virus that causes respiratory illness) Vaccine policy - September 2023
In an interview and joint record review on 05/17/2025 at 11:03 AM, Staff C, Infection Preventionist (IP), stated they had not reviewed the IPCP policies and procedures, or had not reviewed them in Quality Assurance and Performance Improvement meetings. Staff C further stated they were not sure when it was last reviewed. A joint record review of the IPCP policies and procedures with Staff C showed that IPCP policies were not reviewed annually. Staff C stated IPCP policies should be reviewed to be updated with the most current standards, policies, and procedures.
In an interview on 05/17/2025 at 2:25 PM Staff B, Director of Nursing, stated that they expected the IPCP policies and procedures to have been reviewed at least annually.
EYEWASH STATION
Observation on 05/16/2025 at 11:56 AM, showed the eyewash station in the 300 Hall Nurse's Station had two Honeywell (brand name) eye saline [sterile salt water] solution bottles with an expiration date of March 2024.
Observation on 05/16/2025 at 12:14 PM, showed the eyewash station in the 500 RCM Office had two Honeywell eye saline solution bottles with an expiration date of March 2024.
In an interview and joint observation on 05/16/2025 at 2:20 PM with Staff A, Administrator, and Staff I, Maintenance Director, Staff I stated that they checked the eyewash stations monthly. A joint observation showed the eyewash station in the 300 Hall nurse's station had two Honeywell eye saline solution bottles and the 500 RCM office had two Honeywell eye saline solution bottles. Staff A stated all four bottles expired in March 2024. Staff I stated that the bottles should have been replaced. Staff A stated they expected the eye saline solution bottles to be replaced when they expired.
An interview and joint observation on 05/16/2025 at 3:25 PM with Staff I, showed the eyewash station in the laundry room had a Honeywell eye saline solution bottle that expired in January 2025. Staff I stated the bottle expired in January 2025 and that the eye saline solution bottle should have been replaced.
EBP
RESIDENT 1
Review of the Enhanced Barrier Precautions care plan, printed on 05/17/2025, showed Resident 1 was placed on EBP for urinary catheter use.
Observation on 05/14/2025 at 2:50 PM, showed Staff V, Licensed Practical Nurse (LPN) and Staff W, Certified Nursing Assistant (CNA), entered Resident 1's room (EBP room) without wearing PPE (gloves and gown) before repositioning Resident 1.
In an interview and joint record review on 05/14/2025 at 3:00 PM, Staff V stated that for residents on EBP, they would follow the EBP signage instructions. Staff V stated that Resident 1 was on EBP due to urinary catheter, and they provided care and repositioned Resident 1. A joint record review of the EBP signage outside Resident 1's door, showed that staff were required to wear gowns and gloves for high contact resident care activities that included transferring or repositioning. Staff V stated they should have worn gown and gloves prior to providing care to Resident 1.
In an interview on 05/14/2025 at 3:08 PM, Staff W stated that they should have worn gowns and gloves prior to providing care to Resident 1.
In an interview on 05/16/2025 at 4:45 PM, Staff C stated they expected staff to follow the EBP precautions for Resident 1.
In an interview on 05/17/2025 at 2:25 PM with Staff B stated they expected staff to follow the EBP precautions for residents who were on EBP.RESIDENT 38
Observation and interview on 05/15/2025 at 7:52 AM, Staff O, LPN, entered Resident 38's room to provide their medication. Staff O did not do hand hygiene prior to entering Resident 38's room. Staff O moved Resident 38's bedside table to the side, picked up Residents 38's bed control from the floor and handed it to Resident 38. Staff O then placed Resident 38's bedside table closer to them, put on gloves, and handed Resident 38 their medications. Staff O did not do hand hygiene between tasks and prior to putting new gloves on. Staff O stated they should have performed hand hygiene before entering Resident 38's room, after picking up their bed control from the floor, and before putting new gloves on.
In an interview on 05/16/2025 at 3:11 PM, Staff C stated that Staff O should have performed hand hygiene before entering Resident 38's room, after picking up the bed control from the floor, and before putting on gloves. Staff C further stated they expected staff to do hand hygiene before entering/after leaving residents' rooms, after touching residents' belongings, before/after providing resident care.
In an interview on 05/16/2025 at 3:49 PM, Staff B stated they expected staff to do hand hygiene before and after care, when working from dirty to clean, before entering residents' rooms, before placing gloves on, and after touching residents' belongings. Staff B further stated that Staff O should have performed hand hygiene prior to entering Resident 38's room, after picking up their bed control from the floor, and before putting on clean gloves.
TRANSPORTING OF SOILED LINEN/SOILED DISPOSABLE BRIEFS
Review of the facility's policy titled, Laundry and Bedding, Soiled, revised in September 2022, showed that soiled laundry/bedding would be handled, transported, and processed according to best practices for infection prevention and control. The document further showed, All used laundry is handled as potentially contaminated using standard precautions . Contaminated laundry is bagged or contained at the point of collection.
RESIDENT 2
Observation on 05/12/2025 at 9:55 AM, showed Resident 2's soiled bed linens were unbagged and on the floor near their bed.
RESIDENT 19
Observation on 05/12/2025 at 10:01 AM, showed Staff U, CNA, exiting Resident 19's room. Further observation showed Staff U holding an open clear bag of soiled linens and clothing items in their right hand and another clear bag of soiled briefs in their left hand. Staff U then took the soiled bagged items to Resident 2's room and added Resident 2's soiled linens that were on the floor to the opened soiled linen bag.
In an interview on 05/12/2025 at 10:06 AM, Staff U stated that soiled briefs would be tied in a bag and taken to the soiled utility room and the soiled linens would be taken to the laundry chute. Staff U stated that they took the bagged soiled briefs and soiled linens from Resident 19 to Resident 2's room and added Resident 2's soiled linens. Staff U further stated that they placed Resident 2 soiled linens on the floor because they were not visibly soiled and that Resident 19's soiled linens were not visibly soiled when they took them to Resident 2's room.
In an interview on 05/16/2025 at 3:06 PM, Staff C stated they expected soiled linens and soiled briefs to be bagged and sealed in residents' rooms before transporting them to the designated locations. Staff C stated that soiled linens should not be on the floor unbagged. Staff C further stated that Resident 2's soiled linens should not have been left on the floor and that staff [Staff U] should not have taken the soiled linens and soiled briefs from Resident 19's room to Resident 2's room.
In an interview on 05/16/2025 at 3:26 PM, Staff B stated that they expected staff to handle soiled linen and soiled briefs without dragging them on the floor, tied in a bag, and transported to the designated areas. Staff B stated that soiled linens and/or soiled briefs should not be directly touching the floor and should not be taken from one room to another. Staff B further stated that Resident 2's soiled linens should not have been on the floor unbagged and that staff [Staff U] should not have taken Resident 19's soiled briefs and linens to Resident 2's room.
Reference: (WAC) 388-97-1320 (1)(a)(c)(3)
HAND HYGIENE/GLOVE USE
RESIDENT 4
Review of the admission Minimum Data Set (an assessment tool) dated 02/03/2025, showed Resident 4 had a feeding tube (a medical device inserted into the digestive tract to deliver nutrition).
Review of Resident 4's physician orders printed on 05/13/2025, showed an order to change Resident 4's feeding tube daily and as needed for loose or soiled dressings.
Observation on 05/13/2025 at 4:17 PM, showed Staff V removed Resident 4's soiled dressing while wearing a gown, mask, and gloves. Staff V removed their soiled gloves and put on new gloves. No hand hygiene was done between glove changes. Staff V cleaned the wound (feeding tube site), removed their soiled gloves and put on new gloves. No hand hygiene was done between glove changes. Staff V provided Resident 4's wound treatment, removed their soiled gloves and put on new gloves. No hand hygiene was done between glove changes.
In an interview on 05/13/2025 at 4:56 PM, Staff V stated that normally [I] would wash hands or sanitize hands between glove changes.
In an interview on 05/17/2025 at 10:29 AM, Staff C stated that they expected hand hygiene to be done before and after glove use. Staff C further stated that during a dressing change the process was to wash hands, put on clean gloves, provide care, and if have to take off gloves and put on new ones, you should do hand hygiene in-between.
In an interview on 05/17/2025 at 1:42 PM, Staff B stated that they expected hand hygiene to be done before donning [putting on] gloves and after doffing [taking off] gloves.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure expired foods were discarded for 1 of 1 refrig...
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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 expired foods were discarded for 1 of 1 refrigerator (Solarium Room Residents' Refrigerator), and failed to ensure dishwasher temperatures were maintained within the required ranges for 1 of 1 dishwasher, reviewed for food service safety. In addition, the facility failed to follow reheating food requirements for 1 of 1 (Staff L). These failures placed all residents at risk of food-borne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Personal Food Storage, updated in [DATE], showed, food or beverage brought in from outside sources for storage in facility pantries, refrigeration units, or personal room refrigeration units will be monitored by designated facility staff for food safety .The manufacturer's use by/expiration date supersedes any facility labeled use by date.
Review of the facility provided document titled, ELT [Ecolab (brand name) Low Temperature] and ELTHH [Ecolab Low Temperature] Dishmachine, dated 2024, showed that Low-temperature Ecolab dish machine operating temperature for washing would be at a minimum of 120°F (degrees-Fahrenheit - measure of temperature).
Review of the May 2025 Sanitizer Dish Machine Log, revised in April 2015, showed that the temperature for the dishwashing machine would be 120°F to 140°F. Further review of the document showed, report any inappropriate temperatures or sanitizing issues to the supervisor immediately for corrective action.
Review of facility's policy titled, Reheating Food in the Microwave, revised in July 2024, showed, 1. Food heated in the microwave should be covered, rotated, and stirred while cooking for even heating. 2. Using a sanitized, calibrated thermometer, take at least three points of temperature to ensure even, safe heating. 3. Food should reach a minimum temperature of 165°F, holding for 15 seconds. 4. After reheating the resident's foods, the temperature should be taken prior to serving to the resident and this information should be documented on the Microwave Reheating Log.
SOLARIUM ROOM RESIDENTS' REFRIGERATOR
A joint observation and interview on 05/15/2025 at 10:05 AM with Staff S, Dietary Services Manager, showed the Solarium Room Residents' Refrigerator had two cups of Yoplait (brand name) yogurt with use-by-date of 05/14/2025 for Resident 27. Staff S stated that Resident 27's yogurts should have been discarded.
In an interview on 05/16/2025 at 2:59 PM, Staff A, Administrator, stated they expected expired food items in refrigerators to be discarded. Staff A further stated that Resident 27's yogurts should have been discarded by the use-by-date.
DISHWASHER TEMPERATURES
Observation on 05/12/2025 at 6:13 AM showed the kitchen dishwasher machine washing temperature reached a temperature of 106°F that day.
A joint observation and interview on 05/12/2025 at 6:16 AM with Staff T, Dietary Aide, showed the dishwasher washing temperature reached 107°F that day. Staff T stated that the dishwasher machine was a low temperature machine. Staff T stated that low temperature dish machine should reach a minimum of 120°F and the machine has not been reaching a temperature of 120°F or above since last year. Staff T further stated that maintenance personnel had been made aware of the dishwasher machine temperatures.
In an interview and joint observation on 05/15/2025 at 9:44 AM, Staff S stated that the facility used a low temperature dishwasher machine, and that the washing temperature would be ideally above 120°F. A joint observation of the dishwasher washing temperature showed it reached 103°F that day. Staff S stated that the dishwasher washing temperature should reach 120°F.
Multiple joint observations and interview on 05/15/2025 at 10:27 AM and at 10:28 AM with Staff S, showed the dishwasher reached a washing temperature of 111°F that day. Staff S stated that the dishwasher machine had not reached a temperature of 120°F since last year and it should have been.
A joint record review and interview on 05/15/2025 at 1:30 PM with Staff S showed the Sanitizer Dish Machine Log from 05/01/2024 to 05/15/2025 had the following dish machine washing temperatures that were below 120°F:
June 2024
06/10/2024 - 117°F breakfast, 119°F lunch
06/14/2024 - 114°F dinner
September 2024
09/09/2024 - 107°F lunch,
09/10/2024 - 110°F breakfast,113°F lunch
09/16/2024 - 111°F breakfast, 115°F lunch
09/17/2024 - 111°F breakfast,114°F lunch
09/23/2024 - 111°F breakfast,113°F lunch
09/24/2024 - 113°F breakfast, 119°F lunch
09/25/2024 - 118°F lunch
09/30/2024 - 110°F breakfast, 115°F lunch
October 2024
10/01/2024 - 113°F breakfast, 114°F lunch
10/02/2024 - 108°F breakfast,117°F dinner
10/03/2024 - 119°F breakfast, 115°F lunch, 113°F dinner
10/04/2024 - 114°F breakfast, 116°F lunch, 110°F dinner
10/05/2024 - 116°F breakfast, 114°F lunch, 112°F dinner
10/06/2024 - 113°F breakfast, 115°F lunch, 118°F dinner
10/07/2024 - 111°F breakfast, 115°F lunch, 119°F dinner
10/08/2024 - 112°F breakfast, 114°F lunch, 100°F dinner
10/09/2024 - 111°F breakfast, 115°F lunch
10/10/2024 - 113°F breakfast, 113°F lunch
10/11/2024 - 111°F breakfast, 115°F lunch, 110°F dinner
10/12/2024 - 110°F breakfast, 114°F lunch, 112°F dinner
10/13/2024 - 111°F breakfast, 115°F lunch, 110°F dinner
10/14/2024 - 112°F breakfast, 115°F lunch, 117°F dinner
10/15/2024 - 114°F breakfast, 115°F lunch
10/16/2024 - 112°F breakfast, 113°F lunch
10/17/2024 - 112°F breakfast, 113°F lunch
10/18/2024 - 109°F breakfast, 110°F lunch, 116°F dinner
10/19/2024 - 107°F breakfast, 109°F lunch, 107°F dinner
10/20/2024 - 109°F breakfast, 111°F lunch, 112°F dinner
10/21/2024 - 113°F breakfast, 115°F lunch, 110°F dinner
10/22/2024 - 111°F breakfast, 114°F lunch
10/23/2024 - 111°F breakfast, 112°F lunch
10/24/2024 - 111°F breakfast, 111°F lunch, 114°F dinner
10/25/2024 - 110°F breakfast, 111°F lunch, 118°F dinner
10/26/2024 - 111°F breakfast, 110°F lunch, 112°F dinner
10/27/2024 - 109°F breakfast, 110°F lunch, 110°F dinner
10/28/2024 - 116°F breakfast, 116°F lunch, 110°F dinner
10/29/2024 - 110°F breakfast, 112°F lunch, 110°F dinner
10/30/2024 - 109°F breakfast, 118°F lunch, 119°F dinner
10/31/2024 - 108°F breakfast, 112°F lunch, 119°F dinner
November 2024
11/01/2024 - 109°F breakfast, 111°F lunch, 110°F dinner
11/02/2024 - 108°F breakfast, 113°F lunch, 111°F dinner
11/03/2024 - 106°F breakfast, 117°F lunch, 119°F dinner
11/04/2024 - 110°F breakfast, 112°F lunch, 110°F dinner
11/05/2024 - 112°F breakfast, 116°F lunch, 115°F dinner
11/06/2024 - 106°F breakfast, 111°F lunch, 111°F dinner
11/07/2024 - 108°F breakfast, 110°F lunch, 118°F dinner
11/08/2024 - 112°F breakfast, 108°F lunch, 119°F dinner
11/09/2024 - 106°F breakfast, 111°F lunch, 110°F dinner
11/10/2024 - 110°F breakfast, 108°F lunch, 110°F dinner
11/11/2024 - 112°F breakfast, 114°F lunch, 115°F dinner
11/12/2024 - 107°F breakfast, 110°F lunch, 110°F dinner
11/13/2024 - 108°F breakfast, 111°F lunch, 117°F dinner
11/14/2024 - 110°F breakfast, 112°F lunch, 113°F dinner
11/15/2024 - 108°F breakfast, 112°F lunch, 114°F dinner
11/16/2024 - 106°F breakfast, 112°F lunch, 110°F dinner
11/17/2024 - 106°F breakfast, 112°F lunch, 107°F dinner
11/18/2024 - 111°F breakfast, 119°F lunch, 108°F dinner
11/19/2024 - 110°F breakfast, 119°F lunch, 111°F dinner
11/20/2024 - Blank for breakfast, lunch, and dinner
11/21/2024 - 115°F breakfast, 108°F lunch, 115°F dinner
11/22/2024 - 108°F breakfast, 110°F lunch, 114°F dinner
11/23/2024 - 106°F breakfast, 113°F lunch, 108°F dinner
11/24/2024 - 108°F breakfast, 110°F lunch, 111°F dinner
11/25/2024 - 110°F breakfast, 114°F lunch, 111°F dinner
11/26/2024 - 109°F breakfast, 113°F lunch, 115°F dinner
11/27/2024 - 108°F breakfast, 110°F lunch, 115°F dinner
11/28/2024 - 110°F breakfast, 116°F lunch, 110°F dinner
11/29/2024 - 108°F breakfast, 112°F lunch, 118°F dinner
11/30/2024 - 110°F breakfast, 108°F lunch, 110°F dinner
December 2024
12/01/2024 - 111°F breakfast, 111°F lunch, 117°F dinner
12/02/2024 - 110°F breakfast, 115°F lunch, 109°F dinner
12/03/2024 - 112°F breakfast, 113°F lunch, 110°F dinner
12/04/2024 - 109°F breakfast, 111°F lunch, 102°F dinner
12/05/2024 - 110°F breakfast, 112°F lunch, 110°F dinner
12/06/2024 - 112°F breakfast, 115°F lunch, 100°F dinner
12/07/2024 - 111°F breakfast, 112°F lunch, 101°F dinner
12/08/2024 - 107°F breakfast, 106°F lunch, 109°F dinner
12/09/2024 - 111°F breakfast, 115°F lunch, 115°F dinner
12/10/2024 - 109°F breakfast, 113°F lunch, 109°F dinner
12/11/2024 - 108°F breakfast, 111°F lunch, 110°F dinner
12/12/2024 - 110°F breakfast, 113°F lunch, 100°F dinner
12/13/2024 - 111°F breakfast, 112°F lunch, 110°F dinner
12/14/2024 - 108°F breakfast, 111°F lunch, 100°F dinner
12/15/2024 - 110°F breakfast, 113°F lunch, 111°F dinner
12/16/2024 - 109°F breakfast, 111°F lunch, 100°F dinner
12/17/2024 - 108°F breakfast, 109°F lunch, 109°F dinner
12/18/2024 - 106°F breakfast, 108°F lunch, 100°F dinner
12/19/2024 - 111°F breakfast, 106°F lunch, 111°F dinner
12/20/2024 - 111°F breakfast, 111°F lunch, 110°F dinner
12/21/2024 - 106°F breakfast, 109°F lunch, 100°F dinner
12/22/2024 - 110°F breakfast, 112°F lunch, 110°F dinner
12/23/2024 - 112°F breakfast, 110°F lunch, 112°F dinner
12/24/2024 - 113°F breakfast, 112°F lunch, 111°F dinner
12/25/2024 - 108°F breakfast, 110°F lunch, 100°F dinner
12/26/2024 - 110°F breakfast, 106°F lunch, 112°F dinner
12/27/2024 - 106°F breakfast, 110°F lunch, 113°F dinner
12/28/2024 - 104°F breakfast, 108°F lunch, 117°F dinner
12/29/2024 - 106°F breakfast, 110°F lunch
12/30/2024 - 107°F breakfast, 110°F lunch, 115°F dinner
12/31/2024 - 110°F breakfast, 109°F lunch, 110°F dinner
January 2025
01/01/2025 - 108°F breakfast, 106°F lunch
01/02/2025 - 110°F breakfast, 108°F lunch, 112°F dinner
01/03/2025 - 110°F breakfast, 111°F lunch, 110°F dinner
01/04/2025 - 110°F breakfast, 111°F lunch
01/05/2025 - 108°F breakfast, 109°F lunch, 119°F dinner
01/06/2025 - 111°F breakfast, 110°F lunch, 110°F dinner
01/07/2025 - 109°F breakfast, 111°F lunch, 116°F dinner
01/08/2025 - 106°F breakfast, 108°F lunch, 110°F dinner
01/09/2025 - 106°F breakfast, 111°F lunch, 112°F dinner
01/10/2025 - 110°F breakfast, 107°F lunch, 110°F dinner
01/11/2025 - 109°F breakfast, 110°F lunch, 116°F dinner
01/12/2025 - 113°F breakfast, 106°F lunch, 114°F dinner
01/13/2025 - 107°F breakfast, 111°F lunch, 115°F dinner
01/14/2025 - 108°F breakfast, 110°F lunch, 110°F dinner
01/15/2025 - 106°F breakfast, 113°F lunch, 110°F dinner
01/16/2025 - 115°F breakfast, 108°F lunch, 113°F dinner
01/17/2025 - 110°F breakfast, 106°F lunch, 110°F dinner
01/18/2025 - 111°F breakfast, 110°F lunch, 119°F dinner
01/19/2025 - 108°F breakfast, 111°F lunch, 109°F dinner
01/20/2025 - 105°F breakfast, 110°F lunch, 113°F dinner
01/21/2025 - 107°F breakfast, 111°F lunch, 106°F dinner
01/22/2025 - 107°F breakfast, 110°F lunch, 110°F dinner
01/23/2025 - 106°F breakfast, 108°F lunch, 112°F dinner
01/24/2025 - 107°F breakfast, 110°F lunch, 110°F dinner
01/25/2025 - 106°F breakfast, 112°F lunch, 112°F dinner
01/26/2025 - 106°F breakfast, 118°F lunch, 110°F dinner
01/27/2025 - 110°F breakfast, 111°F lunch, 113°F dinner
01/28/2025 - 107°F breakfast, 109°F lunch, 102°F dinner
01/29/2025 - 107°F breakfast, 110°F lunch, 116°F dinner
01/30/2025 - 109°F breakfast, 111°F lunch, 116°F dinner
01/31/2025 - 106°F breakfast, 111°F lunch, 100°F dinner
February 2025
02/01/2025 - 110°F breakfast, 106°F lunch, 112°F dinner
02/02/2025 - 106°F breakfast, 114°F lunch, 110°F dinner
02/03/2025 - 107°F breakfast, 111°F lunch, 111°F dinner
02/04/2025 - 110°F breakfast, 109°F lunch, 116°F dinner
02/05/2025 - 107°F breakfast, 106°F lunch, 106°F dinner
02/06/2025 - 115°F breakfast, 105°F lunch, 110°F dinner
02/07/2025 - 108°F breakfast, 107°F lunch, 110°F dinner
02/08/2025 - 111°F breakfast, 108°F lunch, 112°F dinner
02/09/2025 - 110°F breakfast, 106°F lunch, 106°F dinner
02/10/2025 - 108°F breakfast, 110°F lunch, 111°F dinner
02/11/2025 - 107°F breakfast, 107°F lunch, 116°F dinner
02/12/2025 - 115°F breakfast, 106°F lunch, 110°F dinner
02/13/2025 - 110°F breakfast, 113°F lunch, 106°F dinner
02/14/2025 - 108°F breakfast, 110°F lunch, 100°F dinner
02/15/2025 - 106°F breakfast, 108°F lunch, 112°F dinner
02/16/2025 - 108°F breakfast, 113°F lunch, 100°F dinner
02/17/2025 - 112°F breakfast, 106°F lunch, 119°F dinner
02/18/2025 - 111°F breakfast, 111°F lunch, 112°F dinner
02/19/2025 - 107°F breakfast, 111°F lunch, 106°F dinner
02/20/2025 - 105°F breakfast, 109°F lunch, 101°F dinner
02/21/2025 - 109°F breakfast, 107°F lunch, 106°F dinner
02/22/2025 - 107°F breakfast, 110°F lunch, 100°F dinner
02/23/2025 - 118°F breakfast, 113°F lunch, 107°F dinner
02/24/2025 - 108°F breakfast, 115°F lunch, 115°F dinner
02/25/2025 - 109°F breakfast, 111°F lunch, 100°F dinner
02/26/2025 - 106°F breakfast, 108°F lunch, 116°F dinner
02/27/2025 - 108°F breakfast, 110°F lunch, 100°F dinner
02/28/2025 - 118°F breakfast, 106°F lunch, 114°F dinner
March 2025
03/01/2025 - 107°F breakfast, 111°F lunch, 106°F dinner
03/02/2025 - 109°F breakfast, 112°F lunch, 100°F dinner
03/03/2025 - 108°F breakfast, 111°F lunch, 110°F dinner
03/04/2025 - 107°F breakfast, 110°F lunch, 100°F dinner
03/05/2025 - 108°F breakfast, 100°F lunch, 112°F dinner
03/06/2025 - 113°F breakfast, 118°F lunch, 108°F dinner
03/07/2025 - 111°F breakfast, 110°F lunch, 108°F dinner
03/08/2025 - 106°F breakfast, 107°F lunch, 108°F dinner
03/09/2025 - 115°F breakfast, 108°F lunch, 109°F dinner
03/10/2025 - 111°F breakfast, 115°F lunch
03/11/2025 - 113°F breakfast, 114°F lunch, 108°F dinner
03/12/2025 - 106°F breakfast, 110°F lunch, 108°F dinner
03/13/2025 - 117°F breakfast, 108°F lunch, 115°F dinner
03/14/2025 - 118°F breakfast, 106°F lunch, 106°F dinner
03/15/2025 - 114°F breakfast, 111°F lunch, 110°F dinner
03/16/2025 - 108°F breakfast, 115°F lunch, 100°F dinner
03/17/2025 - 109°F breakfast, 115°F lunch, 113°F dinner
03/18/2025 - 115°F breakfast, 115°F lunch, 116°F dinner
03/19/2025 - 110°F breakfast, 110°F lunch, 100°F dinner
03/20/2025 - 108°F breakfast, 116°F lunch, 112°F dinner
03/21/2025 - 110°F breakfast, 115°F lunch, 114°F dinner
03/22/2025 - 108°F breakfast, 118°F lunch, 116°F dinner
03/23/2025 - 113°F breakfast, 110°F lunch, 100°F dinner
03/24/2025 - 110°F breakfast, 112°F lunch, 112°F dinner
03/25/2025 - 109°F breakfast, 114°F lunch, 106°F dinner
03/26/2025 - 108°F breakfast, 110°F lunch, 106°F dinner
03/27/2025 - 108°F breakfast, 106°F lunch, 106°F dinner
03/28/2025 - 111°F breakfast, 111°F lunch, 108°F dinner
03/29/2025 - 109°F breakfast, 115°F lunch, 112°F dinner
03/30/2025 - 108°F breakfast, 108°F lunch, 110°F dinner
03/31/2025 - 108°F breakfast, 114°F lunch, 116°F dinner
April 2025
04/01/2025 - 110°F breakfast, 114°F lunch, 112°F dinner
04/02/2025 - 106°F breakfast, 110°F lunch, 100°F dinner
04/03/2025 - 110°F breakfast, 111°F lunch, 110°F dinner
04/04/2025 - 114°F breakfast, 113°F lunch, 100°F dinner
04/05/2025 - 110°F breakfast, 108°F lunch, 104°F dinner
04/06/2025 - 115°F breakfast, 108°F lunch, 108°F dinner
04/07/2025 - 109°F breakfast, 115°F lunch, 111°F dinner
04/08/2025 - 111°F breakfast, 113°F lunch, 110°F dinner
04/09/2025 - 107°F breakfast, 110°F lunch, 106°F dinner
04/10/2025 - 108°F breakfast, 112°F lunch, 109°F dinner
04/11/2025 - 113°F breakfast, 115°F lunch, 100°F dinner
04/12/2025 - 108°F breakfast, 110°F lunch, 106°F dinner
04/13/2025 - 107°F breakfast, 115°F lunch, 100°F dinner
04/14/2025 - 111°F breakfast, 112°F lunch, 114°F dinner
04/15/2025 - 109°F breakfast, 114°F lunch, 107°F dinner
04/16/2025 - 108°F breakfast, 115°F lunch, 110°F dinner
04/17/2025 - 111°F breakfast, 115°F lunch, 100°F dinner
04/18/2025 - 114°F breakfast, 115°F lunch, 110°F dinner
04/19/2025 - 111°F breakfast, 115°F lunch, 108°F dinner
04/20/2025 - 115°F breakfast, 114°F lunch, 100°F dinner
04/21/2025 - 110°F breakfast, 113°F lunch, 119°F dinner
04/22/2025 - 112°F breakfast, 116°F lunch, 110°F dinner
04/23/2025 - 108°F breakfast, 109°F lunch, 117°F dinner
04/24/2025 - 115°F breakfast, 119°F lunch, 115°F dinner
04/25/2025 - 109°F breakfast, 111°F lunch, 112°F dinner
04/26/2025 - 108°F breakfast, 111°F lunch, 108°F dinner
04/27/2025 - 106°F breakfast, 110°F lunch, 100°F dinner
04/28/2025 - 111°F breakfast, 112°F lunch, 108°F dinner
04/29/2025 - 113°F breakfast, 115°F lunch, 100°F dinner
04/30/2025 - 111°F breakfast, 114°F lunch, 112°F dinner
May 2025
05/01/2025 - 108°F breakfast, 115°F lunch, 108°F dinner
05/02/2025 - 109°F breakfast, 111°F lunch, 100°F dinner
05/03/2025 - 108°F breakfast, 119°F lunch, 110°F dinner
05/04/2025 - 115°F breakfast, 116°F lunch, 108°F dinner
05/05/2025 - 111°F breakfast, 113°F lunch, 119°F dinner
05/06/2025 - 110°F breakfast, 115°F lunch, 100°F dinner
05/07/2025 - 111°F breakfast, 110°F lunch, 112°F dinner
05/08/2025 - 108°F breakfast, 119°F lunch, 108°F dinner
05/09/2025 - 108°F breakfast, 111°F lunch, 112°F dinner
05/10/2025 - 108°F breakfast, 115°F lunch, 108°F dinner
05/11/2025 - 111°F breakfast, 119°F lunch, 106°F dinner
05/12/2025 - 110°F breakfast, 112°F lunch, 111°F dinner
05/13/2025 - 112°F breakfast, 114°F lunch, 101°F dinner
05/14/2025 - 111°F breakfast, 115°F lunch, 105°F dinner
05/15/2025 - 115°F breakfast
Staff S stated that the dishwasher machine had not been reaching a washing temperature of 120°F and it should have been. Staff S further stated that they had informed maintenance staff of the dishwasher washing temperatures.
In an interview on 05/16/2025 at 2:59 PM, Staff A stated that they expected the low temperature dishwasher machine worked properly and at the required temperature. Staff A further stated that the dishwasher temperature for washing should have been at a minimum of 120°F.
RE-HEATING FOOD
STAFF L
Observation on 05/13/2025 at 3:03 PM, showed Staff L, Certified Nursing Assistant, took Resident 7's lunch tray to the microwave room, warmed it in the microwave, and delivered the tray back to Resident 7 without taking the temperature of their food.
In an interview on 05/13/2025 at 3:51 PM, Staff L stated they warmed up the food for one and half minutes. Staff L stated they did not know that they should have checked the temperature of the food prior to serving it to Resident 7.
A joint observation and interview on 05/17/2025 at 10:42 AM, Staff E, Resident Care Manager, showed that there was a temperature log on top of the microwave and a thermometer next to the temperature log. Staff E stated that Staff L should have checked the temperature of the food prior to serving it to Resident 7.
A joint record review and interview on 05/17/2025 at 10:42 AM, Staff B, Director of Nursing, showed the policy titled, Reheating Food in the Microwave, indicated that After reheating the resident's foods, the temperature should be taken prior to serving [it] to the resident and this information should be documented on the Microwave Reheating Log. Staff B stated that Staff L should have followed the policy and should have taken the temperature of the food prior to serving it to Resident 7.
Reference: (WAC) 388-97-1100(2)(3)
.
Mar 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
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 ensure an Enhanced Barrier Precautions (EBP- precauti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an Enhanced Barrier Precautions (EBP- precautions to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections]) signage was in place and/or use of appropriate Personal Protective Equipment (PPE-gown) were followed during medication administration for 1 of 2 residents (Resident 1), reviewed for infection control. This failure placed the residents, staff, and visitors at an increased risk of infection and related complications.
Findings included .
Review of the facility's policy titled, Infection Control, revised in July 2002, showed that the facility's infection control policies and procedures are to establish guidelines to provide a safe and sanitary environment while preventing the development and transmission of disease and infection.
Review of the facility's policy titled, Enhanced Barrier Precautions, dated 03/21/2024, showed that PPE for EBP were necessary when performing high-contact care activities that included device care or use of feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation).
Resident 1 admitted to the facility on [DATE] with diagnoses that included gastroparesis (a condition in which the stomach muscles do not move food well for digestion).
Observation on 03/05/2025 at 2:39 PM, showed Resident 1 had PPE cart outside their room. Further observation showed no EBP signage was posted outside Resident 1's room.
Observation on 03/05/2025 at 2:40 PM, showed Resident 1 was receiving nutrition supplement via feeding tube. Resident 1 stated they have had their feeding tube for over 25 years.
Observation on 03/05/2025 at 4:07 PM, showed Staff C, Registered Nurse, was observed administering medications to Resident 1 via feeding tube without wearing a gown.
Observation on 03/06/2025 at 4:00 PM, showed Staff D, Licensed Practical Nurse, was observed administering medications to Resident 1 via feeding tube without wearing a gown. Staff D stated that residents with open wounds and feeding tube were placed on EBP where staff would wear a mask, gown, and gloves. Staff D stated that they should have worn a gown when they provided Resident 1 their medications via feeding tube. Joint observation of Resident 1's room did not show a signage for EBP. Staff D stated that there was no EBP signage in place and there should have been one.
On 03/06/2025 at 4:41PM, Staff E, Resident Care Manager, stated that EBP should be in place for residents on feeding tube. Staff E stated that the nurses [Staff C and Staff D] should have worn a gown prior to administering Resident 1's medications via feeding tube.
On 03/05/2025 at 6:06 PM, Staff B, Interim Director of Nursing, stated that staff should follow the precautions signage for residents on EBP. Staff B further stated that the nurses should have worn a gown prior to administering Resident 1's medications via feeding tube.
Reference: (WAC) 388-97-1320 (1)(a)
.
Aug 2024
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the primary care physician was notified when medications wer...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the primary care physician was notified when medications were not administered for 1 of 3 residents (Resident 1) reviewed for medications. The failure to notify the primary care physician when the medication (Levothyroxine) used to treat an underactive thyroid gland (a gland in the neck that affects heart rate, mood, and energy levels) and a medication (Trospium) used to treat an overactive bladder was not administered placed Resident 1 at risk for a decline in medical condition, skin impairments, and a diminished quality of life.
Findings included .
A review of the admission Minimum Data Set (MDS-an assessment tool) dated 07/15/2024, showed Resident 1 was admitted to the facility on [DATE] with a diagnosis list that included a thyroid disorder. The MDS also showed the resident had intact thinking and had a loss of bladder control.
Interview on 08/06/2024 at 3:03 PM, Resident 1 stated, I missed some days of my thyroid medication and the medication I take to control my bladder. I am afraid my heart will start to beat too fast if I don't get my thyroid medication because that is what has happened before when I did not take it. And I constantly urinate if I don't take my Trospium every day that makes me miserable.
A review of the July 2024 Medication Administration Record (MAR) showed an order for Levothyroxine 175 micrograms (one-millionth of a gram) give 1 tablet by mouth one time a day for hypothyroidism (underactive thyroid). The MAR showed on 07/24/2024, and on 07/25/2024, there was the number nine documented [was not given] with staff initials. Further review of the MAR showed an order for Trospium 20 milligrams (a unit of measurement), give 1 tablet by mouth two times a day for overactive bladder. The number nine was documented on 07/24/2024 at 6:30 AM and 8:00 PM, and on 07/25/2024 at 6:30 AM, the number nine was documented both with staff initials.
On 08/12/2024 at 12:31 PM, Staff C, Registered Nurse, stated that on 07/24/2024 and 07/25/2024, the number nine meant the medications had not been administered to Resident 1. Staff C stated the primary care physician should have been notified on 07/24/2024 and 07/25/2024 when the medication had not been administered to Resident 1 as ordered. Staff C further stated that Resident 1 could have bad side effects if the Levothyroxine was stopped and not given for a while.
On 08/12/2024 at 1:13 PM, Staff D, Licensed Practical Nurse, stated that the primary care physician should be notified every time a medication was not administered to the residents as ordered in case they needed to change or adjust the medication.
On 08/12/2024 at 2:07 PM, Staff B, Director of Nursing Services, stated that the primary care physician should have been notified when the Levothyroxine and Trospium were not administered as ordered.
On 08/12/2024 at 2:13 PM, Staff A, Administrator, stated that the primary care physician should have been notified when the medications were not administered to Resident 1.
Reference: (WAC) 388-97-0320
.
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 F0760
(Tag F0760)
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 that 1 of 3 residents (Resident 1) was free from a significa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that 1 of 3 residents (Resident 1) was free from a significant medication error. The failure to administer a medication (Levothyroxine) used to treat an underactive thyroid gland (a gland in the neck that affects heart rate, mood, and energy levels) and a medication (Trospium) used to treat an overactive bladder placed Resident 1 at risk for a decline in medical condition, skin impairments, and a diminished quality of life.
Findings included .
A review of the admission Minimum Data Set (MDS-an assessment tool) dated 07/15/2024, showed Resident 1 was admitted to the facility on [DATE] with a diagnosis list that included a thyroid disorder. The MDS also showed the resident had intact thinking and had a loss of bladder control.
Interview on 08/06/2024 at 3:03 PM, Resident 1 stated, I missed some days of my thyroid medication and the medication I take to control my bladder. I am afraid my heart will start to beat too fast if I don't get my thyroid medication because that is what has happened before when I did not take it. And I constantly urinate if I don't take my Trospium every day that makes me miserable.
A review of the July 2024 Medication Administration Record (MAR) showed an order for Levothyroxine 175 micrograms (one-millionth of a gram) give 1 tablet by mouth one time a day for hypothyroidism (underactive thyroid). The MAR showed on 07/24/2024, and on 07/25/2024, there was the number nine documented [was not given] with staff initials. Further review of the MAR showed an order for Trospium 20 milligrams (a unit of measurement), give 1 tablet by mouth two times a day for overactive bladder. The number nine was documented on 07/24/2024 at 6:30 AM and 8:00 PM, and on 07/25/2024 at 6:30 AM, the number nine was documented both with staff initials.
On 08/12/2024 at 12:31 PM, Staff C, Registered Nurse, stated that on 07/24/2024 and 07/25/2024, the number nine meant the medications had not been administered to Resident 1 and that the medication had run out, the pharmacy was called to deliver the medications but did not deliver until 07/26/2024. Staff C stated that the Trospium was not given to Resident 1 on 07/24/2024, and 07/25/2024 at 6:30 AM because the medication had run out. Staff C further stated that Resident 1 could have bad side effects if the Levothyroxine was stopped and not given for a while.
On 08/12/2024 at 1:13 PM, Staff D, Licensed Practical Nurse, stated that they notified the pharmacy to deliver the medications for the residents when we started to notice the medications were low and close to running out. Staff C further stated that the pharmacy should have delivered the medications before the resident ran out.
On 08/12/2024 at 2:07 PM, Staff B, Director of Nursing Services, stated that the Levothyroxine was not administered to Resident 1 on 07/24/2024 and 07/25/2024 and did not receive the Trospium on 07/24/2024 and the morning dose on 07/25/2024.
On 08/12/2024 at 2:13 PM Staff A, Administrator, stated that the omission of medications for Resident 1 was not a good practice.
Reference: (WAC) 388-97-1060(3)(k)(iii)
.
Jul 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
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 baseline care plans were developed within 48 hours of admiss...
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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 baseline care plans were developed within 48 hours of admission to ensure continuity of care and failed to ensure a summary or copy of the baseline care plan were provided to the residents and/or their representatives for 3 of 4 residents (Residents 1, 3 & 4), reviewed for baseline care plan. This failure placed the residents at risk for unmet care needs and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Baseline Care Plan, revised in March 2022, showed that a baseline plan or care to meet resident's immediate health and safety needs is developed for each resident within 48 hours of admission. The policy further showed that the baseline care plan includes instructions needed to effective, person-centered care of the resident that meet professional standards of quality care.
RESIDENT 1
Resident 1 admitted to the facility on [DATE].
Review of the admission Minimum Data Set (MDS - an assessment tool) dated 06/17/2024 showed Resident 1 was cognitively intact.
Review of Resident 1's progress notes printed on 06/27/2024 did not show documentation that the baseline care plan was offered and/or provided to Resident 1 within 48 hours of admission.
Review of Resident 1's 72 Hour Huddle [an assessment that included the baseline care plan information] document printed on 06/27/2024, did not show documentation that the baseline care plan was provided to Resident 1. Further review of the baseline care plan information on the 72 Hour Huddle document showed it was blank.
On 06/27/2024 at 3:38 PM, Resident 1 stated they were not offered or provided a copy of the baseline care plan.
Joint record review and interview on 07/09/2024 at 2:13 PM with Staff E, Social Services Director, showed Resident 1's 72 Hour Huddle was locked [signed/completed] on 07/02/2024. Staff E stated that Resident 1's 72 Hour Huddle document was locked on 07/02/2024 and it did not show when it was provided to the resident.
RESIDENT 3
Resident 3 admitted to the facility on [DATE].
Review of the admission MDS dated [DATE], showed Resident 3 was cognitively intact.
Review of the nursing progress notes dated 06/17/2024, showed the baseline care plan was reviewed and provided to Resident 3 on 06/17/2024 [was not provided within 48 hours of admission].
On 06/27/2024 at 2:09 PM, Resident 3 stated they did not receive a baseline care plan.
Joint record review and interview on 07/09/2024 at 2:10 PM with Staff E, showed Resident 3's 72 Hour Huddle document dated 06/17/2024 revealed that the baseline care plan was reviewed and provided that date. Staff E stated Resident 3's baseline care plan was reviewed and provided to Resident 3 on 06/17/2024.
RESIDENT 4
Resident 4 admitted to the facility on [DATE].
Review of the nursing progress notes dated 06/21/2024, showed the baseline care plan was reviewed and provided to Resident 4 on 06/21/2024 [was not provided within 48 hours of admission].
Joint record review and interview on 07/09/2024 at 2:12 PM with Staff E, showed Resident 4's 72 Hour Huddle document dated 06/21/2024, revealed that the baseline care plan was reviewed and provided Resident 4 on 06/21/2024. Staff E stated that Resident 4's baseline care plan was provided to the resident on 06/21/2024.
On 07/09/2024 at 1:20 PM, Staff C, Resident Care Manager, stated that baseline care plans should be developed and completed within 48 hours of residents' admission.
On 07/09/2024 at 2:00 PM, Staff E stated baseline care plans were offered to the residents and/or residents' representatives within three days of admission.
On 07/09/2024 at 3:23 PM, Staff B, Director of Nursing, stated that the baseline care plans should have been completed and offered and/or provided to Residents 1, 3 & 4 within 48 hours of admission.
Reference: (WAC) 388-97-1020(3)
.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary assistance for shower/bathing f...
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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 assistance for shower/bathing for 2 of 5 residents (Residents 1 & 2), reviewed for Activities of Daily Living (ADL). This failure placed the residents at risk for unmet care needs, poor hygiene, skin impairment, and a diminished quality of life.
Findings included .
RESIDENT 1
Resident 1 admitted to the facility on [DATE].
Review of Resident 1 admission Minimum Data Set (MDS - an assessment tool) dated 06/17/2024, showed Resident 1 required total assist with shower/bathing. Further review of the MDS showed Resident 1 was cognitively intact.
Review of the undated document titled, Shower Schedule Wing 3, showed room [ROOM NUMBER]-2 (Resident 1's room) was scheduled for shower/bathing on Tuesdays and Fridays.
Review of the June 2024 Documentation Survey Report, showed Resident 1 did not receive a shower/bathing on 06/18/2024 (Tuesday) and on 06/21/2024 (Friday). Further review of the document did not show Resident 1 had refusals for shower/bathing.
On 06/26/2024 at 2:55 PM, Resident 1 stated they had their first bed bath on 06/25/2024 (11 days after admitted to the facility).
On 06/27/2024 at 2:45 PM, Staff D, Certified Nurse Assistant, stated Resident 1 required total assist with bed bath.
Joint record and interview on 06/27/2024 at 3:21 PM with Staff C, Resident Care Manager, showed Resident 1's bathing task had a bed bath documented for 06/25/2024. Staff C stated that there was no documentation to show Resident 1 had shower/bathing on 06/18/20204 and 06/21/2024 and that the resident had no refusals.
RESIDENT 2
Resident 2 admitted to the facility on [DATE].
Review of the ADL care plan dated 04/17/2024, showed Resident 2 required one person assist with shower/bathing.
Review of the undated document titled, Shower Schedule Wing 3, showed room [ROOM NUMBER]-2 (Resident 2's room) was scheduled for shower/bathing on Wednesdays and Fridays.
Review of the June 2024 Documentation Survey Report, showed Resident 2 did not receive shower/bathing on 06/19/2024 (Wednesday) and on 06/21/2024 (Friday). Further review of the document did not show Resident 2 had refusals for shower/bathing.
Joint record review and interview on 06/27/2024 at 3:27 PM with Staff C, showed no documentation to show Resident 2 had shower/bathing on 06/19/2024 and 06/21/2024. Staff C stated that there were no documentation of shower/bathing refusals for Resident 2.
On 07/09/2024 at 4:03 PM, Staff B, Director of Nursing, stated residents' shower/bathing were done according to the wing shower schedules. Staff B stated that residents were offered to have showers at a minimum of twice a week or per their preference. Staff B further stated that Residents 1 & 2 should have been provided shower/bathing according to their shower schedules.
Reference: (WAC) 388-97-1060 (2)(c)
.
Mar 2024
21 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure advance directives (a written instruction, such as a living ...
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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 advance directives (a written instruction, such as a living will or durable power of attorney for health care) were obtained from the residents and/or their representatives and ensure a copy was readily available in the medical records for 2 of 4 residents (Residents 45 & 38), reviewed for advance directives. This failure placed the residents and/or their representatives at risk for losing their right to have their preferences honored to receive care according to their choice.
Findings included .
Review of the facility's policy titled, Advance Directives, revised in September 2022, showed, prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The policy showed that if the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The policy further showed, information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff.
RESIDENT 45
Resident 45 admitted to the facility on [DATE].
Review of the quarterly Minimum Data Set (an assessment tool) dated 01/22/2024, showed Resident 45 was cognitively intact.
Review of Resident 45's advance directive care plan revised on 02/02/2024, directed Social Services Director to determine on admission whether the resident had an advance directive, and if not, determine whether the resident wishes to formulate an advance directive.
Review of the clinical record (electronic health record/hard copy) did not show documentation that Resident 45 had an advance directive. The clinical record did not show Resident 45 and/or their representative were offered to establish an advance directive and/or if they declined to have one.
On 03/14/2024 at 8:14 AM, Resident 45 stated that the facility staff did not discuss or ask them about advance directive.
RESIDENT 38
Resident 38 admitted to the facility on [DATE].
Review of the clinical record did not show documentation that advance directives were offered to Resident 38 and/or their representative, and no documentation to show if they declined to have one.
On 03/13/2024 at 8:16 AM, Resident 38 stated they did not recall if the facility asked about their advance directive. Resident 38 stated they did not have an advance directive.
During a joint record review and interview on 03/14/2024 at 9:21 AM with Staff E, Social Services Director, showed Resident 45 and Resident 38 did not have an advance directive. Staff E stated Resident 45 and Resident 38's advance directive should have been checked to determine whether they have one and/or offered to formulate one.
On 03/18/2024 at 11:55 AM, Staff A, Administrator, stated they expected Social Services to have a conversation with the residents about advance directives during admission or later as needed. Staff A stated Resident 45 and Resident 38's advance directive should have been requested, obtained, and placed in their medical records.
Reference: (WAC) 388-97-0280 (3)(a)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary N...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN - a required form that outlined the transfer of financial liability from the nursing facility to the Medicare [government health insurance program] beneficiary) for 3 of 5 residents (Residents 160, 30 & 161), reviewed for liability notices, who remained in the facility after their Medicare Part A skilled nursing and rehabilitation services ended. This failure placed the residents and/or their representatives at risk for not having adequate information to make financial decisions related to continued stay in the facility.
Findings included .
Review of the facility's policy titled, SNF ABN, revised on 09/01/2023, showed, a SNF ABN shall be issued to qualified beneficiaries following a skilled stay when the beneficiary chooses to remain in the facility. The SNF ABN is a liability notice, and it provides information to the beneficiary so that an informed decision may be made regarding receiving care that may not be covered under the Medicare benefit, thereby assuming financial responsibility.
RESIDENT 160
Resident 160 admitted to the facility on [DATE].
Review of Resident 160's Notice of Medicare Non-Coverage (NOMNC - is a required form used for billing Medicare services) document showed it was issued by telephone and certified mail to the resident on 10/03/2023, which informed the resident their skilled nursing services would end on 10/05/2023. There was no SNF ABN provided to Resident 160 with information regarding the payment amount for which the resident was responsible should the resident elect to continue with skilled services that would not be covered by Medicare.
Review of Resident 160's census showed the resident was active in the facility dated 10/06/2023.
RESIDENT 30
Resident 30 readmitted to the facility on [DATE].
Review of Resident 30's NOMNC document showed it was issued by certified mail to Resident 30's representative on 12/06/2023, which informed the resident their skilled nursing services would end on 12/08/2023. There was no SNF ABN provided to Resident 30's representative with information regarding the payment amount for which the resident was responsible should the resident elect to continue with skilled services that would not be covered by Medicare.
Review of Resident 30's census showed the resident was active in the facility dated 12/09/2023.
RESIDENT 161
Resident 161 readmitted to the facility on [DATE].
Review of Resident 161's NOMNC document showed it was issued by telephone and certified mail to Resident 161's guardian on 09/27/2023, which informed the resident their skilled nursing services would end on 09/29/2023. There was no SNF ABN provided to Resident 161's guardian with information regarding the payment amount for which the resident was responsible should the resident elect to continue with skilled services that would not be covered by Medicare.
Review of Resident 161's census showed the resident was active in the facility dated 09/30/2023.
On 03/14/2024 at 11:02 AM, Staff E, Social Services Director, stated that SNF ABNs were given if residents exhausted their 100 days Medicare coverage and/or remained in the facility. Staff E stated that they were aware that SNF ABN forms were not given to Residents 160, 30 and 161 and that they should have been provided a SNF ABN form.
On 03/14/2024 at 12:54 PM, Staff A, Administrator, stated that they expected staff to issue the SNF ABN forms to Resident 160, 30 and 161.
Reference: (WAC) 388-97-0300 (1)(e)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, and homelike environme...
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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 clean, comfortable, and homelike environment for 1 of 1 room (room [ROOM NUMBER]), reviewed for environment. The failure to prevent excessive odor placed the resident at risk for feeling unclean, undignified, and a diminished self-worth.
Findings included .
Resident 47 admitted to the facility on [DATE].
Review of the Electronic Health Record showed Resident 47 had been in room [ROOM NUMBER] since 10/04/2023.
Review of the quarterly Minimum Data Set (an assessment tool) dated 01/26/2024, showed Resident 47 was cognitively intact.
On 03/12/2024 at 8:49 AM, room [ROOM NUMBER] had a strong smell of urine. The strong urine odor continued through 03/13/2024 at 2:15 PM, on 03/14/2024 at 10:00 AM, on 03/14/2024 at 10:58 AM, and on 03/15/2024 at 12:23 PM.
Observation and interview on 03/13/2024 at 2:15 PM, showed Resident 47 had a urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) bag full of urine. Resident 47 drained their urinary catheter bag into a urinal (a container used to collect urine), spilled urine on the floor, and placed the urinal under the bedside table. Resident 47 stated they sometimes emptied their catheter bag when it gets full. Resident 47 stated that if their urinal was not full, sometimes their urinal would not be emptied and/or washed for a day. Resident 47 further stated that the staff sometimes forgot to put the lid on the urinal and that they could smell the urine.
During a joint observation and interview on 03/14/2024 at 10:48 AM with Staff K, Licensed Practical Nurse, showed room [ROOM NUMBER] had a strong urine odor. Staff K stated the room smelled of urine.
During a joint observation and interview on 03/14/2024 at 10:58 AM with Staff B, Director of Nursing Services, showed room [ROOM NUMBER] had drips of urine on the floor and stated, this room stinks.
On 03/18/2024 at 9:20 AM, Staff L, Certified Nursing Assistant, stated they noticed urine odor every time they go to room [ROOM NUMBER] to help Resident 47 with their shower.
On 03/18/2024 at 12:36 PM, Staff C, Maintenance/Housekeeping/Laundry Manager, stated that two or three weeks ago the housekeeping team made them aware that room [ROOM NUMBER] had urine odor.
On 03/19/2024 at 8:05 AM, Staff G, Resident Care Manager, stated that they were aware Resident 47's room had urine odor.
On 03/19/2024 at 8:55 AM, Staff B stated that they were aware that room [ROOM NUMBER] had urine odor.
Reference: (WAC) 388-97-0880 (1)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
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 identify, initiate, thoroughly investigate, and promp...
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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 identify, initiate, thoroughly investigate, and promptly resolve a grievance for 1 of 2 residents (Resident 15), reviewed for grievances. This failure placed the resident at risk for unmet care needs and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Grievance, revised in May 2000, showed, the nursing facility will listen to and act promptly upon grievances. The policy showed that Formal grievances are to be made in writing and the resident fills out the top portion of the grievance communication form and staff will assist if requested. The appropriate department supervisor will take immediate action toward resolution of the concern and will record the resolution on the bottom section of the form. The policy further showed that resolved grievances will be maintained .for one year.
Resident 15 admitted to the facility on [DATE].
Review of Resident 15's Inventory of Personal Effects document dated 02/29/2020, showed Resident 15 had new complete upper/lower dentures.
Review of Resident 15's progress notes dated 08/21/2023, showed the resident dentures is broken. Broken piece was found in resident room.
Review of Resident 15's nursing progress notes dated 08/29/2023, showed that SSD [Social Services Director] f/u [follow up] c [with] floor nurse who made reports. Floor nurse indicates other [another] half of denture has not been found. SSD will f/u c dentist to ensure [Resident 15] is on the list to be seen by dentist at next visit.
Review of the facility provided grievance log dated 02/20/2023 through 12/20/2023, showed no documentation that a grievance had been initiated for Resident 15's missing denture.
Observation and interview on 03/12/2024 at 12:09 PM, showed Resident 15 had no natural teeth and no dentures. Resident 15 stated that they used to have dentures, but one was broken and the upper denture was missing. Resident 15 stated they would like to have them again.
On 03/14/2024 at 1:05 PM, Staff U, Certified Nursing Assistant, stated that they reported the missing dentures [for Resident 15] to a nurse right away.
On 03/14/2024 at 1:39 PM, Staff V, Licensed Practical Nurse, stated that if a resident reported missing dentures they would look for it and report to social services.
On 03/14/2024 at 2:06 PM, Staff E, Social Services Director, stated that when a resident lost their dentures, they would fill out a grievance form and would expect to have a resolution. Staff E stated that there was no grievance form filled out for Resident 15's missing denture and was unsure if there was a resolution.
On 03/14/2024 at 2:33 PM, Staff B, Director of Nursing, stated that they would expect a grievance form filled out for Resident 15's missing denture and that there should be a resolution.
On 03/19/2024 at 1:08 PM, Staff A, Administrator, stated that they expected a grievance form filled out for missing items and that there should be a resolution within five days whenever possible. Staff A further stated that they expected a grievance form filled out for Resident 15 and that the facility had not been following that process.
Reference: (WAC) 388-97-0460
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess 1 of 6 residents (Resident 49), reviewed for Mini...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess 1 of 6 residents (Resident 49), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding medications placed the resident at risk for unidentified and/or unmet care needs, and a diminished quality of life.
Findings included .
According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.18.11, dated October 2023, showed, coding instructions to code all high risk drug class medications according to their pharmacological (drug's uses, effects, and modes of actions) classification and not how they are being used. It also showed to check if the resident is taking any medication by pharmacological classification during the 7-day observation period.
The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period).
Resident 49 admitted to the facility on [DATE].
Review of the admission MDS with ARD of 01/03/2024, showed Resident 49 was marked for anticoagulants (blood thinner) and was not marked for antiplatelets (helps keep blood flowing in the body) medication.
Review of Resident 49's physician orders showed an order for Plavix (an antiplatelet medication) oral tablet 75 milligrams (unit of measurement) by mouth once a day dated 12/29/2023. Further review of the physician orders did not show Resident 49 had an order for an anticoagulant medication.
Review of the December 2023 and January 2024 Medication Administration Record (MAR) showed Resident 49 received Plavix six times during the look back period. Further review of the MAR did not show Resident 49 received an anticoagulant medication during the look back period.
On 03/15/2024 at 11:03 AM, Staff F, MDS Coordinator, stated that they followed the RAI manual for MDS completion. Staff F reviewed Resident 49's MAR and stated, I missed it and that they should have marked the MDS for antiplatelet instead of the anticoagulant.
On 03/18/2024 at 11:57 AM, Staff B, Director of Nursing, stated that they expected the MDS to be completed timely and accurately. Staff B stated that they expected Resident 49's MDS to be marked for antiplatelet instead of the anticoagulant.
Reference: (WAC) 388-97-1000 (1)(b)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
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 a baseline care plan for 1 of 4 residents (...
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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 a baseline care plan for 1 of 4 residents (Resident 23), reviewed for baseline care plans. The failure to implement the baseline care plan for nutritional risk placed the resident at risk for health complications, unmet care needs, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Care Plans-Baseline, revised in March 2022, showed, The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care.
Review of the facility's policy titled, Dysphagia [difficulty swallowing foods or liquids] Diets and Aspiration [occurs when food or liquid is breathed into the airways or lungs] Precautions, dated October 2021, showed that Dysphagia diets and aspiration precautions will be individualized with modifications made by the Speech Language Pathologist [SLP - treat many types of communication and swallowing problems] working in conjunction with the Licensed Nurse [LN] and/or Registered Dietician [RD] or designee and Nutrition Service Manager.
Resident 23 readmitted to the facility on [DATE] with diagnoses that included cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture) and dysphagia.
Review of Resident 23's nutritional risk care plan revised on 03/11/2024, showed an intervention to assist with all meals in the main dining room and ensure patient [resident] is upright in wheelchair when eating.
Observation on 03/12/2024 at 7:26 AM, showed a sign above Resident 23's bed that stated, All meals eaten in wheelchair.
Observation and interview on 03/12/2024 at 8:06 AM, showed Resident 23 in bed and Staff U, Certified Nursing Assistant, stated I fed him already in their bed.
Observation on 03/14/2024 at 8:11 AM, showed Staff U assisted Resident 23 with eating their meal in bed.
On 03/14/2024 at 12:52 PM, Staff U stated that Resident 23 was on aspiration precautions and that we have to put his head up while feeding. When asked where Resident 23 ate breakfast, Staff U stated, mostly in bed.
On 03/14/2024 at 1:19 PM, Staff V, Licensed Practical Nurse, stated Resident 23 was on aspiration precautions.
On 03/15/2024 at 2:29 PM, Staff Y, Speech Therapist, stated Resident 23 was high risk for aspiration and had precautions that included, having him eat out of bed, up in the wheelchair. Staff Y stated they would expect staff to assist Resident 23 with eating out of their bed and up in their wheelchair.
In an interview and joint record review on 03/18/2024 at 2:08 PM, Staff I, Resident Care Manager, stated Resident 23 was on aspiration precautions and had interventions in place that included making sure Resident 23 gets up in their wheelchair for meals and to encourage eating in the dining room. Staff I stated that they would not expect Resident 23 to be eating in bed. Staff I stated that it was Resident 23's choice if they wanted to eat in bed but would need to be provided risks and benefits for that choice. Joint record review of Resident 23's baseline care plan showed Resident 23 should be upright in their wheelchair when eating. Staff I stated that they expected staff to follow the baseline care plan and if a resident refused, they should tell a nurse who could provide risks and benefits for that refusal.
On 03/19/2024 at 12:20 PM, Staff B, Director of Nursing, stated that staff knew how to care for residents on aspiration precautions because whatever therapy recommends would be put in an aspiration precautions binder, be posted above a resident's bed and would be in the care plan. Staff B stated that staff should follow the care plan and if a resident was refusing, they should let a nurse know so they could provide risks and benefits for refusing care.
Reference: (WAC) 388-97-1020 (3)
.
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 adequate supervision for 1 of 3 residents (Re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision for 1 of 3 residents (Resident 23), reviewed for accidents. The failure to provide necessary supervision placed the resident at risk for accidents, injury, and other negative outcomes.
Findings included .
Review of the facility's policy titled, Assistive Devices and Equipment, revised in January 2020, showed, The following factors are addressed to the extent possible to decrease the risk of avoidable accidents associated with devices and equipment . and .the resident is assessed for lower extremity strength, range of motion, balance and cognitive abilities when determining the safest use of devices and equipment. The policy further showed that staff are required to demonstrate competency on the use of devices and equipment and are available to assist and supervise as needed.
Resident 23 readmitted to the facility on [DATE] with diagnosis that included cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture).
Review of Resident 23's physician orders dated 03/13/2024, showed an order for PWC [Power Wheelchair].
Review of Resident 23's Physical Therapy evaluation dated 03/07/2024, showed a goal for Resident 23 to operate power wheelchair.
Review of Resident 23's Physical Therapy note dated 03/15/2024, showed Resident 23 Would need supervision to negotiate power wheelchair in the hallway.
Review of Resident 23's Physical Therapy note dated 03/18/2024, showed Resident 23 is supervision level with managing hallways and open spaces.
Observation on 03/12/2024 at 11:25 AM, showed Resident 23 in the hallway using their power wheelchair and hitting a medical equipment with one of the power wheelchairs' wheels. An unknown staff then redirected Resident 23 and helped them maneuver their power wheelchair using the controls towards the dining room.
Additional observations on 03/14/2024 at 12:47 PM, on 03/15/2024 at 1:43 PM, and on 03/18/2024 at 9:12 AM, showed Resident 23 was using their power wheelchair in the hallway, with no one assisting or supervising them.
On 03/15/2024 at 10:50 AM, Staff X, Director of Rehab, stated that Resident 23 was clear to use their power wheelchair with supervision and ideally he wouldn't be going down the hall unassisted.
Joint observation and interview on 03/15/2024 at 1:47 PM, with Staff W, Certified Nursing Assistant, showed Resident 23 was using their power wheelchair in the hallway. Staff W stated that no one was assisting or supervising Resident 23 when they were using their power wheelchair.
On 03/18/2024 at 1:53 PM, Staff I, Resident Care Manager, stated that residents needed to be assessed by therapy prior to using their power wheelchair. Staff I stated that they did not have access to therapy's notes and would call Staff X to get their recommendations. Staff I stated that Staff X recommended that Resident 23 use their power wheelchair with supervision.
On 03/19/2024 at 11:49 AM, Staff B, Director of Nursing, stated they expected therapy to assess residents prior to using their power wheelchair. Staff B stated, I know the doctor said they [Resident 23] need to be direct supervision and should not be using their power wheelchair in the hall without supervision. Staff B further stated they did not see documentation of risks and benefits for Resident 23's power wheelchair use.
Reference: (WAC) 388-97-1060 (3)(g)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain and monitor a resident weight for 1 of 2 residents (Resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain and monitor a resident weight for 1 of 2 residents (Resident 23), reviewed for nutrition. This failure placed the resident at risk for unrecognized weight loss, nutrition-related complications, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Nutrition and Hydration: Weight Systems and Assessment, dated October 2023, showed, The purpose of this standard is to ensure baseline weights are obtained; significant weight variance; insidious weight loss; and weight trends are identified, assessed and monitored. The policy further showed, Nursing will obtain patient [resident] weight on the first day of admission, maximum of 24 hours, for admission/readmission and weekly for four weeks thereafter. This weight will be entered into the Electronic Medical Record as the baseline weight.
Resident 23 readmitted to the facility on [DATE].
Review of Resident 23's nutrition care plan revised on 03/11/2024, showed Resident 23 is at nutritional risk.
Review of Resident 23's weight summary document printed on 03/14/2024 at 9:28 AM, showed the most recent recorded weight was on 08/25/2021 from a previous admission.
In an interview and joint record review on 03/14/2024 at 1:19 PM with Staff V, Licensed Practical Nurse, stated they weigh residents at admission. Joint record review of Resident 23's weight summary showed that the last weight recorded was on 08/25/2021. Staff V stated that Resident 23 should have had a weight done on their recent admission on [DATE] and was not sure why [it was] not done.
In an interview and joint record review on 03/14/2024 at 1:59 PM with Staff I, Resident Care Manager (RCM), stated they expected weights to be done for the first three days of admission to establish a baseline. Joint record review of Resident 23's weight summary showed no weights recorded for their admission on [DATE] or readmission on [DATE]. Staff I stated that a weight was obtained today [03/14/2024] at 1:53 PM. The weight summary showed that Resident 23 weighed 125.5 pounds (lbs. - a unit of measurement).
On 03/15/2024 at 9:05 AM, Staff F, Minimum Data Set (MDS-an assessment tool) Coordinator, stated they did a weight for Resident 23's 5-day MDS dated [DATE]. The MDS showed that Resident 23 weighed 138 lbs.
On 03/15/2024 at 10:05 AM, Staff P, Registered Dietician, stated that they expected weights to be done on admission and if there was not a weight done, they would reach out to the RCM and give their recommendation to get a weight. Staff P stated that when they did Resident 23's admission nutrition assessment in February 2024 and March 2024, they couldn't find any weights and that they found out yesterday [03/14/2024] that there had been a weight recorded in the 5-day MDS dated [DATE]. Staff P stated that they were able to do a physical exam and identified some fat and muscle wasting, but needed the weight to determine if there was weight loss. Staff P further stated that now that we know he has significant weight loss the resident would be put on the Nutrition at Risk (NAR - an interdisciplinary approach to review and address residents with nutrition/weight loss concerns) list.
In an interview and joint record review on 03/19/2024 at 12:05 PM with Staff B, Director of Nursing, stated that they expected weights to be obtained on admission or within the first three days. Joint record review of Resident 23's updated weight summary printed on 03/18/2024, showed a weight recorded on 02/23/2024 of 138 lbs. and on 03/14/2024 of 125.5 lbs. Staff B stated that Resident 23 readmitted to the facility on [DATE] and that Resident 23's weight was not done within three days of admission. Staff B further stated that Resident 23 lost 10 lbs. and this was a significant weight loss.
Reference: (WAC) 388-97-1060 (3)(h)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain respiratory equipment to include covering th...
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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 respiratory equipment to include covering the Continuous Positive Airway Pressure (CPAP - a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) mask when not in use, labeling the tubing, and ensure oxygen therapy was given according to standards of practice for 2 of 2 residents (Residents 23 & 26), reviewed for respiratory care. These failures placed the residents at risk for unmet care needs, respiratory infections, and related complications.
Findings included .
RESIDENT 23
Resident 23 readmitted to the facility on [DATE] with a diagnosis that included acute and chronic respiratory failure (a condition that happens when lungs cannot get enough oxygen into the blood).
Review of Resident 23's March 2024 Treatment Administration Record showed CPAP on at HS [at bedtime] and when sleeping, started on 03/12/2024.
Review of Resident 23's respiratory therapy care plan revised on 03/12/2024, showed that oxygen/CPAP tubing to be changed every week, labeled w/ [with] current date.
Observations on 03/12/2024 at 7:26 AM, on 03/13/2024 at 9:55 AM, and on 03/14/2024 at 11:55 AM, showed Resident 23's CPAP mask was uncovered and laying on their bedside table, and with unlabeled tubing.
In an interview and joint observation on 03/14/2024 at 1:26 PM with Staff V, Licensed Practical Nurse, stated that CPAP tubing should be labeled, dated, and that the CPAP mask should be placed in a plastic bag when not in use. Joint observation with Staff V showed Resident 23's CPAP mask was not in a plastic bag and tucked in their nightstand's top drawer. Staff V stated that Resident 23's CPAP mask should be in a plastic bag when not in use, and that they were not sure if the CPAP tubing should be labeled.
On 03/18/2024 at 1:28 PM, Staff I, Resident Care Manager, stated their expectation for CPAP equipment was that the CPAP mask should be kept in a plastic bag when not in use.
On 03/19/2024 at 12:33 PM, Staff B, Director of Nursing, stated they expected staff to label the CPAP tubing and keep the CPAP mask in a plastic bag when not in use.
RESIDENT 26
Resident 26 admitted to the facility on [DATE].
Review of Resident 26's physician orders dated 10/30/2023, showed an order for Oxygen PRN [as needed] at 2 [two] liters [a unit of measurement] per min [minute] via NC [nasal cannula] for SOB [shortness of breath].
Observations on 03/12/2024 at 8:31 AM and on 03/14/2024 at 8:08 AM, showed Resident 26's oxygen concentrator (a machine that delivers oxygen) was set at three liters/minute.
Joint observation and record review on 03/14/2024 at 1:32 PM with Staff V, showed Resident 26's oxygen concentrator was set at three liters/minute. Joint record review of Resident 26's physician orders with Staff V showed Resident 26's oxygen order was for two liters. Staff V stated, I checked it this morning and it was two liters.
During an interview and joint record review on 03/18/2024 at 1:28 PM, Staff I stated they expected staff to check the resident's oxygen settings every shift while on oxygen therapy. Joint record review of Resident 26's physician orders with Staff I showed an order for two liters of oxygen. Staff I stated they expected Resident 26's oxygen setting to be at two liters and if they needed three liters, they would need to get a new order.
In an interview and joint record review on 03/19/2024 at 12:33 PM, Staff B stated that staff should be checking oxygen settings every shift while a resident was on oxygen therapy. Joint record review of the physician orders showed Resident 26's oxygen concentrator was to be set at two liters, Staff B stated they would not expect the resident's oxygen to be set at three liters.
Reference: (WAC) 388-97-1060 (3)(j)(vi)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide the required Registered Nurse (RN) coverage for 1 of 30 days (02/25/2024), reviewed for staffing. This failure placed the residents...
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Based on interview and record review, the facility failed to provide the required Registered Nurse (RN) coverage for 1 of 30 days (02/25/2024), reviewed for staffing. This failure placed the residents at risk for inadequate assessments, delay in care services by an RN, unmet care needs, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Staff, Sufficient and Competent Nursing, revised in August 2022, showed, A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week.
Review of the facility's form titled, Daily Nursing Staff, dated 02/25/2024, showed no RN coverage for all shifts.
Review of the daily nurse schedule for 02/25/2024 showed that Staff D, Registered Nurse, worked as the Resident Care Manager for five and one-half hours (not the required eight hours). No other RNs worked on that day.
In an interview and joint record review on 03/19/2024 at 12:59 PM with Staff B, Director of Nursing, stated that we have a lot [of RNs] on staff when asked what the facility did if there was not an RN available to work the required eight consecutive hours each day. Joint record review of the daily nurse schedule showed no RN worked for eight hours on 02/25/2024 and that Staff D worked five and a half hours. Staff B acknowledged that Staff D worked five and a half hours that day.
Reference: (WAC) 388-97-1080 (3)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
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 medication error rate of less than five perc...
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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 medication error rate of less than five percent (%). The failure to properly administer 9 of 53 medications for 2 of 8 residents (Residents 20 & 52), observed during medication pass resulted in a medication error rate of 16.98%. This failure placed the residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medications and possible adverse effects.
Findings included .
Review of the facility's policy titled, Administering Oral Medications, revised in October 2010, showed their policy provided guidelines for the safe administration of oral medications. It further showed to check the label on the medication, confirm the medication name and dose with the Medication Administration Record (MAR).
Review of the facility's policy titled, Administering Medications through an Enteral Tube [medical device used to provide nutrition directly into the stomach or small intestine], revised in November 2018, showed to administer each medication separately and flush between medications.
RESIDENT 20
Resident 20 admitted to the facility on [DATE].
Review of Resident 20's March 2024 MAR showed an order for Aspirin (used to lower the risk of heart attack, brain attack, or blood clot) 81 milligrams (mg - a unit of measurement) oral tablet delayed release [oral medications that do not immediately disintegrate and release the active ingredients into the body] to be given between 7:00 AM to 10:00 AM.
Observation on 03/18/2024 at 7:14 AM, showed Staff H, Licensed Practical Nurse, gave Aspirin 81 mg chewable tablet (not an Aspirin delayed release) to Resident 20.
Joint record review and interview on 03/18/2024 at 8:57 AM with Staff H, showed Resident 20 had an order for Aspirin 81 mg tablet delayed release. Staff H stated that they gave Resident 20 an Aspirin 81 mg chewable tablet.
On 03/18/2024 at 10:43 AM, Staff H stated they should have obtained an order to change the Aspirin 81 mg delayed release tablet to a chewable tablet prior to giving it to Resident 20.
RESIDENT 52
Resident 52 readmitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty in swallowing food or liquid) following cerebrovascular disease (conditions that impact the blood vessels in the brain) and cerebral infarction (a type of stroke caused by impaired blood flow to the brain) requiring a gastrostomy tube (tube feeding - a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration, or medicine).
On 03/18/2024 at 8:31 AM, Staff H was observed preparing medications for Resident 52. Staff H poured Resident 52's medications in one medication cup, crushed them together, and administered them at once via tube feeding. Resident 52's medications crushed altogether were the following:
- One tablet of Amlodipine (to lower blood pressure) 10 mg.
- One tablet of Doxazosin (to lower high blood pressure) 4 mg.
- One tablet of Aspirin 81 mg.
- One tablet of Atorvastatin (to lower cholesterol) 80 mg.
- One tablet of Baclofen (for muscle spasms) 5 mg.
- One tablet of Lisinopril (to lower blood pressure) 5 mg.
- One and one-half tablet of Sertraline (used for depression) 50 mg.
- One tablet of Sodium Chloride (supplements for low salt) 1 mg.
On 03/18/2024 at 8:55 AM, Staff H stated they crushed and administered Resident 52's medications together. Staff H further stated that they should have crushed and administered Resident 52's medications separately.
On 03/18/2024 at 2:32 PM, Staff I, Resident Care Manager, stated that the nurse [Staff H] should have clarified with the doctor and obtained an order for Aspirin 81 mg chewable tablet prior to administering it to Resident 20. Staff I further stated that the medications for Resident 52 should have been crushed individually and administered them one by one.
On 03/19/2024 at 9:24 AM, Staff B, Director of Nursing, stated that they expected Staff H to call the doctor to change Aspirin 81 mg to chewable tablet prior to administering it to Resident 20. Staff B further stated that the medications for Resident 52 should have been crushed and administered them separately.
Reference: (WAC) 388-97-1060 (3)(k)(ii)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to appropriately label and store drugs and/or biologicals (diverse group of medicines made from natural sources) for 1 of 2 medi...
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Based on observation, interview, and record review, the facility failed to appropriately label and store drugs and/or biologicals (diverse group of medicines made from natural sources) for 1 of 2 medication carts (Wing 1 Medication Cart), reviewed for medication storage. This failure placed the resident at risk for receiving compromised and ineffective medications.
Findings included .
Review of the facility's policy titled, Medication Labeling and Storage, revised in February 2023, showed that multi-dose (more than one dose) vials (small glass container for holding liquid medicine) that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.
Joint observation and interview on 03/14/2024 at 11:36 AM with Staff K, Licensed Practical Nurse, showed the Wing 1 Medication Cart had one opened and undated multi-dose vial of Novolin R insulin (a type of insulin - medication that works by lowering levels of sugar in the blood) for Resident 34. Staff K stated Resident 34's insulin vial should have been dated when it was first opened.
On 03/15/2024 at 2:07 PM, Staff G, Resident Care Manager, stated that multi-dose insulin vials should be dated when first opened because they can only be used for 28 days after being opened.
On 03/18/2024 at 2:51 PM, Staff B, Director of Nursing, stated that Resident 34's insulin vial should have been dated when first opened/used.
Reference: (WAC) 388-97-1300 (2)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 2 residents (Resident 26) reviewed for dental services ...
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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 1 of 2 residents (Resident 26) reviewed for dental services was provided timely referral to a dentist and reimbursement for missing dentures. In addition, the facility failed to have a policy that identified when the loss of dentures was the facility's responsibility. These failures placed the resident at risk for difficulty chewing, oral pain, decreased self-image, financial burden, and diminished quality of life.
Findings included .
Review of the facility's policy titled, Lost Item Policy, revised in September 2004, showed, It is the policy of this facility to protect residents' items from theft or loss to the extent possible. Every effort will be made to insure against theft or loss, to recapture lost items, or to make restitution should a lost item not be recovered.
Resident 26 admitted to the facility on [DATE].
Review of a facility form titled, Inventory of Personal Effects, dated 12/09/2021, showed Resident 26's upper partial dentures and lower full dentures were included on the form.
Review of the grievance log showed Resident 26 had missing dentures on 06/09/2023.
Review of a social services note dated 06/29/2023, showed Resident 26 was missing their lower dentures and that they were on the dentist list.
On 03/12/2024 at 12:53 PM, Resident 26's Representative (RR3), stated that Resident 26 had previously lost dentures in the facility and that the facility did not reimburse them.
In an interview and joint record review on 03/14/2024 at 2:06 PM with Staff E, Social Services Director, stated that if a resident had missing/lost dentures we pay for it. Joint record review of Resident 26's grievance form dated showed the Resident 26 received new dentures and it had no information who paid for the dentures and/or if the facility reimbursed Resident 26 or their representative. Staff E stated that it doesn't look like we ever paid for the replaced dentures.
In another interview on 03/19/2024 at 8:54 AM with Staff E, stated that looking at Resident 26's nursing progress notes, there was no documentation that Resident 26 was referred to a dentist between the time the dentures were missing on 06/09/2023 and the social services note on 06/29/2023.
On 03/19/2024 at 1:08 PM, Staff A, Administrator, stated that if a resident had missing dentures, they would replace them. Staff A stated that they did not have a specific denture policy that would identify when the loss of dentures was the facility's responsibility. Staff A stated that the resident should be referred to a dentist after missing/broken dentures within a month [and did not mention the required three days].
Reference: (WAC) 388-97-1060 (1)(3)(j)(vii)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0847
(Tag F0847)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to explain the arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement i...
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Based on interview and record review, the facility failed to explain the arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement in a manner that the resident and/or representative understood for 1 of 3 residents (Resident 52), reviewed for arbitration agreement. This failure placed the resident at risk of losing legal protections, forfeiture (loss or giving up of something) of the right to a jury or court, lack of understanding of the legal document signed, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Arbitration Agreement, dated 01/04/2021, showed the admission coordinator would review the arbitration agreement with the admission and obtain signature for agreement or decline.
Review of a facility document titled, Patient [resident] and Facility Arbitration Agreement, showed that Resident 52's Representative (RR1) signed the arbitration agreement on 11/28/2023.
On 03/18/2024 at 12:31 PM, RR1, stated they did not remember signing an arbitration agreement. RR1 stated that the facility did not explain they would be giving up their right to take legal action in a court proceeding, and that it was not explained in plain and simple terms. RR1 stated that they were not informed that the arbitration agreement was optional or that they could terminate or withdraw from the agreement within 30 days of signing, and they felt, bombarded with information, it was probably overload. RR1 further stated that the arbitration agreement seemed like it was part of the process to be accepted into the facility and that the agreement wasn't explained clearly, I would remember something like that.
On 03/19/2024 at 10:51 AM, Staff N, Admissions Director, stated that the arbitration agreement was part of the admission packet and that they went over it with the resident and/or representative. Staff N stated it was very important for the resident and/or representative to understand the arbitration agreement so they feel, safe and cared for, and understand that they have rights.
On 03/19/2024 at 11:11 AM, Staff E, Social Services Director, stated that there was a newer version of the arbitration agreement that included more signature spaces, and that the previous version only had one signature and it was recently updated to multiple signatures.
Joint record review and interview on 03/19/2024 at 12:43 PM with Staff E, showed Resident 52's arbitration agreement was signed by RR1. The record showed Staff E had written, agree on the line that said, to be bound by the terms and conditions of this Arbitration Agreement. Staff E stated that they wrote [Staff E] agree on the arbitration agreement form.
On 03/19/2024 at 12:43 PM, Staff A, Administrator, stated it was very important for the resident and/or representative to know and understand the agreement. Staff A stated that they did not expect staff to go over the whole thing rather explain what it was and inform the resident and/or representative that they had the opportunity to change their minds within 30 days. Staff A stated that they expected staff to explain every page in the admission packet that they were signing and explain it in simple terms. Staff A stated they did not know why the representative felt that the arbitration agreement was not explained to them.
No Associated WAC
.
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 residents and/or their representatives received information ...
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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 residents and/or their representatives received information on the current recommendations from the Center for Disease and Control (CDC) Prevention for 2 of 8 residents (Residents 52 & 4) related to pneumococcal vaccinations (vaccines used to prevent pneumonia [lung infection]). This failure placed the residents at risk for acquiring, transmitting and/or experience potentially avoidable complications from pneumonia.
Findings included .
Review of the facility's policy titled, Pneumococcal Vaccine, revised in March 2022, showed All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections . Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission . The policy showed that before the resident received the vaccine the resident or legal representative would receive education regarding the benefits and potential side effects of the vaccine, and such education would be documented in the resident's medical record. The policy further stated that administration of pneumococcal vaccines was made in accordance with CDC recommendations.
Review of the CDC online document for Pneumococcal Vaccine for Adults Aged (greater than or equal to) 19 Years: Recommendations of the Advisory Committee on Immunization [vaccination] Practices [ACIP], United States [U.S.], 2023, dated 09/08/2023, showed In 2021, two new pneumococcal conjugate vaccines, . [PCV15 - vaccine that protects against 15 types of bacteria that cause pneumonia] and PCV20 [vaccine that protects against 20 types of bacteria that cause pneumonia], were licensed for use in U.S. adults aged [greater than or equal to] 18 years by the Food and Drug Administration. It showed that ACIP recommendations specify the use of either PCV20 alone or PCV15 in series with PPSV23 [Pneumococcal Polysaccharide Vaccine for pneumonia] for all adults aged [greater than or equal to] 65 years and for adults aged 19-64 years with certain underlying medical conditions or other risk factors who have not received a PCV or whose vaccination history is unknown. ACIP recommends use of either a single dose of PCV20 or [greater than or equal to] 1 dose of PPSV23 for adults who have started their pneumococcal vaccine series with PCV13 [vaccine that protects against 13 types of bacteria that cause pneumonia] but have not received all recommended PPSV23 doses.
RESIDENT 52
Resident 52 admitted to the facility on [DATE].
Review of the immunization record for Resident 52 showed they received a dose of PCV13 on 12/26/2018, and records did not show the resident received the recommended pneumonia vaccine after receiving the PCV13 dose.
Joint record review and interview on 03/18/2024 at 12:08 PM, with Resident 52's Representative (RR1), showed Resident 52's undated consent for flu and pneumococcal was signed and consented for the flu vaccine, and the pneumococcal vaccine was not marked/checked. RR1 stated that they were not able to read consent's fine print and that they were not given information regarding the pneumococcal vaccines. RR1 stated they were unaware that Resident 52 was not up to date with their pneumococcal vaccines and further stated that given Resident 52's history, the pneumococcal vaccine would be something they would be interested in.
On 03/19/2024 at 10:21 AM, Staff D, Infection Preventionist, stated that Resident 52 was not up to date with their pneumococcal vaccines. Staff D stated that while obtaining consent they had only informed them about the flu vaccine and did not offer the pneumococcal vaccine.
RESIDENT 4
Resident 4 admitted to the facility on [DATE].
Review of the immunization record for Resident 4 showed they had last received a dose of PPSV23 on 09/12/2017, and records did not show they received the PCV20 since it had been five years since they received the PPSV23.
On 03/15/2024 at 11:01 AM, Resident 4's Representative (RR2), stated they had not been provided information regarding the newest CDC pneumococcal vaccine recommendations.
Joint record review and interview on 03/19/2024 at 10:25 AM with Staff D, showed Resident 4's facility document titled, Consent for Flu and Pneumococcal Vaccines, dated 10/16/2023, had no information regarding the pneumococcal vaccine and only the flu vaccine. Staff D stated that Resident 4 could get the newest pneumococcal vaccine based on the CDC recommendation and that there was no documentation to show that this had been offered to the representative.
On 03/19/2024 at 1:31 PM, Staff B, Director of Nursing, stated that it was their expectation that the resident and/or their representative were informed of both the flu and pneumococcal vaccines and that Resident 52 and Resident 4 should have been offered the newest recommendations for the pneumococcal vaccine.
Reference: (WAC) 388-97-1340 (2)
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** CARE PLAN MEETINGS
Resident 45 admitted to the facility on [DATE].
Review of the quarterly MDS dated [DATE], showed Resident 45...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** CARE PLAN MEETINGS
Resident 45 admitted to the facility on [DATE].
Review of the quarterly MDS dated [DATE], showed Resident 45 was cognitively intact.
On 03/12/2024 at 11:03 AM, Resident 45 stated that they did not have any care conference/care plan meeting since they were admitted to the facility. Resident 45 stated that the facility did not invite them to participate in any care plan meetings.
A joint record review and interview on 03/18/2024 at 7:36 AM with Staff E, did not show Resident 45 had a care conference/care plan meeting since admission. Staff E stated Resident 45 should have had a care conference and should be documented.
A joint record review and interview on 03/18/2024 at 8:41 AM with Staff I, did not show Resident 45 had a care conference or care plan meeting. Staff I stated that there should have been a meeting/discussion with Resident 45 about their care.
On 03/19/2024 at 8:55 AM, Staff B stated that their expectation was for residents to have care conference/care plan meetings on admission, quarterly, and as needed. Staff B stated Resident 45 should have had care plan meetings.
Reference: (WAC) 388-97-1020 (2)(f)(4)(b)(5)(b)
REFUSAL OF BATHING/SHOWERS
Resident 49 admitted to the facility on [DATE].
Review of the admission MDS dated [DATE], showed Resident 49 required partial to moderate assistance with bathing/showers.
Review of the Task: Bathe/Shower report printed on 03/14/2024, showed Resident 49 refused to bathe/shower on 02/28/2024, 03/05/2024, 03/06/2024, 03/11/2024 and 03/13/2024.
Review of the Activities of Daily Living Self Care Performance deficit care plan dated 12/28/2023, showed Resident 49 required staff participation with bathing due to impaired mobility and functional ability. Further review of the care plan did not show Resident 49 had a history of refusing baths/showers.
On 03/15/2024 at 2:00 PM, Staff M, CNA, stated that residents received showers twice a week and that if residents refused, they reported it to the nurse and documented the refusal. Staff M stated that they would communicate the refusal to the other shower aide, would go back and ask the resident again. Staff M stated Resident 49 refused their showers and that they had informed the RCM about it.
An interview and joint record review on 03/18/2024 at 10:37 AM, Staff I, RCM, stated that they would care plan refusals of care when the refusals become habitual. Staff I stated that staff should report refusals to the RCM, get the resident representative involved and explain the risks/benefits. Joint record review of the clinical records showed Resident 49 refused baths/showers in the last 30 days and that refusal of care was not included in Resident 49's care plan prior to 03/16/2024.
On 03/18/2024 at 1:38 PM, Staff B stated they expected Resident 49's refusals of baths/showers to be included in their care plan.
DISCHARGE PLANNING
Resident 53 admitted to the facility on [DATE].
Review of the admission MDS dated [DATE] showed Resident 53's overall goal for discharge was to discharge to the community and that active discharge planning was occurring.
Review of Resident 49's care plan printed on 03/12/2024, showed an elopement risk care plan and an intervention that showed Resident 49 wished to discharge. Further review of the care plan did not show a discharge care plan.
On 03/18/2024 at 9:32 AM, Staff E, Social Services Director, stated that discharge would be a part of resident's care plan, would be initiated on admission, and revised as needed. Staff E stated that Resident 49's discharge care plan should have been initiated on admission.
On 03/18/2024 at 12:20 PM, Staff B stated that they expected Resident 49's care plan to include discharge planning.
Based on observation, interview, and record review, the facility failed to revise comprehensive care plans for 4 of 13 residents (Residents 4, 49, 53 & 45), reviewed for care plan revision. The failure to revise care plans for bed placed against the wall, refusal of showers, discharge planning, and involve resident in their care plan meetings, placed the residents at risk for unmet care needs and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Care Plans, Comprehensive Person - Centered, revised in March 2022, showed assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The policy showed that the interdisciplinary team reviews and updates care plans when there has been a significant change in the resident's condition, when the desired outcome is not met, when resident has been readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS-an assessment tool).
BED AGAINST THE WALL
Resident 4 admitted to the facility on [DATE].
Observations on 03/12/2024 at 10:35 AM, on 03/13/2024 at 9:02 AM and 12:14 PM, on 03/14/2024 at 8:58 AM, on 03/15/2024 at 2:52 PM, and on 03/18/2024 at 1:45 PM, showed Resident 4's bed was against the wall.
Review of Resident 4's care plan printed on 03/13/2024, did not show a care plan for bed against the wall.
Review of Resident 4's [NAME] (care guide for Certified Nursing Assistants [CNA]) printed on 03/14/2024, did not show a care plan for bed against the wall.
Joint observation and interview on 03/19/2024 at 8:39 AM with Staff H, Licensed Practical Nurse (LPN), showed Resident 4's bed was against the wall. Staff H stated that it was Resident 4's preference to have their bed against the wall.
On 03/19/2024 at 8:45 AM, Staff G, Resident Care Manager (RCM), stated that Resident 4's bed was placed against the wall per their preference. Staff G stated that Resident 4 did not have a care plan for bed against the wall prior to today [03/19/2024], and that it should have been initiated at the time their bed was placed against the wall.
On 03/19/2024 at 9:15 AM, Staff B, Director of Nursing, stated that residents' beds that were against the wall were care planned, and that Resident 4 should have had a care plan when their bed was placed against the wall.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
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 clarify a physician's order for 1 of 8 residents (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 clarify a physician's order for 1 of 8 residents (Resident 20) and failed to ensure staff documented residents' medications in accordance with professional standards for 5 of 8 residents (Residents 5, 20, 9, 361 & 52), reviewed for medication administration. This failure placed the residents at risk for medication errors and negative outcomes.
Findings included .
Review of the facility's policy titled, Administering Oral Medications, revised in October 2010, showed their policy provided guidelines for the safe administration of oral medications. The policy further showed to check the label on the medication and confirm the medication name and dose with the Medication Administration Record (MAR).
Review of the facility's policy titled, Documentation of Medication Administration, revised in November 2022, showed that administration of medication is documented immediately after it is given. A MAR is used to document all medications administered.
PHYSICIAN'S ORDER
Resident 20 admitted to the facility on [DATE].
Review of Resident 20's March 2024 MAR showed an order for Aspirin (used to lower the risk of heart attack, brain attack, or blood clot) 81 milligrams (mg - a unit of measurement) oral tablet delayed release [oral medications that do not immediately disintegrate and release the active ingredients into the body] to be given between 7:00 AM to 10:00 AM.
Observation on 03/18/2024 at 7:14 AM, showed Staff H, Licensed Practical Nurse, gave Aspirin 81 mg chewable tablet (not an Aspirin delayed release) to Resident 20.
During a joint record review and interview on 03/18/2024 at 8:57 AM with Staff H, showed an order for Aspirin 81 mg tablet delayed release for Resident 20. Staff H stated that they gave Resident 20 an Aspirin 81 mg chewable tablet.
On 03/18/2024 at 10:43 AM, Staff H stated they should have obtained an order to change the Aspirin 81 mg delayed release tablet to a chewable tablet prior to giving it to Resident 20.
On 03/18/2024 at 2:32 PM, Staff I, Resident Care Manager (RCM), stated that the nurse [Staff H] should have clarified with the doctor and obtained an order for Aspirin 81 mg chewable tablet prior to administering it to Resident 20.
MEDICATION ADMINISTRATION DOCUMENTATION
Observation on 03/18/2024 at 7:06 AM, showed Staff H prepared and signed off medications in the MAR prior to medication administration for Resident 5.
Observation on 03/18/2024 at 7:14 AM, showed Staff H prepared and signed off medications in the MAR prior to medication administration for Resident 20.
Observation on 03/18/2024 at 7:22 AM, showed Staff H prepared and signed off medications in the MAR prior to medication administration for Resident 9.
Observation on 03/18/2024 at 7:25 AM, showed Staff H prepared and signed off medications in the MAR prior to medication administration for Resident 361.
Observation on 03/18/2024 at 8:31 AM, showed Staff H prepared and signed off medications in the MAR prior to medication administration for Resident 52.
On 03/18/2024 at 8:57 AM, Staff H stated they signed the MAR after they prepared the medications. Staff H further stated that they should have signed the MAR after Residents 5, 20, 9, 361 and 52 took their medications.
On 03/19/2024 at 8:45 AM, Staff G, RCM, stated that medications should have been signed off in the MAR after Residents 5, 20, 9, 361 and 52 took their medications.
On 03/19/2024 at 9:24 AM, Staff B, Director of Nursing, stated they expected Staff H to call the provider to change Aspirin 81 mg to chewable tablet prior to administering it to Resident 20. Staff B further stated that medications for Residents 5, 20, 9, 361 and 52 should have been signed off in the MAR after they took their medications.
Reference: (WAC) 388-97-1620 (2)(b)(i)(ii)
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing information included the actual hours worked by registered and licensed nursing staff ...
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Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing information included the actual hours worked by registered and licensed nursing staff directly responsible for resident care per shift for 2 of 6 days reviewed for posted nurse staffing information. The failure to post a complete and accurate form daily prevented the residents, family members, and visitors from exercising their rights to know the actual nursing staff hours worked in the facility.
Findings included .
Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, revised in August 2022, showed that within two hours of the beginning of each shift, the number of licensed nurses and the number of unlicensed nurses directly responsible for resident care is posted in a prominent location and in a clear and readable format. The information recorded should include the actual time worked during that shift for each category and type of nursing staff and total number of licensed and non-licensed nursing staff working for the posted shift. The policy further showed that within two (2) hours of the beginning of each shift, the charge nurse or designee computes the number of direct care staff and completes the Nurse Staffing Information form.
Observations on 03/12/2024 at 6:42 AM at the main entrance, and at 7:13 AM at the nurse's station, showed the Daily Nursing Staff posting dated 03/11/2024 did not display the actual nursing staff hours worked for each shift (day, evening, and night shift).
Observations on 03/14/2024 at 7:36 AM at the main entrance, and at 7:37 AM at the nurse's station, showed the Daily Nursing Staff posting dated 03/13/2024 did not display the actual nursing staff hours worked for each shift (day, evening, and night shift). Additional observation on 03/14/2024 at 11:58 AM at the main entrance showed the Daily Nursing Staff posting dated 03/14/2024 did not display the actual nursing staff hours for day shift.
In an interview on 03/18/2024 at 8:01 AM with Staff Q, Staffing Coordinator, stated their process for filling out the Daily Nursing Staff posting was to put in the scheduled staffing the night before and then the next day, they would put in the actual hours after each shift. When asked about the missing actual hours on the Daily Nursing Staff posting dated 03/11/2024, 03/13/2024, and 03/14/2024, Staff Q stated, it probably just got missed.
On 03/18/2024 at 11:20 AM, Staff B, Director of Nursing, stated I know we aren't doing the daily nurse posting correctly. We are doing it at the end of each shift.
No associated WAC
.
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 foods were handled appropriately in accordance with professional standards of food safety for 3 of 4 freezers (Kitchen...
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Based on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 3 of 4 freezers (Kitchen Freezer, Kitchen Walk-In Freezer and Downstairs Storage Freezer), 1 of 2 refrigerators (Cellarium Refrigerator), and 1 of 1 seasoning shelf (Kitchen Shelf) reviewed for food services. The failure to date and discard expired food items and/or before use by date, placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Food Safety and Sanitation, revised on 01/2024, showed that opened food products will be used or discarded by timeframes consistent with federal guidelines and state food rules/codes. The policy showed that if use-by guidelines exceed the printed use by/expiration date from the manufacturer, the food item/s are to be used or discarded by the printed manufacturer use by/expiration date. The policy further showed that canned and dry foods without expiration dates are used within six months of delivery or according to the manufacturer's guidelines.
KITCHEN FREEZER
Joint observation and interview on 03/12/2024 at 6:20 AM with Staff P, Registered Dietitian/Kitchen Manager, showed a bag of biscuit with best use by date of 02/24/2024. Staff P stated that the biscuit should have been discarded on the day of best use by date.
KITCHEN WALK IN FREEZER
Joint observation and interview on 03/12/2024 at 6:30 AM with Staff P, showed an opened half bottle of jam with best use by date of 03/09/2024. Staff P stated that the jam should have been discarded.
DOWNSTAIRS STORAGE FREEZER
Joint observation and interview on 03/12/2024 at 6:49 AM with Staff P, showed 20 packages of bread without use by/expiration date. Staff P stated that they use bread five days after they were pulled out from the freezer. Staff P further stated that the 20 packages of bread should have had a use by date.
CELLARIUM REFRIGATOR
Joint observation and interview on 03/15/2024 at 11:53 AM with Staff P, showed one opened/undated bag with five pizza slices. Staff P stated the bag with slices of pizza should have been dated.
KITCHEN SHELF
Joint observation and interview on 03/15/2024 at 8:05 AM with Staff P, showed one opened bottle of light corn syrup dated 08/01/2023. Staff P stated the light corn syrup was good to use for six months once opened, and that it should have been discarded.
On 03/18/2024 at 11:55 AM, Staff A, Administrator, stated that they expected kitchen staff to check the food items regularly, to date when first opened, and discarded when expired/passed the use by date. Staff A further stated the food items that were undated/passed the use by date should have been dated/discarded.
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 have a comprehensive water management program that as...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a comprehensive water management program that assessed, measured, and/or monitored potential risk for exposure to Legionnaire's disease (Legionella - a potentially dangerous bacteria that grows in water, which could cause a serious lung infection) or other waterborne pathogens (a bacterium, virus, or other microorganisms that can cause a disease). In addition, the facility failed to ensure hand hygiene practices and/or proper use of gloves were followed during resident care for 2 of 4 staff (Staff R & S), failed to appropriately disinfect medical equipment for 3 of 4 staff (Staff S, T & J), and failed to do hand hygiene during dining meal observations for 2 of 3 staff (Staff J & M), reviewed for infection control. These failures placed the residents at risk for facility acquired or healthcare-associated infections and related complications.
Findings included .
WATER MANAGEMENT PROGRAM
Review of the facility's policy titled, Legionella Water Management Program, revised in July 2017, showed that the water management program would include, a detailed description and diagram of the water system in the facility, the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, the identification of situations that can lead to Legionella growth, and specific measures used to control the introduction and/or spread of Legionella. The policy further showed the water management program was based on the Centers for Disease Control (CDC) and Prevention and the American Society of Heating, Refrigerating and Airconditioning Engineers recommendations for developing a Legionella water management program.
Review of the facility provided document [from CDC] titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in buildings, dated 06/05/2017, showed a facility, should develop a water management program to reduce Legionella growth and spread that is specific to your building [facility]. The toolkit further states, The bottom line is that you need to: Identify building water systems for which Legionella control measures are needed .Assess how much risk the hazardous conditions in those water systems pose .Apply control measures to reduce hazardous conditions, whenever possible, to prevent Legionella growth and spread .Make sure the program is running as designed and is effective.
On 03/18/2024 at 10:18 AM, Staff C, Maintenance/Housekeeping/Laundry Manager, stated that they had not had a chance to read the water management program, but that there were a few tasks on TELS (web-based software designed to help Senior Living operators and maintenance teams drive efficiency and cost savings) like checking water temperatures randomly throughout the building or checking for water hardness (test strip that checks for calcium buildup), and water pressure that were setup to address facility maintenance.
Joint record review and interview on 03/19/2024 at 11:36 AM with Staff C, showed the document for Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings was not specific to the facility. Staff C stated that this was a guide and not a comprehensive water management program specific to the facility. Staff C stated that the facility was trying to get a company to make the program personalized, tailored to the facility, and that they did not think they had anything like this in place and that they had never seen a flow diagram for the facility. Staff C stated that there was no flow chart or anything in the water management program itself to indicate specific control measures. Staff C further stated that they would prefer something more specific to the facility rather than just a guide.
In another joint record review and interview on 03/19/2024 at 11:43 AM with Staff C, showed the TELS work history report for the water heaters/boilers from September 2023 to February 2024, was completed once on 03/12/2024 for the due date of 02/29/2024, and it was marked done late. It further showed that from September 2023 to January 2024, no action was recorded. Staff C stated that this task should be done monthly and that no action recorded meant the task was not done. Joint record review of the TELS work history report for water hardness from September 2023 to January 2024, showed that the task was not completed. Staff C stated that the water hardness should be done once a month. Joint record review of the TELS work history report for temperatures from 09/02/2023 to 03/16/2024, showed that the task was not completed for 38 out of 57 weeks, and an additional three weeks were marked done late. Staff C stated that the temperatures should be checked weekly, and that all the tasks should have been completed on time. Further joint record review of the TELS work history report for the ice machines/ice bins from May 2023 to November 2023, showed no action recorded for 08/31/2023, Staff C stated that it was not completed as there was no documentation recorded.
On 03/19/2024 at 12:13 PM, Staff A, Administrator, stated that they would expect to have a detailed building water management program specific to the facility. Staff A stated that they would expect for staff to complete the TELS tasks related to the water management program and that they would expect the staff to follow the CDC guide. Staff A stated that they would not expect to see specific control measures, or reasons to intervene in the water management program itself, rather they would expect to see them in the TELS tasks. Joint record review of the TELS task work history report for water heaters/boilers, water hardness, temperatures, and ice machines/ice bins, showed several tasks were not completed. Staff A stated that based on the reports, there was no consistency and that it was their expectation that staff be on top of it and make sure they are done.
HAND HYGIENE AND/OR GLOVE USE
Review of the facility's undated policy titled, Hand Washing and Hand Hygiene showed, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.
On 03/14/2024 at 9:54 AM, Staff R, Certified Nursing Assistant (CNA), was observed entering Resident 52's room, an enhanced barrier precaution sign (use of gown and glove during high contact resident care activities) was observed for Resident 52's room. Staff R assisted Resident 52 with peri-care (cleaning of private areas), wiping front to back using multiple wipes, and rolled Resident 52 on their side to remove the soiled brief, and cleaned Resident 52's buttocks. Staff R then applied barrier cream to Resident 52's bottom and put a clean brief on. Staff R rolled Resident 52, touching their hands, legs, catheter tubing (a semi-flexible tube inserted into the bladder to drain urine), brief, clothes, and arms. Staff R assisted with getting Resident 52 into their wheelchair via mechanical (Hoyer) lift. Staff R touched multiple surfaces of the Hoyer lift, the sling, wheelchair, wheelchair brakes, footrests, bed control, and multiple items in Resident 52's closet. Staff R proceeded to make Resident 52's bed. Staff R provided peri-care assistance to Resident 52 without changing their gloves and/or performing hand hygiene when going from a dirty to a clean task.
On 03/14/2024 at 10:51 AM, Staff R stated that they should have taken off their gloves after assisting Resident 52 with peri-care, washed their hands, and applied new gloves.
On 03/14/2024 at 2:16 PM, Staff H, Licensed Practical Nurse (LPN), stated that staff should wash their hands after assisting with peri-care and apply new gloves for the next task.
On 03/15/2024 at 1:08 PM, Staff D, Infection Preventionist, stated that they would expect staff to remove their soiled gloves after assisting with peri-care, do hand hygiene, and put on a new pair of gloves before moving on the next task to prevent contamination.
On 03/19/2024 at 1:19 PM, Staff B, Director of Nursing, stated that they would expect staff to do hand hygiene after assisting with peri-care, and put on a new pair of gloves.
GLOVE USE AND DISINFECTION OF VITAL SIGN EQUIPMENT
Review of the facility's policy titled, Cleaning and Disinfecting Non-Critical Resident-Care Items, revised in June 2011, showed that reusable items are cleaned and disinfected or sterilized between residents.
Review of the 2024 Medline Manufacturer's website, showed that the Medline's sterile alcohol prep pads product was intended for use on the body only.
Observation on 03/12/2024 at 6:37 AM, showed Staff S, CNA, entered room [ROOM NUMBER] with vital sign (a measurement of the body's most basic functions [blood pressure (amount of force your blood uses to get through blood vessels), pulse rate and temperature]) equipment. Staff S exited room [ROOM NUMBER], wearing the same gloves that were used in room [ROOM NUMBER]. Staff S removed their gloves in room [ROOM NUMBER] and did hand hygiene, no disinfecting wipes were observed on the vital sign equipment machine. Staff S went into room [ROOM NUMBER], an enhanced barrier precaution room and exited room [ROOM NUMBER], no disinfection of the vital sign equipment was observed. Staff S went into room [ROOM NUMBER] with the vital sign equipment, after obtaining the resident's vital signs, Staff S exited the room and did not disinfect the vital sign equipment.
On 03/19/2024 at 9:11 AM, Staff S stated that the process to disinfect the vital sign equipment was to use two to three alcohol prep pads. Staff S further stated that they should not be wearing gloves in the hallway and should have taken them off in the resident room that they were in and do hand hygiene prior to exiting the resident room.
On 03/19/2024 at 9:44 AM, Staff H stated that staff should take off their gloves in the room, wash their hands or do hand hygiene, and not wear gloves in the hallway. Staff H stated that the vital sign equipment should be disinfected with Sani-Cloth [brand name - disposable wipes that kill germs] wipes in between residents.
On 03/19/2024 at 10:00 AM, Staff D stated that after use of the vital sign equipment it should be disinfected using the Sani-Cloth wipes in between residents' use. Staff D further stated that the alcohol prep pads would not be used for anything other than skin as alcohol isn't as strong, and that the Sani-Cloth wipes were more effective.
On 03/19/2024 at 1:19 PM, Staff B stated that their expectation was for the vital sign equipment to be disinfected in between residents using the Sani-Cloth wipes and that staff should remove gloves and wash their hands prior to exiting resident rooms. Staff B further stated that staff should not wear gloves in the hallway.Another dining observation on 03/12/2024 at 12:10 PM, showed Staff M, CNA, moved Resident 37 in their wheelchair from one table to another. Staff M then assisted Resident 22 with their lunch meal. Staff M did not perform hand hygiene between task and/or before assisting Resident 22 with their meal.
On 03/12/2024 at 12:46 PM, Staff M stated that they moved Resident 37 from one table to another and did not perform hand hygiene but should have.
On 03/14/2024 at 12:33 PM, Staff D stated they expected staff to perform hand hygiene after touching anything during resident care or when assisting resident with meals. Staff D stated that Staff M should have performed hand hygiene after they moved Resident 37's wheelchair.
On 03/15/2024 at 10:20 AM, Staff B stated they expected staff to perform hand hygiene in between resident care and that Staff M should have performed hand hygiene after they moved Resident 37's wheelchair.
Reference: (WAC) 388-97-1320 (1)(a)(c)(5)(c)
HAND HYGIENE DURING DINING
Observation on 03/12/2024 at 12:12 PM, showed Staff J assisted Resident 17 with their lunch. Staff J left the dining room and did not perform hand hygiene after assisting Resident 17.
On 03/12/2024 at 12:46 PM, Staff J stated they would perform hand hygiene before and after resident care, before serving meals, and when they leave the dining room.
On 03/14/2024 at 11:57 AM, Staff G stated that staff should perform hand hygiene if hands were visibly soiled, prior to touching residents, before/after glove use, when they enter the dining room, prior to passing trays, and assisting residents with meals. Staff G stated that they expected staff to perform hand hygiene before they leave the dining room.
On 03/14/2024 at 12:42 PM, Staff D stated that staff should perform hand hygiene before they leave the dining room and/or after assisting a resident with their meal. Staff D stated, staff should gel out after working with residents.
On 03/14/2024 at 12:48 PM, Staff B stated that they expected Staff J to perform hand hygiene after assisting resident with their meal and before leaving the dining room. Another observation of vital sign equipment on 03/13/2024 at 2:17 PM showed, Staff J, CNA, checked the residents' vital signs using a blood pressure cuff (medical device used to check blood pressure) and thermometer (medical device to check the body's temperature) in room [ROOM NUMBER]. Staff J then took the blood pressure cuff and thermometer to room [ROOM NUMBER]. After leaving room [ROOM NUMBER], Staff J went to room [ROOM NUMBER] then to room [ROOM NUMBER] to take residents' vital signs. Staff J did not sanitize/disinfect the medical/vital signs equipment in between resident use.
On 03/14/2024 at 2:31 PM, Staff J stated that they did not clean/disinfect the vital signs equipment in between residents' use in Rooms 102, 106, 108 & 402 and that they should have used Sani-Cloth wipes to clean/disinfect the vital signs equipment in between residents' use.
On 03/15/2024 at 1:59 PM, Staff G, RCM, stated that vital sign equipment should be cleaned/disinfected before use, between every resident, and after use.
On 03/19/2024 at 9:24 AM, Staff B stated that vital sign equipment should have been cleaned between residents' use in Rooms 102, 106, 108 and 402. DISINFECTION OF VITAL SIGN EQUIPMENT
Observation on 03/13/2024 at 2:31 PM, showed Staff T, CNA, took the vital sign equipment to room [ROOM NUMBER]-1 to check the vital signs. Staff T left the room and went to room [ROOM NUMBER]-1 to check vital signs. Staff T left room [ROOM NUMBER]-1 and brought the vital sign equipment to room [ROOM NUMBER] and went to room [ROOM NUMBER] to take the residents' vital signs. Staff T did not sanitize/disinfect the medical/vital signs equipment in between residents' use.
On 03/13/2024 at 2:47 PM, Staff T stated that they clean the vital sign equipment at the end of their shift. Staff T further stated that they should have cleaned the vital sign equipment between residents but did not.
On 03/18/2024 at 1:28 PM, Staff I, Resident Care Manager (RCM), stated that vital sign equipment should be cleaned/disinfected between residents and that anti-bacterial wipes should be used to clean them.
On 03/19/2024 at 12:55 PM, Staff B stated that they expected staff to clean/disinfect vital sign equipment between residents and that they should use the Sani-Cloth wipes.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review of room size measurements, seven single resident rooms (Rooms 405, 407, 501, 503, 505, 507 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review of room size measurements, seven single resident rooms (Rooms 405, 407, 501, 503, 505, 507 & 509) failed to meet the minimum room size requirement of at least 100 square feet (sq ft) for a single resident room. The failure to ensure residents reside in rooms which met the regulatory requirements for square footage, placed them at risk for living in a physical environment too small to meet their needs.
Findings included .
Square footage:
-room [ROOM NUMBER]- 85 sq ft
-room [ROOM NUMBER]- 95 sq ft
-room [ROOM NUMBER]- 83 sq ft
-room [ROOM NUMBER]- 87 sq ft
-room [ROOM NUMBER]- 87 sq ft
-room [ROOM NUMBER]- 87 sq ft
-room [ROOM NUMBER]- 87 sq ft
Review of the facility's census dated 03/12/2024 showed Rooms 405, 407, 501 and 507 were occupied with residents.
RESIDENT 27
Resident 27 admitted to the facility on [DATE] in room [ROOM NUMBER].
On 03/19/2024 at 12:13 PM, Resident 27 stated that their room was a little bit crowded and sometimes it was hard to move around in their wheelchair.
RESIDENT 33
Resident 33 admitted to the facility on [DATE].
Review of Resident 33's census showed they were in room [ROOM NUMBER] since 02/05/2024.
On 03/19/2024 at 12:16 PM, Resident 33 stated that the lack of space bothered them. Resident 33's representative stated that staff had a hard time moving and repositioning Resident 33's wheelchair.
On 03/19/2024 at 8:42 AM, Staff C, Maintenance/Housekeeping/Laundry Manager, stated that there have been no changes made to the square footage in Rooms 405, 407, 501, 503, 505, 507 and 509.
On 03/19/2024 at 8:48 AM, Staff A, Administrator, stated that there were no changes in the room's square footage since the last recertification. Staff A stated that they did not have a current room size waiver.
On 03/19/2024 at 1:52 PM, Staff A was not able to provide documentation of the approved bedroom size waiver.
Reference: (WAC) 388-97-2440 (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
Abuse Prevention Policies
(Tag F0607)
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 staff followed and implemented abuse and neglect policies an...
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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 staff followed and implemented abuse and neglect policies and procedures for the protection of residents during an abuse investigation for 1 of 3 residents (Resident 1) reviewed for allegations of potential staff to resident abuse. This failure placed the residents at risk for abuse and/or neglect.
Findings included .
Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, showed, Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete.
Resident 1 admitted to the facility on [DATE].
Review of the quarterly Minimum Data Set (an assessment tool) dated 07/18/2023, showed Resident 1 had no impairment in cognition.
Review of an allegation by Resident 1, dated 07/22/2023 at 6:00 AM, showed Resident 1 reported Staff D, Nursing Assistant Certified, beat them all over and told them to get themselves up and get dressed.
In an interview on 07/25/2023 at 10:13 AM, Resident 1 stated Staff D was rough during morning care on 07/22/2023, and they reported the incident to a facility staff member.
Review of the facility investigation timeline showed that Staff C, Registered Nurse/Resident Care Manager, received report of the allegation on 07/22/2023 at 8:40 AM. Further review showed Staff C changed Staff D's assignment at 8:45 AM, and notified the facility's Administrator, Director of Nursing Services and Social Worker.
Review of the 07/22/2023 and 07/23/2023 facility staffing schedule, showed the facility allowed Staff D to continue to work and provide care to residents prior to the completion of the abuse allegation made by Resident 1.
During an interview on 07/28/2023 at 9:51 AM, Staff D denied the reported allegation. When asked if they were suspended pending investigation, Staff D stated on 07/22/2023 their assignment was changed from 500 hall rooms (where Resident 1's room was located) to 200 hall rooms of the facility and completed their shift that day and was never suspended.
In an interview on 07/28/2023 at 10:53 AM, Staff C, stated upon learning of the allegation, they assessed Resident 1, received statements, and reported the allegation. Staff C stated they reassigned staff D's assignment to another hall of the facility. Staff C stated Staff D continued working with vulnerable residents on the day of the allegation. Staff C stated Staff D should have been suspended per the facility's policy.
In an interview on 07/28/2023 at 11:32 AM, Staff A, Administrator, stated they were not aware Staff D was not suspended and allowed to work during the investigation. Staff A stated Staff D should have been suspended with no contact with the facility's residents until the alleged abuse was investigated and Staff D was cleared. Staff A stated they expected the facility staff to follow the facility's abuse and neglect policy and procedures.
Reference: (WAC) 388-97-0640 (2)
.
Dec 2022
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide hot water to the sink in the room of 1 of 47 residents (Resident 42) reviewed for accommodation of needs. The failure...
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Based on observation, interview, and record review, the facility failed to provide hot water to the sink in the room of 1 of 47 residents (Resident 42) reviewed for accommodation of needs. The failure to have hot water and weak water pressure placed the resident at risk for unmet care needs and a diminished quality of life.
Findings included .
The facility did not have a policy to address water temperatures in the resident rooms.
Review of Resident 42's Face Sheet revealed Resident 42 was admitted to the facility originally on 09/10/2022. The resident's diagnoses included encounter for orthopedic aftercare following surgical amputation.
Review of Resident 42's admission Minimum Data Set with an assessment reference date of 09/17/2022 revealed Resident 42 had a Brief Interview for Mental Status score of 15 out of 15 indicating the resident was cognitively intact.
Observation on 12/19/2022 at 10:07 AM, revealed Resident 42 was seated on his bed in his room. During this meeting, Resident 42 said the hot water in his room never got hot and stated, It is not hot enough to wash your face after letting it run for over eight minutes. And the water pressure is very weak.
Observation on 12/19/2022 at 10:13 AM, the hot water in the sink of Resident 42's room was observed to run for over five minutes and the water was slightly warm to the touch.
Observation and interview with the Plant Manager, Staff E, on 12/22/2022 at 3:15 PM, confirmed the highest temperature measurement of the water in Resident 42's sink after running the water for several minutes was 92 degrees Fahrenheit. Staff E confirmed that was much lower than the standard of 120 degrees Fahrenheit [100 degrees]. Staff E stated several things can be done to alleviate this problem and this problem would have affected all the resident rooms on this side of the building. Staff E also said that several things could be done to improve the low temperature and low water pressure.
Reference: (WAC) 388-97-860 (2)
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
Based on interview and record review, the facility failed to report an allegation of neglect or mistreatment that did not result in bodily harm, no later than 24 hours after the allegation was reporte...
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Based on interview and record review, the facility failed to report an allegation of neglect or mistreatment that did not result in bodily harm, no later than 24 hours after the allegation was reported for 1 of 1 resident (Resident 66) reviewed for abuse and neglect. This failure placed the resident at risk for neglect, mistreatment, and unreported allegations.
Findings included .
Review of the facility policy titled, ''Abuse and Neglect Policy and Procedure,'' dated 07/05/2022, showed, 5. This facility will report all alleged violations to the State Agency and to other agencies as required.''
Review of the electronic medical record (EMR) for Resident 66 under the Census tab, revealed an admission date of 08/09/2022, and a diagnosis that included anxiety.
Review of the EMR under the Care Plan tab revealed an undated ''Behavior Care Plan for Aggressive Behavior (Verbal/Physical) Template,'' which indicated Resident 66 was irritable, verbally threatening and makes false accusations related to medical issues and psychological issues ''(such as dementia [memory loss], depression and psychosis [disruption to a person's thoughts/perceptions], etc.).'' The Behavior Template did not direct the facility to investigate for the potential reporting of Resident 66's allegation of neglect as it occurred.
An interview with Resident 66 on 12/19/2022 at 12:38 PM, revealed a potential allegation of neglect/mistreatment when Resident 66 stated they informed Staff J (a nurse aide) they needed to toilet. Resident 66 reported that Staff J failed to assist them to the commode (a portable toilet device) and Resident 66 urinated in the bed, which caused Resident 66 distress. The allegation of neglect or mistreatment was reported to the Administrator/Abuse Coordinator on 12/19/2022 at 12:45 PM. The Administrator/Abuse Coordinator stated Resident 66 had made previous allegations of neglect/mistreatment.
An interview with the Administrator/Abuse Coordinator and the Director of Nursing on 12/22/2022 at 10:35 AM, confirmed the facility had not investigated nor reported Resident 66's allegation of neglect/mistreatment.
Reference: (WAC) 388-97-0640 (5)(a)(6)(a)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to investigate an allegation of neglect or mistreatment for 1 of 1 resident (Resident 66) reviewed for abuse and neglect. This failure placed ...
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Based on interview and record review, the facility failed to investigate an allegation of neglect or mistreatment for 1 of 1 resident (Resident 66) reviewed for abuse and neglect. This failure placed the resident at risk for unrecognized abuse or neglect, and a diminished quality of life.
Findings included .
Review of the facility policy titled, ''Abuse and Neglect Policy and Procedure'' dated 07/05/2022, stated, ''All resident events reported . will be investigated to determine if abuse has occurred .'' The Procedure section ''3. Any alleged . abuse will be reported to the Administrator and Director of Nursing as soon as possible .'' The Procedure continues ''4. All investigations will include a statement form staff involved as well as from the resident.'' The policy directs that the residents will be protected during the investigation.
Review of Resident 66's the Electronic Medical Record, under the census tab revealed an admission date of 08/09/2022, and a diagnosis that included anxiety.
Review of the Care Plan revealed an undated ''Behavior Care Plan for Aggressive Behavior (Verbal/Physical) Template,'' which indicated Resident 66 was irritable, verbally threatening and made false accusations related to medical issues and psychological issues ''(such as dementia [memory loss], depression, psychosis [disruption to a person's thoughts/perceptions], etc.).'' The Behavior Template did not direct the facility staff to investigate potential allegation of neglect as it occurred for Resident 66.
An interview on 12/19/2022 at 12:38 PM, Resident 66 revealed an allegation of neglect/mistreatment when Resident 66 stated they informed Staff J (nurse aide) they needed to toilet. Resident 66 reported that Staff J failed to assist them to the commode (a portable toilet device) and Resident 66 urinated in the bed, which caused Resident 66 distress.
The allegation neglect or mistreatment was reported to the Administrator/Abuse Coordinator on 12/19/2022 at 12:45 PM. The Administrator/Abuse Coordinator stated Resident 66 had made previous allegations of neglect/mistreatment.
An interview with the Administrator/Abuse Coordinator (Staff A) and the Director of Nursing (Staff B) on 12/2220/22 at 10:35 AM, revealed the facility did not plan to investigate Resident 66's allegation of neglect/mistreatment due to Resident 66's history of making false allegations. They confirmed Staff J remained on the schedule to work.
Reference: (WAC) 388-97-0640 (6)(a)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on interview and review, the facility failed to consistently complete and/or transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe...
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Based on interview and review, the facility failed to consistently complete and/or transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframes for 3 of 21 residents (Residents 27, 12 & 10) reviewed for timeliness in submitting Minimum Data Set (MDS) assessments and/or completing and transmitting death in facility tracking record. These failures placed the residents at risk for inaccurate/incomplete assessments, unmet care needs, and a diminished quality of life.
Findings included .
Review of the ''Resident Assessment Instrument [RAI] Manual,'' October 2019 edition, used by the facility to direct the type of assessment needed and instructions of how to complete the assessment, indicated on page 2-32 revealed, The MDS must be transmitted (submitted and accepted into the QIES [Quality Improvement and Evaluation System] ASAP [Assessment Submission and Processing] system) electronically no later than 14 calendar days after the MDS completion date (Z0500B + 14 calendar days). Page 2-36 of the RAI Manual also showed, Death in facility tracking record must be completed within 7 days after the resident's death, which is recorded in item A2000, discharge date (A2000 + 7 calendar days), and must be submitted within 14 days after the resident's death.
RESIDENT 27
Review of Resident 27's Electronic Medical Record (EMR) revealed an admission date of 04/05/2021. Review of the MDS tab, revealed a quarterly MDS assessment with an Assessment Reference Date (ARD) of 10/05/2022, and was Export Ready [to be transmitted]. The facility failed to transmit the quarterly assessment within 14 days, as required.
RESIDENT 12
Review of Resident 12's EMR revealed an admission date of 04/10/2012. Review of the MDS tab, revealed a quarterly MDS assessment with an ARD of 10/11/2022, and was Export Ready. The facility failed to transmit the quarterly assessment within 14 days, as required.
RESIDENT 10
Review of Resident 10's EMR revealed an admission date of 02/09/2017, and a death date of 12/10/2022. Review of the MDS tab revealed the facility failed to complete the death in facility tracking record within 7 days and failed to transmit the death in facility tracking record to the QIES ASAP system within 14 days after the resident's death, as required.
During an interview on 12/20/2022 at 12:19 PM, the MDS Coordinator (Staff F) confirmed the facility used the RAI Manual as the instructions for the completion of the MDS assessments for each residents. Staff F confirmed that there were many incomplete assessments including transmission of the completed assessments [for Residents 27, 12 & 10].
Reference: (WAC) 388-97-1000 (5)(a)(e)(i)(ii)(iii)
.
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 implement a comprehensive care plan for 1...
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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 implement a comprehensive care plan for 1 of 1 resident (Resident 3) with a tracheostomy stoma (an artificial opening in the neck for breathing and respiratory secretions). This failure placed the resident at risk for unmet care needs and a diminished quality of life.
Findings included .
Review of Resident 3's Electronic Medical Record under the Census tab revealed Resident 3's admission date was 08/13/2013. Resident 3's diagnoses included diabetes (a disorder in which the body has high sugar levels for prolonged periods of time), sleep apnea (potentially serious sleep disorder in which breathing repeatedly stops and starts), and a tracheostomy.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed tracheostomy was coded/marked on the MDS.
Review of the care plan revealed no goals or interventions for the care of Resident 3's tracheostomy stoma.
Review of Orders revealed there were no orders for the care of Resident 3's tracheostomy stoma.
Observation of Resident 3 on 12/19/2022 at 9:29 AM, revealed Resident 3 was breathing and coughing through the stoma.
An interview on 12/20/2022 at 10:49 AM, Registered Nurse (Staff O) stated Resident 3 had a tracheostomy stoma that was healing but remained open for the passage of air and secretions. Additional interview with Staff O on 12/21/22 at 2:50 PM, confirmed the resident's stoma remained open and functioning.
An interview on 12/21/2022 at 10:30 AM, the Director of Nursing (Staff B) confirmed the tracheostomy stoma was not included in Resident 3's care plan, and that a resident with a stoma had specific care needs. Staff B confirmed the facility lacked a policy for the completion of a care plan. Staff B stated the tracheostomy care policy applied to residents with new tracheostomies that require suctioning and dressing changes, not the routine care of a healing tracheostomy.
Reference: (WAC) 388-97-1020 (1)(2)(a)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status,...
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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 acceptable parameters of nutritional status, such as usual body weight, for 1 of 6 residents (Resident 15) reviewed for nutritional status. The facility's failure to ensure Resident 15 received the appropriate diet texture and assess for needed changes in interventions resulted in significant weight loss.
Findings included .
Review of the facility's policy titled, Nutrition and Hydration Monitoring updated on 05/17/2021 indicated the Facility will attempt non-drug interventions to address weight loss which may include but not limited to: a. Enhanced calorie intake based on RD [Registered Dietitian] recommendation b. Assess and modify diet and assistance received c. Assess for any special utensils, texture modification, cut-up, feeding assistance d. Offer pudding, cottage cheese, ice cream, milk shakes per RD recommendations . All nutritionally at-risk resident weights will be tracked and monitored weekly, until weight is stable, or physician has acknowledged weight loss is unavoidable and expected.
Review of the facility's diet manual titled, Dysphagia [difficulty swallowing] Mechanically Altered (Level 2) Diet undated, indicated Meat or meat alternative: Ground as tolerated, moistened with sauce or gravy; Vegetables: Cooked, tender, chopped, or shredded; Grains: Pureed or slurried and gelled; well cooked noodles, soft pancakes well moistened with syrup or sauce.
Review of Resident 15's admission Record, undated and located in the resident's Electronic Medical Record (EMR) under the Profile tab, documented an admission date of 11/30/2022 with initial admission date of 03/25/2019. The admission Record indicated Resident 15 had diagnoses which included: end stage renal [kidney] disease, protein-calorie malnutrition, type 2 diabetes mellitus (a disorder in which the body has high sugar levels for prolonged periods of time), and muscle weakness.
According to the Minimum Data Set assessment dated [DATE], Resident 15 had a Brief Interview for Mental Status (BIMS) of 11 out of 15, which indicated the resident had moderately impaired cognition.
Review of the Speech Therapy Evaluation, located in the EMR, under the Miscellaneous tab, dated 07/01/2022, indicated Reason for referral: referred for ST [Speech Therapy] evaluation to rule out swallowing deficits given recent weight loss . Recommendations: mechanical soft textures, thin liquids.
Review of the discharge orders from the hospital records dated 11/30/2022, located in the EMR under the Miscellaneous tab, indicated Regular diet.
Review of Resident 15's December 2022 physician orders, under the Orders tab revealed the resident was on Regular diet Dysphagia Mechanical Soft Texture, Thin consistency. Start date 11/30/2022.
Review of the Hemodialysis [blood purifying treatment when kidneys are failing] Treatment Information reports provided by the facility indicated:
-09/07/2022: post weight: 154.66 pounds (#)
-10/24/2022: post weight: 142.56#
-11/21/2022: post weight: 137.94#
-12/19/2022: post weight: 121.66# (11.8% weight loss x 1 month, 21% weight loss x 3 months)
Review of the physician Admit History and Physical assessment, located under the Miscellaneous tab and dated 12/09/2022, indicated only complaint is the modified diet texture that she has right now while lower dentures are being fixed (food doesn't taste good, so she doesn't eat much).
An interview on 12/19/2022 at 2:28 PM, Resident 15 stated she had weight loss because of the taste of the food.
An observation on 12/20/2022 at 8:09 AM, Resident 15 received pureed scrambled eggs and pureed muffin. Review of her tray ticket revealed she was on a dysphagia mechanical soft diet.
Another interview on 12/20/2022 at 8:09 AM, Resident 15 stated she actually liked the real thing. She stated she was on pureed food so I don't choke I guess. She stated the pureed food did not look appealing.
An interview on 12/21/2022 at 1:47 PM, the Speech Language Pathologist (Staff H) stated she had not been in the facility much lately. Staff H stated the dysphagia mechanical soft was a hybrid between the pureed and mechanical soft diet. Staff H stated the meat should have been easy to chew, and bite sized. Staff H stated the soft vegetables were ok.
An interview on 12/22/2022 at 12:25 PM, the Dietary Manager/ Registered Dietitian (Staff D) stated she did not follow any weight losses. Staff D was aware some of the residents refused the food.
Another interview on 12/22/22 at 1:25 PM, Staff H stated if the resident came in on an International Dysphagia Diet Standardization Initiative (IDDSI, a global standard with terminology and definitions to describe texture modified foods) diet for minced and moist, then they used the dysphagia mechanical soft diet for the facility. Staff H stated the foods still had texture but were able to chew. Staff H stated Resident 15 did not have lower dentures, so she was on the dysphagia mechanical soft diet. Staff H stated she was aware Resident 15 disliked the pureed food.
An interview on 12/22/2022 at 1:42 PM, the Registered Dietitian (Staff C) stated she was in the facility about once a week. Staff C stated they had a weight loss meeting every week. Staff C stated the dysphagia mechanical soft diet had softer items, more ground meat. Staff C stated the mechanical soft was a step above the dysphagia mechanical soft with chopped, fork tender. She confirmed they used the diet manual as a guide for the diet. Staff C stated she would ensure that everything was done properly. Staff C stated she was aware Resident 15 had weight loss and her diet had been downgraded at the hospital. Staff C stated they had recommended Speech Therapy see Resident 15 for a possible upgrade. Staff C stated the dysphagia mechanical texture may have had pureed textures at time. Staff C stated the kitchen had tried to get preferred foods for Resident 15. Staff C stated Resident 15 had refused all supplements. Staff C stated the facility did have fortified foods with cereals and puddings and they could offer Resident 15 those items. Staff C stated Resident 15 liked Mexican foods. At 2:22 PM, Staff C stated the resident was going to the grocery store but declined to do that anymore.
An interview on 12/22/2022 at 3:32 PM, the Director of Nursing (Staff B) stated they had a weight loss meeting every week. Staff B stated Resident 15 had been declining. She stated Resident 15 was more active and energetic initially. Staff B stated the resident did not always eat the food and would hide it. Staff B stated Resident 15 had been on a dysphagia mechanical soft for a long time. Staff B stated Resident 15 had trouble chewing with her lack of dentures. Staff B stated she was not aware of the diet inconsistencies in the kitchen. Staff B stated fortified foods had been attempted for Resident 15, but she did not want them. Staff B stated they would investigate getting her dentures and have the speech therapy look at her again. Staff B stated Resident 15 had been without dentures for quite a while.
Reference: (WAC) 388-97-1060 (3)(h)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the risks and benefits of side rails were comp...
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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 risks and benefits of side rails were completed and that the side rails were regularly evaluated for safety for 1 of 1 resident (Resident 11) who had two, one-fourth siderails on their bed. This failure placed the resident at risk for entrapment and/or injury.
Finding included .
Observation and interview on 12/20/2022 at 8:41 AM, Resident 11 was in bed with 2 upper 1/4 bed rails in the raised position. Interview revealed Resident 11 was unable to reposition with the side rails and required assistance from the staff.
Review of Resident 11's significant change Minimum Data Set assessment dated [DATE] revealed Resident 11 required extensive assistance from two staff for bed mobility.
Review of the Electronic Medical Record revealed no evidence of a side rail assessment for Resident 11 that indicated Resident 11 used the rails as an enabler to assist in repositioning.
An interview on 12/22/2022 at 3:37 PM, the Administrator (Staff A) and Director of Nursing (Staff B) confirmed Resident 11 was the only resident with side rails on their bed. Staff B confirmed the facility lacked policies and procedure for the routine inspection and maintenance of the siderails. Staff B confirmed there was no assessment to demonstrate Resident 11 would benefit from the use of side rails. Staff B confirmed there was no routine maintenance or inspection of the side rails for safety.
Reference: (WAC) 388-97-1060 (3)(g) - 2100 (1)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide behavioral health services for 1 of 47 residents (Resident 41) reviewed for mental health provision and services. Thi...
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Based on observation, interview, and record review, the facility failed to provide behavioral health services for 1 of 47 residents (Resident 41) reviewed for mental health provision and services. This failure placed the residents at risk for unmet psycho-social needs and diminished quality of life.
Findings included .
Review of the facility policy titled, Behavioral Health Services, updated on 07/07/2022, revealed Policy statement: Each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes but is not limited to, the prevention and treatment of mental and substance use disorders.
Review of Resident 41's Electronic Medical Record (EMR), under Face Sheet revealed that Resident 41 was admitted to the facility originally on 10/20/2022 with diagnosis that included depression.
Review of Resident 41's admission Minimum Data Set assessment dated of 10/26/2022, revealed that Resident 41 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact.
Review of Resident 41's care plan revealed a problem of Alteration in mood related to depression, goals included, Resident will report experiencing their normal sleep pattern, Date Initiated: 10/21/2022, Revision on: 11/07/2022, and Target Date: 01/31/2023. The other goal was the Resident will score 10 or less on the PHQ-9, Date Initiated: 10/21/2022, Revision on: 11/07/2022, and Target Date: 01/31/2023. Interventions included: Administer PHQ-9 Quarterly and with any significant change in condition; Complete psychoactive review per facility protocol; Encourage family/friends to visit; . Inform SW [social worker] and LN [licensed nurse] of significant changes in mood Initiate Mental health evaluation, if ordered by Medical Provider and consented to; Involve resident and family/friends; in mutual problem solving; Monitor target behaviors for -# of hours of sleep and Sad statements. SW follow up as needed.
Further review of the EMR revealed no documentation that staff monitored behaviors for depression (sad statements) for Resident 41.
Review of Psychiatry Evaluation, located in the EMR, under the Miscellaneous tab dated 11/17/2022 by Advanced Registered Nurse Practitioner-Board Certified (Staff S), revealed Resident 41 had a diagnoses of major depressive disorder, a history of suicidal attempts/ideation, and was not on antidepressants. Further review revealed Resident 41 was unsure why her anti-depressant was discontinued. The evaluation recommended continued mental health treatments and indicated Resident 41 was willing to participate in mental health treatments.
Observation on 12/19/2022 at 9:40 AM, revealed Resident 41 was laying in her bed flat on her back. During this meeting, Resident 41 said that she had stayed in bed since she got to the facility. She said she did not get up, because of the pain. Resident 41 stated, I do not get out of bed at all.
An interview on 12/19/2022 at 9:40 AM, a licensed practical nurse (Staff T) stated Resident 41 did not get out of bed because she chose not to, but Resident 41 said she wants to move home.
An interview with the Social Services Director (Staff R) on 12/19/2022 at 3:30 PM said, the resident is not a long-term care resident, she is going to home so [the outpatient behavioral health] won't see her. She further stated, she will have to figure out behavioral health services after she gets out of the facility. She refuses everything anyway. She just chooses not to get out of bed.
A follow-up interview on 12/22/2022 at 12:06 PM, Resident 41 confirmed she would be interested in receiving mental health services to get better.
An interview with the Administrator (Staff A) on 12/22/2022 at 2:45 PM stated he knew Resident 41 had some behavioral health concerns around not participating in her own care. Staff A stated he was unsure why Resident 41 was not receiving further treatment for her depression and stated he would check into it.
All documentation was requested regarding Resident 41's depression. Additional documentation provided by Staff A did not include evidence of continued behavioral health treatments being available for Resident 41 following the evaluation made on 11/17/2022 and/or documentation that behaviors (sad statements) were monitored for Resident 41.
No Associated WAC
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure proper diet texture consistency for 1 of 1 resident (Resident 374) reviewed for nutrition and specialty diet. This fai...
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Based on observation, interview, and record review, the facility failed to ensure proper diet texture consistency for 1 of 1 resident (Resident 374) reviewed for nutrition and specialty diet. This failure placed the resident at risk for nutritional imbalance, weight changes and a diminished quality of life.
Findings included .
Review of the undated facility's diet manual titled, Dysphagia [difficulty swallowing] Mechanically Altered (Level 2) Diet indicated Meat or meat alternative: Ground as tolerated, moistened with sauce or gravy; Vegetables: Cooked, tender, chopped, or shredded; Grains: Pureed or slurried and gelled; well cooked noodles, soft pancakes well moistened with syrup or sauce.
Review of the undated facility policy titled, Dietary Services-Food and Drink indicated The facility will provide to each resident: Food prepared in a form designed to meet individual needs.
Review of the undated facility policy titled, Menu Planning indicated Regular and therapeutic menus are written by the facility's food and nutritional professional in accordance with the facility's approved diet manual.
Review of Resident 374's admission Record undated, located in the resident's electronic medical record (EMR) under the Profile tab, indicated an admission date of 12/08/2022.
Review of Resident 374's EMR for the December 2022 physician orders, under the Orders tab, revealed the resident was on Regular diet Dysphagia Mechanical Soft Texture, Nectar consistency. Start date 12/08/2022.
Observation on 12/19/2022 at 12:39 PM, Resident 374 was observed to have received pureed food at her meal. She was eating in the dining room with family member (FM). The FM stated the resident had received pureed food, then more regular texture and now back to pureed. She stated Resident 374 was tired of receiving the same foods.
Review of the menu provided by the facility, revealed the lunch meal for 12/20/2022 dysphagia mechanical soft: Pureed red beans and sausage; Pureed cornbread; Rice; and Tapioca pudding. The menu did not align with the diet manual for dysphagia mechanical soft diets.
Observation of the main kitchen tray line on 12/20/2022 at 11:58 AM, Resident 374 was observed to have received ground sausage and mashed potatoes with no additional vegetables for lunch meal. The resident did not receive the pureed cornbread and did not receive the pureed items listed on the menu. The menu did not have mashed potatoes listed.
Review of the menu provided by the facility, revealed the lunch meal on 12/21/2022 dysphagia mechanical soft: Ground chicken and green beans, slurried white roll, and cheesecake.
Observation in the dining room on 12/21/2022 at 12:13 PM, Resident 374 received ground chicken with gravy, mashed potatoes, pudding, and pureed vegetables. The resident received pureed green beans instead of the ground mixture listed on the menu. The menu did not have mashed potatoes listed.
An interview on 12/21/2022 at 1:47 PM, the Speech Language Pathologist (Staff H) stated she had not been in the facility much lately. Staff H stated the dysphagia mechanical soft was a hybrid between the pureed and mechanical soft diet. She stated the meat should have been easy to chew, and bite sized. She stated the soft vegetables were ok. She stated Resident 374 had been seen the previous week and they had talked about liberalizing her diet from dysphagia mechanical to a mechanical soft diet.
Review of the menu provided by the facility, revealed the breakfast meal on12/22/2022 dysphagia mechanical soft: Cranberry juice, cream of wheat, scrambled egg, and pureed wheat toast.
Observation on 12/22/2022 at 8:00 AM, Resident 374 was eating in the dining room. She received ground toast, scrambled eggs, and oats. She did not receive any additional fruit or juice. She received a cup of thickened hot beverage with the appearance of pudding thick liquid. She declined all food, beverages. She did not receive the nectar thick liquids list on the diet order.
An interview on 12/22/2022 at 12:25 PM, the Dietary Manager/ Registered Dietitian (Staff D) confirmed not all the cooks were consistent with diet texture. Staff D confirmed they should follow the diet manual for proper diet textures and would need to change the menu. Staff D stated she was aware some of the residents refused the food. Staff D stated she was working with some of the residents for a selective menu. She stated the nurses thickened the beverages. She stated she would work with the RD (Staff C) to review needed menu changes.
An interview on 12/22/2022 at 1:25 PM, Staff H stated if the resident came in on an International Dysphagia Diet Standardization Initiative (IDDSI) diet for minced and moist, then they used the dysphagia mechanical soft diet for the facility. She stated the foods still had texture but were able to chew. She stated they were in the process of liberalizing Resident 374's diet texture. She stated she would like to change the facility's mechanical textures to better align with the IDDSI levels.
An interview on 12/22/2022 at 1:42 PM, Staff C stated she was in the facility about once a week. She stated the dysphagia mechanical soft diet had softer items, more ground meat. She stated the mechanical soft was a step above the dysphagia mechanical soft with chopped, fork tender. She confirmed they should have used the diet manual as a guide for the diet. She stated the dysphagia mechanical texture may have had pureed textures at times.
An interview on 12/22/2022 at 3:32 PM, the Director of Nursing (Staff B) stated she was not aware of the diet inconsistencies in the kitchen. Staff B confirmed she had noted Resident 374's beverage was very thick.
Reference: (WAC) 388-97- 1100 (1) and 1220.
.
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 ready-to-eat food was handled appropriately in accordance with professional standards for food service safety for 1 of...
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Based on observation, interview, and record review, the facility failed to ensure ready-to-eat food was handled appropriately in accordance with professional standards for food service safety for 1 of 1 dining room. This failure placed the resident at risk for food-borne illness.
Findings included .
Review of the undated facility's policy titled, General Food Preparation and Handling indicated Bare hands should never touch raw food directly . Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods.
Observation in the dining room on 12/20/2022 at 7:47 AM, the Nurse Aide (Staff I) was observed putting butter and jelly on Resident 5's bread. Staff I picked up the resident's bread with her bare hands.
An interview on 12/20/2022 at 8:40 AM, Staff I acknowledged she handled the resident's bread with her bare hands. She said she had been previously educated on the proper handling of ready-to-eat food.
An interview on 12/22/2022 at 3:32 PM, the Director of Nursing (Staff B) confirmed Staff I handled the resident's bread with her bare hands. She stated, We all know better.
Reference: (WAC) 388-97-1100 (3)
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure annual comprehensive Minimum Data Set (MDS) assessments were completely timely as required for 5 of 21 residents (Residents 3, 22, 3...
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Based on interview and record review, the facility failed to ensure annual comprehensive Minimum Data Set (MDS) assessments were completely timely as required for 5 of 21 residents (Residents 3, 22, 30, 10 & 35) reviewed for comprehensive assessments. The facility's failure to conduct annual comprehensive assessments placed the residents at risk of unidentified physical, psychological, functional changes, other unmet care needs and a diminished quality of life.
Findings included .
Review of the Resident Assessment Instrument (RAI) Manual, October 2019 edition, revealed the facility is to conduct a comprehensive assessment no more than 366 days from the previous comprehensive assessment.
RESIDENT 3
Review of the Electronic Medical Record (EMR) revealed an admission date of 08/13/2013 for Resident 3. Review of the MDS list of activity for Resident 3, revealed an annual comprehensive assessment was last completed on 12/20/2021, more than one year ago.
RESIDENT 22
Review of the EMR revealed an admission date of 11/14/2021 for Resident 22. Review of the MDS list of activity for Resident 22, revealed a comprehensive assessment was last completed on 11/10/2021, more than one year ago.
RESIDENT 30
Review of the EMR revealed an admission date of 10/31/2019 for Resident 30. Review of the MDS list of activity for Resident 30, revealed a comprehensive assessment was last completed on 10/14/2021, more than one year ago.
RESIDENT 10
Review of the EMR revealed an admission date of 02/09/2017 for Resident 10. Review of the MDS list of activity for Resident 10, revealed a comprehensive assessment was last completed on 11/12/2021, more than one year ago.
RESIDENT 35
Review of the EMR revealed an admission date of 01/19/2018 for Resident 35. Review of the MDS list of activity for Resident 35, revealed a comprehensive assessment was completed on 11/23/2021, more than one year ago.
During an interview on 12/20/2022 at 12:19 PM, the MDS Coordinator, Staff F, confirmed the facility used the RAI Manual as the instructions for the completion of the MDS assessments for each residents. Staff J confirmed there were ''many'' incomplete assessments [Residents 3, 22, 30, 10 & 35], and that the facility was ''trying to catch up.''
Reference: (WAC) 388-97-1000 (1)(b)(5)(a)
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
Based on staff interview and record review, facility failed to ensure Minimum Data Set (MDS) assessments were conducted timely for 11 of 21 residents (Residents 27, 66, 13, 39, 24, 46, 36, 14, 23, 12 ...
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Based on staff interview and record review, facility failed to ensure Minimum Data Set (MDS) assessments were conducted timely for 11 of 21 residents (Residents 27, 66, 13, 39, 24, 46, 36, 14, 23, 12 and 37) reviewed for Quarterly MDS Assessments. This failure placed the residents at risk for delayed and/or unmet care needs, and a diminished quality of life.
Findings included .
Review of the ''Resident Assessment Instrument [RAI] Manual,'' October 2019 edition, used by the facility to direct the type of assessment needed and instructions of how to complete the assessment, indicated that a quarterly assessment was to be completed at least every 92 days when a comprehensive assessment was not required.
RESIDENT 27
Review of Resident 27's Electronic Medical Record (EMR), under the Census tab revealed an admission date of 04/05/2021. Review of the MDS tab, revealed Resident 27's last assessment was a comprehensive MDS assessment completed on 07/05/2022. The facility failed to perform a quarterly assessment within 92 days.
RESIDENT 66
Review of Resident 66's EMR revealed an admission date of 08/09/2022. Review of the MDS tab, revealed a comprehensive MDS assessment was last completed on 08/15/2022. The facility failed to perform a quarterly assessment within 92 days.
RESIDENT 13
Review of Resident 13's EMR revealed an admission date of 04/06/2022. Review of the MDS tab, revealed a quarterly assessment was completed on 06/24/2022. The facility failed to perform a quarterly assessment within 92 days.
RESIDENY 39
Review of Resident 39's EMR revealed an admission date of 05/22/2019. Review of the MDS tab, revealed a quarterly assessment was last completed on 07/27/2022. The facility failed to perform a quarterly assessment within 92 days.
RESIDENT 24
Review of Resident 24's EMR revealed an admission date of 05/08/2020. Review of the MDS tab, revealed a quarterly MDS assessment was last completed on 07/29/2022. The facility failed to perform a quarterly assessment within 92 days.
RESIDENT 46
Review of Resident 46's EMR revealed an admission date of 10/23/2020. Review of the MDS tab revealed a quarterly MDS assessment was last completed on 07/29/2022. The facility failed to perform a quarterly assessment within 92 days.
RESIDENT 36
Review of Resident 36's EMR revealed an admission date of 08/08/2019. Review of the MDS tab revealed a quarterly MDS assessment was last completed on 07/14/2022. The facility failed to perform a quarterly assessment within 92 days.
RESIDENT 14
Review of Resident 14's EMR revealed an admission date of 10/14/2021. Review of the MDS tab, revealed a comprehensive MDS assessment was last completed on 01/22/2022, and the last quarterly assessment was completed 07/06/2022. The facility failed to perform a quarterly assessment within 92 days.
RESIDENT 23
Review of Resident 23's EMR revealed an admission date of 08/05/2015. Review of the MDS tab, revealed a quarterly MDS assessment was last completed on 07/18/2022. The facility failed to perform a quarterly assessment within 92 days.
RESIDENT 12
Review of Resident 12's EMR revealed an admission date of 04/10/2012. Review of the MDS tab, revealed a quarterly MDS assessment was last completed on 07/18/2022. The facility failed to perform a quarterly assessment within 92 days.
RESIDENT 37
Review of Resident 37's EMR revealed an admission date of 02/14/2020 and a discharge date of 10/13/2022. Review of the MDS tab, revealed a quarterly MDS assessment was last completed on 06/29/2022. The facility failed to perform a quarterly assessment within 92 days.
An interview with the MDS Coordinator (Staff F) on 12/20/2022 at 12:19 PM, confirmed the facility used the RAI Manual as the instructions for the completion of the MDS assessments for each residents. Staff F confirmed that there were ''many'' incomplete assessments [Residents 27, 66, 13, 39, 24, 46, 36, 14, 23, 12 and 37], and that the facility was ''trying to catch up.''
Reference: (WAC) 388-97-1000 (4)(a)
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the food was palatable, attractive, and at a safe and appetizing temperature for 6 of 6 residents (Residents 14, 42, 3...
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Based on observation, interview, and record review, the facility failed to ensure the food was palatable, attractive, and at a safe and appetizing temperature for 6 of 6 residents (Residents 14, 42, 374, 35, 40 and 15) reviewed for palatability. This failure placed the residents at risk for weight change, less than adequate nutritional intake, and dissatisfaction with meals.
Findings included .
Review of the undated facility's policy titled, Food Temperatures indicated All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees F [Fahrenheit] . Temperatures should be taken periodically to ensure hot foods stay above 135 degrees F and cold foods stay below 41 degrees F during the portioning, transporting and serving process until received by the resident.
Review of the undated facility's policy titled, Dietary Services- Food and Drink indicated The facility will provide to each resident: Food prepared by methods that conserve nutritive value, flavor, and appearance; Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
An interview on 12/19/2022 at 9:05 AM, Resident 14 stated the food was terrible and it was cold.
An interview on 12/19/2022 at 10:15 AM, Resident 42 stated the food was always cold and too many chicken was served.
Observation on 12/20/2022 at 7:34 AM, Resident 374 had her food tray at bedside. The resident was sleeping. A nurse aide was observed taking her to the dining room. The resident's tray was brought into the dining room at 7:56 AM. She received scrambled eggs, pureed muffin, and water. The food was not reheated. The resident declined to eat the food. The nurse aide was observed to help assist her with her food. Resident 374 was observed to have spit the food into her napkin.
An interview on 12/22/2022 at 7:43 AM, Resident 35 stated breakfast was the only good meal. He stated the lunch and dinner meals did not taste good.
An interview on 12/22/2022 at 7:53 AM, Resident 40 stated the meals did not have a lot of variety and it was cold.
Observation on 12/22/2022 at 8:00 AM, Resident 374 was eating in the dining room. She received ground toast, scrambled eggs, and oats. She did not receive any additional fruit or juice. She received a cup of thickened hot beverage with the appearance of pudding thick liquid. She declined all food, beverages. The food was not reheated or replaced.
An interview on 12/22/2022 at 8:06 AM, Resident 374 stated she did not like the food.
Observation on 12/22/2022 at 8:18 AM, Resident 15 received cut up processed fried egg, slurried cut up toast, cut canned peaches. She did not eat the food provided.
An interview on 12/22/2022 at 8:18 AM, Resident 15 stated she did not like the food. She stated she had not seen many vegetables or fruits. She stated she did not want the food.
During a test tray evaluation on 12/22/2022 at 12:23 PM, the Dietary Manager/ Registered Dietitian (Staff D) took the temperatures of the food. The test tray left the kitchen at 12:04 PM. The last tray off the cart was at 12:23 PM. The temperatures revealed the following:
-Apple crisp: 53.6 degrees F
-Taco meat- 95.5 degrees F
-Noodles: 103.1 degrees F
-Green beans: 105.6 degrees.
An interview on 12/22/2022 at 12:27 PM, Staff D stated she would have liked the temperature to be 165 degrees F. She confirmed they had heard about residents complaining about the food temperatures. She took the temperature of the apple juice with a temperature of 60 degrees F and stated it should have been below 41 degrees F.
Observation on 12/22/2022 at 12:33 PM, the test tray revealed the green beans were undercooked and bland; the meat and noodles were bland; the noodles were dry; and the apple crisp was soggy.
Another interview on 12/22/2022 at 12:25 PM, Staff D stated she took the temperatures of the food at the end of tray line. Staff D stated the taco meat was 130.4 degrees F, angel hair pasta was 130.5 degrees F, green beans were 140.9 degrees F, and the apple crisp was 52.7 degrees F. Staff D stated the hot food should have been at least 160 degrees F before leaving the kitchen. Staff D stated she tasted the food, and the pasta was sticky with no seasoning, the green beans lacked seasoning, and the dessert was very gummy. Staff D stated the texture of the green beans was too crunchy for mechanical texture. Staff D stated she was aware some of the residents refused the food. She stated she was working with some of the residents for a selective menu.
An interview on 12/22/2022 at 1:42 PM, the Registered Dietitian (Staff C) stated she was in the facility about once a week. She stated she completed kitchen sanitation audits, provided support, menu, and policy development. She stated they had talked about a better system for food temperatures. She stated she was not aware the steam table was not holding food temperatures.
Reference: (WAC) 388-97-1100 (1)(2)
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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 develop and implement a water management program to re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a water management program to reduce the potential for exposure to opportunistic waterborne pathogens (a bacterium, virus, or other microorganisms that can cause a disease) including Legionnaire's disease, a potentially dangerous bacteria that grows in water, which could cause a serious lung infection (Pneumonia). This failure created a potential risk for the facility residents to be exposed to Legionella, other opportunistic water-borne pathogens, and related complications.
Findings included .
Review of the website for American Society of Heating, Refrigerating and Air-Conditioning Engineers titled, Risk Management for Legionellosis, dated 10/15, indicated . The design engineer first needs to evaluate which requirements of the standard apply to their project. This evaluation determines if the project contains any of the following building risk factors . Health-care facility with patient stays over 24 hours . Facilities designated for housing occupants over age [AGE] . The risk of disease or illness from exposure to Legionella bacteria is not as simple as the bacteria being present in a water system. Other factors that contribute to the risk are environmental conditions that promote the growth and amplification of the bacteria in the system, a means of transmitting this bacteria (via water aerosols generated by the system), and the ultimate exposure of susceptible persons to the colonized water that is inhaled or aspirated by the host providing a pathway to the lungs. The bacteria are not transmitted person-to-person, or from normal ingestion of water. Susceptible persons at high risk for legionellosis include, among others, the elderly, dialysis patients, persons who smoke, and persons with medical conditions that weaken the immune system .
Review of the Centers for Disease Control and Prevention website titled, Legionella . Prevention and Control dated 03/25/2021, indicated . The key to preventing Legionnaires' disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella . Key Elements . Seven key elements of a Legionella water management program are to . Establish a water management program team . Describe the building water systems using text and flow diagrams . Identify areas where Legionella could grow and spread . Decide where control measures should be applied and how to monitor them . Establish ways to intervene when control limits are not met . Make sure the program is running as designed (verification) and is effective (validation) . Document and communicate all the activities . Principles . In general, the principles of effective water management include . Maintaining water temperatures outside the ideal range for Legionella growth . Preventing water stagnation . Ensuring adequate disinfection . Maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella . Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met.
Review of the facility's infection prevention policies and procedures dated 11/19/2022, revealed the lack of water management policies and procedures, including the identification and management of water-borne pathogens.
Observation on 12/19/2022 at 10:07 AM, revealed Resident 42 was seated on his bed in his room. During this meeting, Resident 42 said the hot water in his room never got hot and stated, It is not hot enough to wash your face after letting it run for over eight minutes. And the water pressure is very weak.
Observation on 12/19/2022 at 10:13 AM, showed the hot water in the sink of Resident 42's room was observed to run for over five minutes and the water was slightly warm to the touch.
Observation and interview with the Plant Manager, Staff E, on 12/22/2022 at 3:15 PM, confirmed the highest temperature measurement of the water in Resident 42's sink after running the water for several minutes was 92 degrees Fahrenheit. Staff E confirmed that was much lower than the standard of 120 degrees Fahrenheit. Staff E stated several things can be done to alleviate this problem and this problem would have affected all the resident rooms on this side of the building. Staff E also said that several things could be done to improve the low temperature and low water pressure.
An interview on 12/22/2022 at 3:30 PM, the Administrator, Staff A, and the Director of Nursing, Staff B, confirmed the facility lacked water management policies and procedures including the management and preventions of water borne pathogens in the facility's water system.
Reference: (WAC) 388-97-1320 (1)(a)(2)(a)
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure the menu met the nutritional needs of residents in accordance with the established national guidelines for well-balanc...
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Based on observation, interview, and record review, the facility failed to ensure the menu met the nutritional needs of residents in accordance with the established national guidelines for well-balanced diet/menu. This failure placed the residents at risk for not having their food choices honored, unmet nutritional needs, and a diminished quality of life.
Findings included .
Review of the undated facility's policy titled, Menu Planning indicated the Nutritional needs of individuals [residents] will be provided in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences . through nourishing, well-balanced diets, unless contraindicated by medical needs . Menus are written using an accepted, standard meal planning guide, such as the USDA [United States Department of Agriculture] MyPyramid.
Review of the USDA Dietary Guidelines for Americans 2020-2025 [This was retrieved on 12/25/2022] indicated, Calorie Level: 1800: Vegetables: 2 1/2 cups/day; Fruits: 1 1/2 cups/day; Dairy: 3 cups/day; Protein foods: 5 ounces/day; Grains: 6 ounces/day . Calorie Level 2000: Vegetables: 2 1/2 cups/day; Fruits: 2 cups/day; Dairy: 3 cups/day; Protein foods: 5 ounces/day; Grains: 6 ounces/day.
Review of the four-week menu cycle provided by the facility indicated:
Week one:
Thursday: the only fruit included was a glass of juice at breakfast.
Saturday: the only fruit included was a glass of juice at breakfast and the dinner meal contained no vegetables.
Week two:
Monday lunch meal: missing vegetable.
Tuesday: the only fruit included a glass of juice at breakfast, lunch meal: no vegetables and the dinner meal: the only vegetable listed was lettuce and tomato slice.
Thursday: the only fruit included a glass of juice at breakfast.
Week three:
Monday: the only fruit included a glass of juice at breakfast.
Friday lunch: the only vegetable was shredded lettuce.
Saturday: the only fruit included a glass of juice at breakfast.
Sunday: the only fruit included a glass of juice at breakfast.
Week four:
Saturday dinner: the only vegetable listed: lettuce and tomato slice.
Sunday: the only fruit included a glass of juice at breakfast.
Observation on 12/20/2022 at 12:28 PM in the main kitchen, Resident 15 was observed to have received mac-n-cheese with no fruits or vegetables for meal.
An interview on 12/20/22 at 12:43 PM, Resident 15 stated she had never seen any fruits and vegetables with her meals. She stated she liked broccoli and brussels sprouts. She stated she would like to see the vegetables she liked.
Observation of the main kitchen tray line on 12/20/2022 at 11:58 AM, Resident 374 was observed to have received ground sausage and mashed potatoes with no additional vegetables for lunch meal.
An interview on 12/20/2022 at 12:22 PM, the cook (Staff K) stated she served mashed potatoes with the mechanical soft diets, because they did not have any vegetables on the menu. Staff K stated the mechanical soft diets received the ground meat, rice, and mashed potatoes.
Observation on 12/20/2022 at 12:33 PM, Resident 374 received ground sausage and mashed potatoes. An interview on 12/20/2022 at 12:38 PM, Resident 374's Responsible Party confirmed the resident did not receive any non-starchy vegetables at this meal.
An interview on 12/22/2022 at 7:32 AM, Resident 32 stated they were served the same foods every day. She stated they did not get many fruits. She stated she would like to see more fruit. She stated they received half of a strawberry this morning and would like more strawberries. She stated she was tired of always receiving an orange.
An interview on 12/22/2022 at 1:31 PM, Staff D, Dietary Manager/Registered Dietitian (RD) stated she was not sure who prepared the menu. Staff D stated she noticed the menu did not have a vegetable for Monday, so they added a vegetable. Staff D stated she would work with the RD (Staff C) to see what they could do with the menu.
An interview on 12/22/2022 at 1:42 PM, Staff C stated she was in the facility about once a week and she completed kitchen sanitation audits, provided support, menu, and policy development. Staff C stated she was not aware the menu was missing fruits and vegetables and that she would ensure that everything was done properly.
An interview on 12/22/2022 at 3:32 PM, the Director of Nurses (Staff B) stated she was not aware of the diet inconsistencies.
Reference: (WAC) 388-97-1160 (1)(a)(b)
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MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of room size measurements, seven single resident rooms failed to meet the minimum ro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of room size measurements, seven single resident rooms failed to meet the minimum room size requirement of at least 100 square feet for single resident room. These rooms were: 405, 407, 501, 503, 505, 507 and 509.
Findings included .
Square footage:
room [ROOM NUMBER] - 85 square feet
room [ROOM NUMBER] - 95 square feet
room [ROOM NUMBER] - 83 square feet
room [ROOM NUMBER] - 87 square feet
room [ROOM NUMBER] - 87 square feet
room [ROOM NUMBER] - 87 square feet
room [ROOM NUMBER] - 87 square feet
The residents in these rooms were screened during the survey and were not found to be negatively impacted by their room size.
room [ROOM NUMBER] and 501 were not occupied by a resident during the survey.
On 12/22/2022 at 1:19 PM, Staff E, Plant Manager, said that there was no change made to these rooms' square footage since the last recertification survey.
On 12/22/2022 at 3:21 PM, Staff A, Administrator, confirmed there was no change made to these rooms' square footage since the last recertification survey and acknowledged the rooms listed above did not meet the required room measurement per the federal and state regulations.
Reference: (WAC) 388-97-2440(1)
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • $3,250 in fines. Lower than most Washington facilities. Relatively clean record.
- • 32% turnover. Below Washington's 48% average. Good staff retention means consistent care.
Concerns
- • 74 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (58/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 58/100. Visit in person and ask pointed questions.
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About This Facility
What is Avamere Rehabilitation Of Shoreline's CMS Rating?
CMS assigns AVAMERE REHABILITATION OF SHORELINE 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 Avamere Rehabilitation Of Shoreline Staffed?
CMS rates AVAMERE REHABILITATION OF SHORELINE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 32%, compared to the Washington average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Avamere Rehabilitation Of Shoreline?
State health inspectors documented 74 deficiencies at AVAMERE REHABILITATION OF SHORELINE during 2022 to 2025. These included: 72 with potential for harm and 2 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Avamere Rehabilitation Of Shoreline?
AVAMERE REHABILITATION OF SHORELINE 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 AVAMERE, a chain that manages multiple nursing homes. With 115 certified beds and approximately 59 residents (about 51% occupancy), it is a mid-sized facility located in SEATTLE, Washington.
How Does Avamere Rehabilitation Of Shoreline Compare to Other Washington Nursing Homes?
Compared to the 100 nursing homes in Washington, AVAMERE REHABILITATION OF SHORELINE's overall rating (3 stars) is below the state average of 3.2, staff turnover (32%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Avamere Rehabilitation Of Shoreline?
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 Avamere Rehabilitation Of Shoreline Safe?
Based on CMS inspection data, AVAMERE REHABILITATION OF SHORELINE 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 Avamere Rehabilitation Of Shoreline Stick Around?
AVAMERE REHABILITATION OF SHORELINE has a staff turnover rate of 32%, 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 Avamere Rehabilitation Of Shoreline Ever Fined?
AVAMERE REHABILITATION OF SHORELINE has been fined $3,250 across 1 penalty action. This is below the Washington average of $33,111. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Avamere Rehabilitation Of Shoreline on Any Federal Watch List?
AVAMERE REHABILITATION OF SHORELINE 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.