PARK SHORE
Non profit - Corporation
28 Beds
Independent
Data: November 2025
Trust Grade
63/100
#78 of 190 in WA
Photo by Parkshore Senior Living Community
Photo by Parkshore Senior Living Community
Photo by Parkshore Senior Living Community
1 / 10 photos
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Park Shore in Seattle has a Trust Grade of C+, indicating it is slightly above average among nursing homes. It ranks #78 out of 190 facilities in Washington, placing it in the top half, and #17 out of 46 in King County, meaning there are only 16 local options that are better. The facility is improving, with a decrease in issues from 25 in 2023 to 11 in 2024. Staffing is a strong point, earning a 4/5 star rating and experiencing 0% turnover, which is well below the state average of 46%, suggesting that staff remain committed and familiar with the residents. However, there are concerns, such as $14,888 in fines, which is average but indicates some compliance issues; and specific incidents where a resident fell and fractured their arm due to inadequate fall interventions, as well as failures in food safety and pest control that could impact residents' health and quality of life. Overall, while the facility has strengths in staffing and is on an upward trend, there are notable weaknesses that families should consider.
- Trust Score
- C+
- In Washington
- #78/190
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ⚠ Watch
- $14,888 in fines. Higher than 82% of Washington facilities, suggesting repeated compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 65 minutes of Registered Nurse (RN) attention daily — more than 97% of Washington nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 53 deficiencies on record. Higher than average. Multiple issues found across inspections.
63/100
Top 41%
Needs review
25 → 11 violations
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 25 issues
2024: 11 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
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Federal Fines: $14,888
Below median ($33,413)
Minor penalties assessed
The Ugly 53 deficiencies on record
1 actual harm
Oct 2024
11 deficiencies
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 10 residents (Resident 11), reviewed for Min...
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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 10 residents (Resident 11), reviewed for Minimum Data Set (MDS - an assessment tool). The failure to ensure accurate assessments regarding active diagnosis 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, .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 . Active Diagnoses- Physician-documented diagnoses in the last 60 days that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Medical record sources for physician diagnoses include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/ problem list, and other resources as available.
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 11 admitted to the facility on [DATE].
Review of the physician orders printed on 10/11/2024, showed Resident 11 was receiving a medication [for depression (or mood disorder)] for diagnosis of anxiety and pain that started on 08/03/2024.
Review of Resident 11's quarterly MDS dated [DATE], showed that anxiety was not marked on the diagnoses section (Section I) of the MDS.
Joint record review and interview on 10/16/2024 at 10:35 AM with Staff D, Resident Care Manager/MDS Coordinator, showed Resident 11's physician's order had an antidepressant order for anxiety and pain. Staff D stated that anxiety was the diagnosis for Resident 11's antidepressant medication. Joint record review of the quarterly MDS dated [DATE], showed anxiety was not marked on Section I. Staff D stated that Resident 11's MDS should have had anxiety marked in Section I and that the MDS was inaccurate.
On 10/16/2024 at 11:45 AM, Staff C, Assistant Director of Nursing, stated that they expected MDS assessments to be accurate and that Resident 11's MDS was not accurate.
On 10/16/2024 at 11:53 AM, Staff B, Director of Nursing, stated they expected the MDS assessment to be accurate and have accurate diagnoses.
Reference: (WAC) 388-97-1000(1)(b)(j)
.
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** RESIDENT 68
A review of Resident 68's face sheet showed they admitted to the facility on [DATE] with multiple diagnoses includin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 68
A review of Resident 68's face sheet showed they admitted to the facility on [DATE] with multiple diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder.
A review of Resident 68's Level 1 PASARR form dated 10/07/2024 showed that mental mood disorders and anxiety disorders were marked in the SMI section. Further review of the document showed the SMI Indicators section was marked yes [has SMI] and no [does not have SMI].
In an interview and joint record review on 10/16/2024 at 10:19 AM, Staff E stated that they reviewed the Level I PASARR either on the day the resident arrives to the facility or the day before. Staff E stated that they had reviewed Resident 68's Level I PASARR form multiple times and did not know how they missed that Section IA and that it was mismarked.
In an interview on 10/16/2024 at 1:56 PM, Staff A stated that their expectations included the PASARR forms to be reviewed prior to a new resident's admittance. Staff A further stated that any new admit with a mental health diagnosis, they would review and update the PASARR activity according to standard.
Reference: (WAC) 388-97-1915 (1)(2) (a-c) (4), 1975(1)(4)
RESIDENT 14
Review of a face sheet showed Resident 14 admitted to the facility on [DATE].
Review of Resident 14's Level I PASARR form dated 09/18/2024, showed the name of the resident and the hospital staff member who completed the form. Further review of the Level I PASARR form did not show the required four sections (Sections I to IV) were completed or filled out.
In an interview and joint record review on 10/15/2024 at 3:17 PM, Staff E stated that they ensured the Level I PASARR be completed upon admission. A joint record review with Staff E showed Resident 14's Level I PASARR form did not have the four sections completed. Staff E stated that Resident 14's Level I PASARR form was incomplete and that it needed to be redone properly.
In an interview on 10/16/2024 at 2:33 PM, Staff A stated that Resident 14's Level I PASARR was not reviewed properly, and it should have been. :33 PM, Staff A stated that Resident 14's PASARR Level I was not reviewed properly, and it should have been.
Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR - a federally required screening of all individuals who has both an Intellectual Disability [ID] or Related Condition [RC] and a Serious Mental Illness [SMI] prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form was completed prior to admission and according to the guidelines specified for 3 of 5 residents (Residents 11, 14 & 68), reviewed for unnecessary medications. This failure placed the residents at risk for inappropriate placement and/or lack of access to specialized services for residents with identified mental health diagnosis or disability.
Findings included .
Review of the facility's policy titled, PASARR, revised on 04/01/2023, showed that the facility would ensure all residents had a PASARR level I completed on admission and would ensure PASARR Level II referrals were made in accordance with State requirements. The document further showed that the facility's social services team would review the Level I PASARR for accuracy within 72 hours on all admissions. If the PASARR level I was inaccurate, a new accurate Level I PASARR would be immediately completed. If the PASARR Level I screening identified possible SMI or ID or RC, the social services team member would notify the DDA (Developmental Disability Administration) and/or mental health PASARR evaluator so a Level II evaluation can be conducted.
RESIDENT 11
Review of the face sheet printed on 10/11/2024, showed Resident 11 admitted to the facility on [DATE].
Review of the physician orders printed on 10/11/2024, showed Resident 11 was receiving an antidepressant medication for diagnosis of anxiety and pain that started on 08/03/2024.
Review of Resident 11's Level I PASARR dated 08/27/2024, showed the diagnosis of anxiety was not marked in Section I (SMI/ID/RC).
Joint record review and interview on 10/16/2024 at 10:02 AM with Staff E, Social Services Coordinator, showed Resident 11's physician order had an order for an antidepressant medication for diagnosis of anxiety and pain since 08/03/2024. Staff E stated that anxiety was the diagnosis for Resident 11's antidepressant medication.
Another joint record review and interview on 10/16/2024 at 10:02 AM with Staff E, showed no diagnosis of anxiety was listed under Section IA [SMI] of Resident 11's Level I PASARR dated 08/27/2024. Staff E stated that the diagnosis of anxiety should have been listed in Resident 11's Level I PASARR. Staff E further stated that Resident 11's Level I PASARR was not referred to the PASARR evaluator for a PASARR level II evaluation and it should have been.
On 10/16/2024 at 1:17 PM, Staff A, Health Services Administrator, stated they expected the PASARR forms to be accurate. Staff A further stated that Resident 11's most current Level I PASARR form should have had a diagnosis of anxiety marked in the SMI section and that it should had been sent to the PASARR evaluator for a PASARR level II evaluation upon completion.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 6
Resident 6 admitted to the facility on [DATE].
Review of Resident 6's physician orders printed on 10/15/2024, showed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 6
Resident 6 admitted to the facility on [DATE].
Review of Resident 6's physician orders printed on 10/15/2024, showed an order for a medication for depression [persistent feeling of sadness, loss, anger, or frustration that interferes with everyday life]) 50 milligram (mg-unit of measurement) tablet by mouth in the morning dated 08/15/2024.
Review of Resident 6's antidepressant medication care plan, revised on 08/27/2024 did not show there were target behaviors and non-pharmacological interventions identified and/or listed in the care plan.
In an interview on 10/16/2024 at 10:18 AM, Staff B stated they expected target behaviors and non-pharmacological interventions for Resident 6 to be in place and that they should have been included in Resident 6's antidepressant medication care plan when the antidepressant medication was started.
Reference: (WAC) 388-97-1020 (1) (2)(a)(3)
Based on interview and record review, the facility failed to develop and implement care plans for 3 of 8 residents (Residents 14, 2 & 6), reviewed for comprehensive care plan. The failure to implement care plans for Activities of Daily Living (ADL), use of medication to reduce swelling, and use of psychoactive [mind-altering] medication to include target behaviors and non-pharmacological interventions placed the residents at risk for unmet care needs and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Comprehensive Resident Centered Care Plans, revised on 02/09/2024, showed the facility must develop and implement a comprehensive person-centered care plan for each resident . that includes measurable objections and periods to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.
Review of the facility's policy titled, Policy and Procedure - Psychoactive Drug use, revised on 07/01/2024, showed, Care plan documentation will include measures to monitor, avoid and prevent decline in function and a plan to attempt other alternatives . Each resident's behavior monitoring record will be identifying the specific symptoms for which the drug is being used . Documentation of the behaviors will be quantitative and objective.
ACTIVITIES OF DAILY LIVING
RESIDENT 2
Review of the face sheet showed that Resident 2 was admitted to the facility on [DATE].
Review of the quarterly Minimum Data Set (MDS - an assessment tool) dated 08/09/2024 showed Resident 2 had severe cognitive impairment and required total assist with showering/bathing.
Review of the ADL care plan printed on 10/10/2024, showed Resident 2's showers were scheduled for twice a week on Tuesdays and Fridays. The care plan further showed that hospice [a type of end -of-life care that provides comfort, dignity, and peace for people who are dying] services would provide Resident 2 a shower/bath every Monday morning.
Review of the facility provided undated and untitled document, showed that room [ROOM NUMBER] (Resident 2's room) was scheduled for a shower on Mondays and Fridays. Further review of the undated document showed that the hospice bath aide would come every Monday to provide shower to Resident 2.
Review of the July 2024 to September 2024 Documentation Survey Report [documentation for shower/bath], showed Resident 2 received showers on 07/03/2024 (Wednesday) and 07/12/2024 (Friday). The document further showed that Resident 2 did not receive any showers in August 2024 and received one shower on 09/27/2024. Further review of the document showed no documentation to show Resident 2's refusals for shower.
On 10/10/2024 at 10:55 AM, Collateral Contact 1 (CC1) stated that Resident 2 received one shower a week for 10 consecutive weeks. CC1 mentioned that when they reported their concern to the nurse manager [Staff C, Assistant Director of Nursing], the manager responded that they had instructed the aides to offer one shower a week.
In an interview on 10/14/2024 at 1:12 PM, Staff K, Certified Nurse Assistant (CNA), stated that Resident 2 required total assist with showering/bathing.
In an interview and joint record review on 10/15/2024 at 3:01 PM, Staff D stated that Resident 2 was scheduled for two showers a week. A joint record review with Staff D showed Resident 2 received showers on 07/03/2024 and 07/12/2024 for the month of July 2024, did not receive any showers in August 2024, and received one shower on 09/27/2024 for the month of September 2024. Staff D stated that Resident 2 should have received two showers a week and that the care plan should have been followed.
In an interview and joint record review on 10/15/2024 at 10:21 AM, Staff C, stated that Resident 2's shower schedule was initially for Tuesdays and Fridays but was recently changed to Mondays and Fridays. Staff C stated, It seems that while the resident had been receiving showers, the NACs [CNAs] have not documented it properly. Staff C further stated that there was no documentation that showers were provided twice a week.
A joint record review and interview on 10/16/2024 at 12:01 PM with Staff B, Director of Nursing, showed that Resident 2 received two showers in July 2024, no showers in August 2024, and one shower in September 2024. When asked if the care plan was followed, Staff B stated it was not and it should have been followed.
USE OF MEDICATIONS
RESIDENT 14
Review of the face sheet showed Resident 14 admitted to the facility on [DATE].
Review of Resident 14's September 2024 Medication Administration Record showed an order for a diuretic (helps to reduce fluid buildup [edema or swelling] in the body) medication 1 milligram (unit of measurement) take three tablets by mouth twice a day for edema that started on 09/19/2024.
Review of Resident 14's comprehensive care plan printed on 10/14/2024, did not show a care plan for diuretic use.
Observations on 10/11/2024 at 9:23 AM and on 10/14/2024 at 10:17 AM, showed Resident 14 had swelling to both legs.
In an interview on 10/15/2024 at 3:01 PM, Staff D, Resident Care Manager/Minimum Data Set [Assessment] Coordinator, stated that Resident 14 had been on diuretic medication for edema since 09/19/2024. Staff D stated that a diuretic care plan was just added on 10/15/2024.
In an interview and joint record review on 10/15/2024 at 10:21 AM, Staff C stated that residents on diuretic medication needed a care plan when they started using it. A joint record review with Staff C showed that Resident 14's care plan for diuretic use was developed on 10/15/2024. Staff C stated that the care plan should have been developed immediately after the medication was started [09/19/2024].
On 10/16/2024 at 12:01 PM, Staff B stated that they were aware Resident 14 was on a diuretic medication. Staff B stated that they expected a care plan was developed as soon as Resident 14 started using diuretics.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise a comprehensive care plan for 1 of 10 residents (Resident 11...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise a comprehensive care plan for 1 of 10 residents (Resident 11), reviewed for care plan revision. The failure to revise the care plan for use of a diuretic (reduce swelling/fluid buildup in the body) and psychoactive [mind-altering] medications placed the resident at risk for unmet care needs and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Comprehensive Resident Centered Care Plans, revised on 02/09/2024, showed that care plans should be reviewed and revised after each assessment comprehensive and quarterly. The policy further showed that the facility was to update care plans upon change in planned interventions, new diagnosis, and new medications.
Review of the facility's policy titled, Psychoactive [chemicals that change the brain and can alter mood, perception, or behavior] Drug Use, revised on 07/01/2024, showed that each resident with a potential need for a psychoactive drug and/or currently receiving a psychoactive drug will be assessed upon admission and according to resident condition. Care plan documentation will include measures to monitor, avoid and prevent decline in function and a plan to attempt other alternatives as the team deems appropriate.
Resident 11 admitted to the facility on [DATE].
Review of the physician orders printed on 10/11/2024, showed Resident 11 had an order for a diuretic medication that started on 08/06/2024 and an order for antipsychotic [min-altering] medication that started on 08/03/2024.
Review of the care plan printed on 10/11/2024, showed Resident 11 had no care plan for use of diuretic medication. Further review of the care plan did not show non-pharmacological interventions were in place for antipsychotic medication use.
A joint record review and interview on 10/16/2024 at 10:29 AM with Staff D, Resident Care Manager/Minimum Data Set [Assessment] Coordinator showed Resident 11's had no care plan for diuretic medication. Staff D stated that Resident 11 should have had a care plan for diuretic use.
On 10/16/2024 at 11:31 AM, Staff C, Assistant Director of Nursing, stated Resident 11 should have had a care plan for use diuretic medication. Staff C further stated that Resident 11 should have had non-pharmacological interventions for their targeted behaviors in their physician orders for staff to monitor and document in the medication administration record, and that it should have been care planned.
On 10/16/2024 at 11:53 AM, Staff B, Director of Nursing, stated they expected diuretic medication and non-pharmacological interventions for Resident 11's targeted behaviors be care planned.
Reference: (WAC) 388-97-1020 (2)(a)(5)(b)
.
CONCERN
(D)
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 interview and record review, the facility failed to provide necessary assistance with showering/bathing for 1 of 2 resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide necessary assistance with showering/bathing for 1 of 2 residents (Resident 2), reviewed for Activities of Daily Living (ADL). This failure placed the resident at risk for unmet care needs, and a diminished quality of life.
Findings included .
Review of the face sheet printed on 10/10/2024 showed Resident 2 admitted to the facility on [DATE].
Review of the quarterly Minimum Data Set (MDS - an assessment tool) dated 08/09/2024 showed Resident 2 had severe cognitive impairment and required total assist with showering/bathing.
Review of the ADL care plan printed on 10/10/2024, showed Resident 2's showers were scheduled twice a week on Tuesdays and Fridays. The care plan further showed that hospice [a type of end -of-life care that provides comfort, dignity, and peace for people who are dying] services would provide Resident 2 a shower/bath every Monday morning.
Review of the facility provided undated and untitled document, showed that room [ROOM NUMBER] (Resident 2's room) was scheduled for a shower on Mondays and Fridays. Further review of the undated document showed that the hospice bath aide would come every Monday to provide shower to Resident 2.
Review of the July 2024 to September 2024 Documentation Survey Report [documentation for shower/bath], showed Resident 2 received showers on 07/03/2024 (Wednesday) and 07/12/2024 (Friday). The document further showed that Resident 2 did not receive any showers in August 2024 and received one shower on 09/27/2024. Further review of the document showed no documentation to show Resident 2's refusal for shower.
On 10/10/2024 at 10:55 AM, Collateral Contact 1 (CC1) stated that Resident 2 received one shower a week for 10 consecutive weeks. CC1 mentioned that when they reported their concern to the nurse manager [Staff C, Assistant Director of Nursing/Infection Preventionist], the manager responded that they had instructed the aides to offer one shower a week.
On 10/14/2024 at 1:12 PM, Staff K, Certified Nurse Assistant (CNA), stated that Resident 2 required total assist with bathing.
In an interview and joint record review on 10/15/2024 at 3:01 PM, Staff D, Resident Care Manager/MDS Coordinator, stated that Resident 2 was scheduled for two showers a week. A joint record review with Staff D showed Resident 2 received showers on 07/03/2024 and on 07/12/2024 for the month of July 2024, did not receive any showers in August 2024, and received one shower on 09/27/2024 for the month of September 2024. Staff D stated that Resident 2 should have received two showers a week.
In an interview and joint record review on 10/15/2024 at 10:21 AM, Staff C, stated that Resident 2's shower schedule was initially for Tuesdays and Fridays but was recently changed to Mondays and Fridays. Staff C stated, It seems that while the resident had been receiving showers, the NACs [CNAs] have not documented it properly. Staff C further stated that they believed Resident 2 had received more showers than what it was documented but was not able to provide documentation.
A joint record review and interview on 10/16/2024 at 12:01 PM with Staff B Director of Nursing, showed that Resident 2 received two showers in July 2024, no showers in August 2024, and one shower in September 2024. Staff B stated, that cannot be true because Resident 2 was receiving more showers than that. Staff B further added, It seems there is an issue with documentation. [If there was] no documentation, we have lost the battle.
Reference: (WAC) 388-97-1060 (2)(c)
.
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 interview and record review, the facility failed to ensure consistent communication and collaboration of care occurred ...
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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 consistent communication and collaboration of care occurred between the facility and hospice care for 1 of 1 resident (Resident 2), reviewed for hospice services. In addition, the facility failed to ensure adverse side effects for diuretic medication (that helps with edema [swelling] to reduce fluid buildup in the body) use and monitoring of edema were conducted for 1 of 1 resident (Resident 11), reviewed for unnecessary medications. These failures placed the residents at risk for not receiving necessary comfort care services, unmet care needs, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Nursing Services - Hospice, revised on 02/13/2024, showed that the facility would ensure all documentation of hospice visits were completed according to the state and federal regulations.
Review of the face sheet printed on 10/10/2024 showed Resident 2 admitted to the facility on [DATE].
Review of the nursing progress notes dated 08/15/2024, showed that the Resident 2's hospice referral was made on 08/15/2024.
Review of Resident 2's Electronic Health Records (EHR and paper charting) did not show documentation of hospice care referral order and/or hospice visit notes.
In an interview and joint record review on 10/15/2024 at 3:01 PM with Staff D, Resident Care Manager/Minimum Data Set [Assessment] Coordinator, stated that Resident 2 was receiving hospice services. A joint record review of the EHR showed there was no documentation of hospice care referral order and/or hospice visit notes. Staff D stated that the hospice referral order and/or the hospice notes should have been in Resident 2's EHR.
In an interview and joint record review on 10/15/2024 at 3:38 PM with Staff F, Medical Records Coordinator, stated that the order for hospice service and visit notes should have been in Resident 2's EHR. A joint record review showed no documentation of the hospice care referral order and/or hospice visit notes. Staff F stated that if the records were not in Resident 2's EHR, it meant that the hospice agency did not send them to the facility.
In an interview and joint record review on 10/15/2024 at 10:21 AM with Staff C, Assistant Director of Nursing, stated that Resident 2 received hospice services since 08/19/2024. A joint record review of Resident 2's EHR showed no documentation of hospice care referral order and/or hospice visit notes. Staff C stated that they expected the order for hospice care and visit notes documented in Resident 2's EHR.
In an interview on 10/15/2024 at 3:17 PM, Staff E, Social Services Coordinator, stated that they coordinated communication between the hospice agency and the facility. Staff E further stated that the hospice care order and/or visit notes should have been in Resident 2's EHR.
In an interview on 10/16/2024 at 12:01 PM with Staff B, Director of Nursing, stated that there was verbal communication between the facility and hospice agency staff. Staff B further stated that there should have been both verbal and written communication to coordinate care between the facility and hospice.
USE OF DIURETIC MEDICATION/EDEMA MONITORING
Review of the facility's policy titled, Medication Administration, revised on 04/11/2024, showed that medications were administered by licensed nurses in accordance with professional standards of practice.
Review of the face sheet printed on 10/11/2024, showed Resident 11 admitted to the facility on [DATE].
Review of the physician orders printed on 10/11/2024, showed Resident 11 had an order for a diuretic medication that started on 08/06/2024. Further review of the physician order did not show Resident 11 was being monitored for adverse side effects related to the use of diuretic medication and/or monitoring of edema.
A joint record review and interview on 10/16/2024 at 10:29 AM with Staff D showed Resident 11's physician orders had a diuretic medication order that started on 08/06/2024. Staff D stated that there should have been an order to monitor the adverse side effects for use of diuretic medication and monitoring of edema. Staff D further stated that the order should have had a documentation of the specific location of the edema.
On 10/16/2024 at 11:31 AM, Staff C stated that Resident 11 should have had an order for monitoring the side effects of the diuretic medication and edema for staff to monitor and document in the medication administration record.
On 10/16/2024 at 11:53 AM, Staff B stated that they expected diuretic medication side effects and edema were monitored.
Reference: (WAC) 388-97-1060 (1)(3)(k)(4)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure target behaviors and non-pharmacological interventions were ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure target behaviors and non-pharmacological interventions were identified and monitored for residents receiving psychotropic medications (drugs that affects how the brain works, and causes changes in mood, awareness, thoughts, feelings or behavior) for 2 of 5 residents (Residents 6 & 11), reviewed for unnecessary medications. This failure placed the residents at risk for receiving unnecessary medications, adverse side effects, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Policy and Procedure - Psychoactive (chemicals that change the brain and can alter mood, perception, or behavior) Drug use, revised on 07/01/2024, showed, Assessment will include the medical symptoms and specific conditions necessitating need for the drug, results of behavior monitoring and interventions .Each resident's behavior monitoring record will be identifying the specific symptoms for which the drug is being used .Documentation of the behaviors will be quantitative and objective.
RESIDENT 6
Resident 6 admitted to the facility on [DATE].
Review of Resident 6's physician orders printed on 10/15/2024, showed an order for an antidepressant medication 50 milligrams (mg-unit of measurement) tablet by mouth in the morning for depression [persistent feeling of sadness, loss, anger, or frustration that interferes with everyday life]). Further review of the physician orders showed Resident 6 started on the antidepressant medication on 08/15/2024.
Review of Resident 6's October 2024 Medication Administration Record (MAR) printed on 10/15/2024, did not show target behaviors were identified and/or monitored. Further review of the MAR did now show non-pharmacological interventions and monitoring were in place.
Joint record review and interview on 10/15/2024 at 9:19 AM with Staff C, Assistant Director of Nursing, showed Resident 6's physician orders did not have non -pharmacological interventions identified and/or monitored. Staff C stated, I don't see it, it's supposed to be in the [Physician] orders. Further review of the physician orders showed Resident 6 had an order written to monitor target behaviors on 10/15/2024. Staff C stated Resident 6 did not have target behaviors identified and/or monitored and that they updated Resident's 6's physician orders to include target behaviors related to the antidepressant medication, starting on 10/15/2024. Staff C then stated their expectation was for the facility to monitor target behaviors and non-pharmacological interventions for residents on psychotropic medication.
In an interview on 10/16/2024 at 10:18 AM, Staff B, Director of Nursing, stated they expected target behaviors and non-pharmacological interventions for Resident 6 to be in place and that they should have been monitored in the MAR when the antidepressant medication was started.
RESIDENT 11
Review of the face sheet printed on 10/11/2024, showed Resident 11 admitted to the facility on [DATE].
Review of the physician orders printed on 10/11/2024 showed Resident 11 had an order for an antipsychotic [mind altering] medication for dementia (memory loss) with combative behaviors that started on 08/03/2024.
A joint record review and interview on 10/16/2024 at 10:32 AM with Staff D, Resident Care Manager/ Minimum Data Set [Assessment] Coordinator, did not show Resident 11 had non-pharmacological interventions for their targeted behaviors identified and/or monitored in the physician order. Staff D stated Resident 11's non-pharmacological interventions should have been identified in the care plan and/or monitored in the MAR.
Joint record review and interview on 10/16/2024 at 11:45 AM with Staff C showed Resident 11's physician orders did not have non-pharmacological interventions or monitoring in place. Staff C stated they expected non-pharmacological interventions specific to targeted behaviors were in Resident 11's MAR from when the antipsychotic medication was started.
On 10/16/2024 at 11:53 AM, Staff B stated they expected non-pharmacological interventions for Resident 11 to be in place and that they should have been monitored in the MAR when the antipsychotic medication was started.
Reference: (WAC) 388-97-1060 (3)(k)(i)(4)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to appropriately label and store drugs and/or biological...
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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 appropriately label and store drugs and/or biologicals for 1 of 1 medication refrigerator, reviewed for medication storage. This failure placed the residents at risk for receiving compromised and/or ineffective medications.
Findings included .
Review of the facility's policy titled, Controlled Substance Storage, dated [DATE], showed that the facility's pharmacy recommended the best practice for storage for schedule II-V medications and other medications subject to abuse or diversion was in a permanently affixed, double-locked compartment separate from all other medications.
Review of the facility's policy titled, Medication Storage in the Facility: Storage of Medications, revised on [DATE], showed that the facility should verify the refrigerator or freezer in which vaccines were stored was maintained at the outlined temperature range, at least two times a day, per the Centers of Disease Control and Prevention guidelines.
Review of the facility's policy titled, Specimen [biological material taken for testing] Collection and Storage, revised on [DATE], showed that the staff will be educated on the proper storage of specimens, ensuring proper infection control practices are used. It further showed that storage of collected specimens were preferably kept in a separate area away from medications, that a separately marked refrigerator may be used for specimens that may be held until picked up by or transported to a lab for testing.
NARCOTIC BOX IN THE MEDICATION REFRIGERATOR
In a joint observation and interview on [DATE] at 9:37 AM with Staff H, Licensed Practical Nurse, showed an unlocked medication refrigerator was in the medication room. Further observation showed there was a locked narcotic box that was not permanently affixed to the medication refrigerator. Staff H stated the narcotic box was not permanently affixed to the medication refrigerator and that there were controlled substances stored inside it.
A joint observation and interview on [DATE] at 10:30 AM with Staff C, Assistant Director of Nursing, showed liquid Ativan (or Lorazepam - a medication used to manage anxiety disorders [a mental health condition that causes people to experience excessive and persistent worry that interferes with their daily lives]) prescribed to Resident 3 was stored inside the narcotic box within the unlocked medication refrigerator. Staff C stated their pharmacy delivered the narcotic box as a separate locked box and that it was not permanently affixed to the inside of the medication refrigerator.
On [DATE] at 9:51 AM with Staff B, Director of Nursing, stated that the narcotic box was not permanently affixed to their medication refrigerator and that the medication refrigerator was not locked. Staff B further stated they expected controlled substances to be stored safely in a storage unit in accordance with requirements.
SPECIMEN STORAGE IN MEDICATION REFRIGERATOR
Joint observation and interview on [DATE] at 9:37 AM with Staff H, showed there was a specimen tube of plasma (the liquid part of blood) stored in the medication refrigerator's freezer. Staff H stated specimens should not be stored in the medication refrigerator because it was unsanitary.
Joint observation and interview on [DATE] at 10:00 AM with Staff C, showed the plasma specimen found in the medication refrigerator was moved to the specimen refrigerator located inside the soiled utility room by staff H. Staff H stated that the plasma specimen should not have been there [in the medication refrigerator].
On [DATE] at 9:51 AM, Staff B stated the facility's procedure for specimen collection and storage was that collected specimens were placed in the specimen refrigerator located in the soiled utility room. Staff B further stated they would not expect any specimen collected to be stored in the medication refrigerator including the freezer and that they [staff] should not be mixing [medications and specimens].
VACCINE STORAGE
A joint observation on [DATE] at 9:37 AM with Staff H, showed there was an [unexpired] pneumococcal vaccine (protects against bacterial infections that can cause serious illness) that was dispensed (prepared and distributed by the facility's pharmacy) on [DATE], stored in the medication fridge.
Review of the facility's [DATE] refrigerator temperature log for the medication refrigerator, showed Refrigerator temperature should be monitored twice a day if vaccines are present.
A Joint record review and interview on [DATE] at 10:58AM with Staff C, showed the [DATE] medication refrigerator log was not checked a second time on [DATE] through [DATE] and on [DATE]. Staff C stated they expected that staff followed the facility's policies and procedures to check the temperature log for the medication refrigerator twice daily.
On [DATE] at 9:51 AM, Staff B stated they expected that staff followed the facility's policy and procedures for the proper storage of vaccines.
Reference: (WAC) 388-97-1300 (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
Based on observation, interview, and record review, the facility failed to ensure glucometers (portable device used to measure blood sugar) were disinfected properly for 2 of 2 residents (Residents 16...
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Based on observation, interview, and record review, the facility failed to ensure glucometers (portable device used to measure blood sugar) were disinfected properly for 2 of 2 residents (Residents 168 & 14), clean insulin [medication that works by lowering levels of sugar in the blood] pen rubber seal prior to attaching a needle for 2 of 2 residents (Residents 168 & 14), and ensure Enhanced Barrier Precautions (EBP- gown and glove use to protect residents from multidrug-resistant organism [germ that is resistant to medications that treat infections]) practices were followed for 2 of 5 residents (Residents 12 & 68), reviewed for infection control. In addition, the facility failed to ensure hand hygiene practices and/or proper use of gloves were followed for 3 of 7 residents (Residents 168, 15 & 7), reviewed for medication administration, and for 2 of 2 staff (Staff J and I), reviewed for dining observations. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.
Findings included .
Review of the facility's policy titled, Glucometer Disinfection, revised on 04/01/2024, showed that the purpose for the disinfection of glucometers was to prevent transmission of blood borne diseases to residents and employees. The policy showed that the glucometers would be disinfected with a wipe pre-saturated with an EPA (Environment Protection Agency) registered healthcare disinfectant that is effective against HIV (Human Immunodeficiency Virus- a virus [a tiny infectious agents that requires a host cell to replicate and survive] that attacks the body's immune system), Hepatitis [inflammation of the liver] C and Hepatitis B Virus.
Review of the facility's policy titled, Handwashing-Hand hygiene, revised on 02/07/2024, showed hand hygiene should be performed before and after entering a resident's room, before performing invasive procedures, before and after manipulation of an IV [Intravenous - a flexible tube is inserted into a vein, to deliver medicine or fluids into the bloodstream] device before and after handling indwelling catheters [a medical device used to drain urine from the bladder], to include handling the catheter drainage bags and/or tubing. The policy further showed that the use of gloves did not replace handwashing.
Review of the facility's policy, Insulin Injection, revised 01/02/2024, showed that when attaching the pen needle, the insulin pen rubber seal must be wiped with an alcohol pad first before screwing on the pen needle onto the insulin pen. The policy further showed that gloves must be worn when administering insulin.
Review of the facility's policy titled, Enhanced Barrier Precaution, revised on 04/11/2024, showed EBP referred to a set of infection control practices that involve wearing gowns and gloves during high-contact care of residents in nursing homes. High contact resident care activities included dressing, transferring, providing hygiene, and device care or use (such as central lines, urinary catheters).
DISINFECTING GLUCOMETERS
In a joint observation and interview on 10/14/2024 at 10:44 AM, showed Staff H, Licensed Practical Nurse, was cleaning the glucometer for Resident 168 with alcohol pads. At 10:48 AM, Staff H was observed cleaning the glucometer with alcohol wipes after checking Resident 14's blood sugar. Staff H stated that they were out of Clorox [brand, disinfectant] wipes and had to use alcohol wipes to clean the glucometer.
In an interview on 10/16/2024 at 2:06 PM, Staff B, Director of Nursing, stated that the facility cleaned the glucometers with alcohol wipes and not with disinfectant wipes.
INSULIN ADMINISTRATION
RESIDENT 168
Review of the October 2024 Medication Administration Record (MAR) showed Resident 168 had an order for Insulin Lispro injection 100 units per milliliter (mL-unit of measurement) inject 8 units subcutaneously (in fatty tissue under the skin) with meals.
An observation on 10/14/2024 at 11:38 AM, showed Staff H placed a needle onto the insulin pen rubber seal without cleaning the rubber seal first. Staff H entered Resident 168's room and injected the insulin into their arm. Staff H did not perform hand hygiene and did not wear gloves when giving the insulin injection. Staff H stated they did not wear gloves when giving insulin to Resident 168.
RESIDENT 14
Review of the October 2024 MAR showed Resident 14 had an order for Insulin Lispro Injection 100 units per mL inject 6 units subcutaneously with meals.
An observation and interview on 10/14/2024 at 11:42 AM, showed Staff H placed a needle to the insulin pen without cleaning the insulin pen rubber seal. Staff H stated they did not wipe the insulin pen rubber seal because it belonged to Resident 14 and that they cleaned the surface of the pen. Staff H entered the room and administered the insulin to Resident 14. Staff H did not perform hand hygiene before and/or after entering the room and did not wear gloves to administer the insulin to Resident 14.
An interview on 10/16/2024 at 2:06 PM, Staff B stated that they [staff] should be hand sanitizing [in between tasks] and wear gloves when giving insulin injection.
ENHANCED BARRIER PRECAUTIONS
RESIDENT 12
Review of the October 2024 MAR showed Resident 12 had an order for Cefazolin [treats infections] 2 grams [unit of measure] intravenously [through a vein] every 8 hours for bacteremia [infection in the bloodstream]. The MAR further showed that the resident had a Peripherally Inserted Central Catheter (PICC-a thin flexible tube inserted into a vein) line.
An observation on 10/14/2024 at 1:48 PM, showed an EBP signage outside of Resident 12's door that directed staff to use gloves and gowns when handling a PICC line. Staff H did not put on a gown when handling Resident 12's PICC line.
On 10/16/2024 at 2:06 PM, Staff B stated that when there was an EBP precaution sign at the door and that staff were expected to wear gloves and gown.
RESIDENT 68
Observations on 10/15/2024 at 8:05 AM of Staff H and Staff L did not show they wore gowns when they provided high contact resident care activities that included repositioning, emptying the catheter bag, handling a condom (urine collection device) catheter and changing soiled reusable incontinent pad for Resident 68.
On 10/15/2024 at 8:24 AM, Staff H stated that Staff A, Health Services Administrator, had just informed them that they should be wearing a gown when care was being provided. Staff H stated that they have to improvise and that they knew they should be wearing a gown. Staff H then told Staff L they needed to wear a gown.
On 10/15/2024 at 8:30 AM, Staff H was observed connecting the IV antibiotics to Resident 68's PICC line without wearing a gown.
In an interview on 10/16/2024 at 2:06 PM, Staff B stated that they [staff] should be gowning before providing resident care [on EBP precautions].
MEDICATION PASS
RESIDENT 168
Observation on 10/14/2024 at 10:41 AM, showed Staff H was entering Resident 168's room, donned gloves, checked the resident's blood sugar level, removed the soiled gloves, and then left the room. Staff H did not do hand hygiene before entering/after leaving the room and before and after glove use.
RESIDENT 15
Another observation on 10/14/2024 10:46 AM, showed Staff H entered Resident 15's room without performing hand hygiene. Staff H was observed donning a pair of clean of gloves and then walked over to the medication cart (outside of the room) to retrieve a lancet [small needle used to make a tiny prick on the skin] from the medication cart. Staff H then removed their soiled gloves and donned a new pair. No hand hygiene was observed between glove change.
RESIDENT 7
Observation on 10/14/2024 at 10:46 AM, showed Staff H was adjusting the magnetic door holder before they entered Resident 7's room. Staff H gave Resident 7 their oral medications, picked up their breakfast tray, and carried it out of their room. Staff H closed Resident 7's door with their hand and left the room. Staff H did not perform hand hygiene before entering or after leaving the resident's room.
In an interview on 10/14/2024 at 2:20 PM, Staff H stated that they were to use gloves during resident care, when checking blood sugars, and administering injections. Staff H stated that the appropriate times to sanitize their hands was when they remove their gloves and when they exit the resident's room.
In an interview on 10/16/2024 at 2:06 PM, Staff B stated that they [staff] should be hand sanitizing, then gloving and gowning before providing resident care.
An interview on 10/16/2024 at 1:56 PM, Staff A stated that hand hygiene should have been done before and after resident's care and between gloving.
An interview on 10/16/2024 at 2:06 PM, Staff B stated that they [staff] should be hand sanitizing [do hand hygiene in between tasks (and between glove change) for Residents 168, 15 & 7].
DINING ROOM OBSERVATION
STAFF J
Observations on 10/10/2024 at 12:16 PM and on 10/14/2024 at 11:51 AM, showed Staff J, CNA, was holding a sandwich with their bare hands and brought it up to Resident 11's mouth.
On 10/16/2024 at 8:43 AM, Staff J stated they used their bare hands to hold Resident 11's sandwich when assisting them with eating and that their hands were clean. Staff J further stated they did not know they needed to wear gloves prior to touching Resident 11's food.
MEAL TRAY PASS OBSERVATION
STAFF I
On 10/11/2024 at 11:34 AM, Staff I, CNA, was observed delivering meal trays to residents' room from a meal rolling cart. Staff I delivered Resident 10's lunch to their side table, moved the side table closer to the resident, and left their room without performing hand hygiene. Staff I then delivered Resident 5's lunch to their side table, Staff I moved Resident 5's trash can to their left side, uncovered the plate and pushed it closer to the resident, touched Resident 5's shoulder, then donned gloves to cut resident's quesadilla with utensils, and left the room. Staff I, then went to the dining room, took a meal tray, delivered it to Resident 7's side table, and left the room. Staff I did not perform hand hygiene before entering and/or after leaving the room for Residents 10, 5 and 7.
On 10/11/2024 at 11:49 AM, Staff I stated that hand hygiene should have been performed before entering and after leaving Residents 10, 5, and 7's room. Staff I further stated that hand hygiene should be performed before serving lunch, after providing resident care, and when they touched the resident or their environment.
On 10/16/2024 at 8:53 AM, Staff H stated that it was not okay for staff to touch the resident's food with their bare hands and that gloves should have been worn. Staff H further stated that staff [Staff I] should have performed hand hygiene before entering and after leaving residents' room, after touching the resident and their environment, and after removing their [used/soiled] gloves.
On 10/16/2024 at 9:24 AM, Staff C stated that Staff J should not have touched Resident 11's food with their bare hands. Staff C further stated they expected staff to perform hand hygiene before entering and after leaving the residents' room, after providing care, after removing soiled gloves, and after touching the residents' and their environment.
On 10/16/2024 at 11:25 AM, Staff B stated that Staff J should not have touched Resident 11's food with their bare hands and that they should have used a fork or gloves when assisting the resident with their meals. Staff B further stated that Staff I should have performed hand hygiene prior to entering/after leaving the rooms for Residents 10, 5 and 7, and after touching the residents' and their environment.
Reference: (WAC) 388-97-1320 (1)(a)(c)(5)(c)
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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
Based on observation, interview, and record review, the facility failed to ensure foods stored were labeled/dated and discarded after the expiration date or use by date in accordance with professional...
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Based on observation, interview, and record review, the facility failed to ensure foods stored were labeled/dated and discarded after the expiration date or use by date in accordance with professional standards for food safety for 2 of 2 refrigerators (Dairy Refrigerator and Main Walk-In Refrigerator) and 1 of 1 freezer (Walk-In Freezer), reviewed for food services. This failure placed the residents at risk for food borne illness [caused by the ingestion of contaminated food or beverages] and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Date Marking for Food Safety, revised on 03/01/2024, showed that the food items would be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The policy further showed, the individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared.
DAIRY REFRIGERATOR
Joint observation and interview on 10/10/2024 at 8:13 AM with Staff M, Lead Cook, showed an unopened coleslaw dressing with a manufacturer expiration date of 09/14/2024. Follow up observation on 10/15/2024 at 9:05 AM with Staff M, showed butter for bread prepared on 10/07/2024 with a use by date of 10/13/2024. Further observation showed four jugs of hollandaise sauce with no dates. Staff M stated that both the coleslaw and butter should have been discarded. Staff M stated that the hollandaise sauce came in a box with a manufacturer date on it, but they were unsure where the box was. Staff M further stated that they would need to put dates on the hollandaise sauce when they unbox and place them on the shelf.
MAIN WALK-IN REFRIGERATOR
Joint observation and interview on 10/10/2024 at 8:27 AM with Staff M, showed one opened and undated container of heavy whipping cream, and a half can of cheese with a preparation date of 09/29/2024 and a use by date of 10/04/2024. Staff M stated that the heavy whipping cream should have been dated when it was first opened, and the expired cheese should have been discarded.
WALK-IN FREEZER
Joint observation and interview on 10/10/2024 at 8:45 AM with Staff M, showed seven bags of diced carrots with use by date of 07/01/2024 and with shelf life of 10/08/2024. Staff M stated that the dates did not seem accurate, but the diced carrots were still considered good to use.
In an interview on 10/16/2024 at 2:33 PM, Staff A, Health Services Administrator, stated that it was their expectation for the kitchen staff to maintain food safety according to State and Federal guidelines. Staff A further stated that the kitchen staff should have followed the facility's food safety and storage policies.
Reference: (WAC) 388-97-1100 (3)
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was maintained to keep the facility free of fruit flies (small insects that are attr...
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Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was maintained to keep the facility free of fruit flies (small insects that are attracted to ripe, rotting, or fermenting fruits and vegetables) in the kitchen area of the facility. This failure placed residents at risk for infection, maggot infestation (small, worm like bugs that hatch from fly eggs) and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Policy and Procedure - Pest Control, revised on 01/02/2024, showed, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.
Observation on 10/15/2024 at 10:30 AM, and at 10:43 AM showed fruit flies in the dish washing and hand wash areas of the kitchen. Another observation on 10/15/2024 at 11:04 AM showed flies in the kitchen fridge area (where ready to eat cold food were stored).
During a joint observation and interview on 10/15/2024 at 11:07 AM with Staff N, Executive Chef, showed that one trash can was full and overflowing, while another trash can was unclean and had dark stains on the lid. Further joint observation showed flies on the wall near the trash can and landed on unwashed utensils that were returned from breakfast. Staff N stated that they would ensure the area was cleaned immediately and that there should have been no flies in the kitchen.
On 10/16/2024 at 11:56 AM, Staff C, Assistant Director of Nursing/Infection Preventionist, stated that there should be no insects in the kitchen as that was unacceptable.
On 10/16/2024 at 2:33 PM, Staff A, Health Services Administrator, stated that having flies in the kitchen is unacceptable and that they would arrange for the pest control team to come and inspect.
Reference: (WAC) 388-97-3360 (1)
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Oct 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure used N95 respirator/mask were discarded, disin...
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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 used N95 respirator/mask were discarded, disinfection of face shields were conducted, and use of proper N95 were followed when caring for COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) positive residents in 4 of 4 rooms (Rooms 202, 204, 206 & 208) to non-COVID positive resident in 1 of 1 room (room [ROOM NUMBER]), reviewed for infection control. This failure placed the residents at risk for facility acquired or healthcare-associated infections, and related complications.
Findings included .
Review of the Washington State Department of Health COVID-19 guidelines, dated June 2023, showed staff need to wear full Personal Protective Equipment (PPE - gown, gloves, N95 respirator/mask and eye protection/face shield) upon entering COVID-19 resident rooms for one resident encounter, then PPE was to be discarded and/or disinfect reusable PPE. Staff don (put on) new PPE prior to entering the next resident room.
Review of the Centers for Disease Control and Prevention guidelines on National Institute for Occupational Safety and Health (NIOSH) approved N95 respirators dated 08/25/2023, showed respirator labeled as a KN95 is not an approved NIOSH respiratory protective device.
Observation on 10/06/2023 at 9:24 AM, showed the facility did not have a designated COVID-19 unit or dedicated staff to take care of COVID-19 positive residents. Residents in Rooms 202, 204, 206 and 208 were positive for COVID-19, and these rooms had a special droplet/contact precaution [procedures that reduce the risk of transmission of infection] sign, instructing staff to perform hand hygiene, put on mask, eye protection, gown, and gloves prior to entering the rooms. The special droplet/contact precaution sign also included to use patient [resident] dedicated or disposable equipment, clean and disinfect shared equipment.
Observation on 10/06/2023 at 12:12 PM, showed Staff D, Certified Nursing Assistant (CNA), was delivering lunch meal trays to COVID positive residents in Rooms 204, 208 and 206. Staff D was wearing their N95 mask, face shield, gown, and gloves, and entered room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. Staff D was in close contact with the residents and assisted them with their meal tray set-up. Staff D then disposed their used gown and gloves prior to exiting room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER], but did not change their N95 mask and did not change or disinfect their face shield between delivery of meal trays in Rooms 204, 208 and 206.
On 10/06/2023 at 12:42 PM, Staff D stated they did not change their N95 or face shield unless it was soiled or if they felt uncomfortable. Staff D was asked if they also entered non-COVID rooms using the same N95 mask, Staff D stated yes.
Further observation on 10/06/2023 at 1:08 PM, showed Staff E, Licensed Practical Nurse, entered room [ROOM NUMBER] wearing their KN95 mask, face shield, gown and gloves and gave the resident their medication. Staff E removed their soiled gown, gloves, and wiped down their face shield. Staff E then walked to the medication cart and then to the bathroom without changing their KN95 mask.
On 10/06/2023 at 1:20 PM, Staff E was asked about the expectation for proper PPE removal prior to leaving the room with COVID-19 positive resident. Staff E stated they take off their gown, gloves, disinfect their face shield and change their KN95 mask. Staff E acknowledged they should have put on a new KN95 mask. Staff E also stated that they could not wear an N95 mask because it hurts.
Observation on 10/09/2023 at 11:49 AM, showed Staff F, CNA, was wearing their face shield, two layers of mask (the inner layer was a surgical mask, and the outer layer was an N95 mask), and gown and gloves. Staff F entered room [ROOM NUMBER] (the resident was COVID-19 positive) to deliver a meal tray. Staff F then disposed their soiled gown and gloves and performed hand hygiene prior to leaving room [ROOM NUMBER] but did not change their N95 mask and did not change or disinfect their face shield. Continued observation showed Staff F entered room [ROOM NUMBER] (non-COVID-19 resident) to deliver their meal tray. Staff F then entered rooms [ROOM NUMBERS] (both positive with COVID-19) without changing their N95 mask and disinfecting their face shield.
On 10/09/2023 at 12:15 PM, Staff F was asked about PPE removal process prior to leaving the residents' room positive with COVID-19. Staff F stated they dispose their gown and gloves and kept their face shield, and they need to change their mask. Staff F stated, I'm sorry I did not change it [N95]. Staff F also stated they were wearing a surgical mask as the inner layer because the N95 mask causes pain around the edges.
10/09/2023 at 1:33 PM, Staff C, Resident Care Manager, stated that when staff exit the resident's room positive for COVID-19, they should dispose of used gown and gloves, perform hand hygiene, and then wipe their face shield. Staff C also stated they received instructions from corporate that they could reuse their N95 mask if it was not visibly soiled or torn. Staff C acknowledged that staff have been wearing the same mask when providing care between COVID-19 positive residents and/or non-COVID residents. When asked about PPE shortage, Staff C stated they have enough PPE supplies. When asked about double masking, Staff C stated that staff should not be double masking because the N95 mask would not fit correctly if wearing another mask under it.
Reference: (WAC) 388-97-1320(2)(a)
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Jun 2023
24 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure fall interventions were updated, to ensure care was provided...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure fall interventions were updated, to ensure care was provided to residents at the care level they were assessed to required, and that care staff had access to fall prevention interventions for 1 of 2 resident (Resident 8) reviewed for falls. This failure caused harm to Resident 8 who fell while ambulating and experienced a fractured left humerus (long bone in the arm that runs from the shoulder to the elbow). In addition, the facility failed to ensure 1 of 1 housekeeping storage rooms, reviewed for accident hazards, was locked. These failures placed all residents at potential risk for avoidable falls, injury, unsafe exposure to potentially hazardous cleaning chemicals, and a diminished quality of life.
Findings included .
<Falls>
The Purple Book Nursing Home Reporting Guidelines, dated October 2015, showed that injuries of an unknown source, such as substantial, substantial reasonable related, and unknown superficial injuries, should be reported to the Department of Social and Health Services (DSHS) Hotline and require DSHS notification within five days. Repeated injuries, even when related to condition, may become abuse or neglect if preventive measures are not taken. All incidents require thorough investigation and reporting, as necessary, according to state and federal regulations. All such investigations attempt to determine if such injury or allegation of injury results from abuse or neglect.
Review of the facility policy titled, Fall Management, revised on 04/01/2023, showed that revisions to the care plan will be documented in the chart and communicated to caregivers. The facility will have in place a fall management protocol utilizing assessments and interventions to minimize the risk of falling for residents to reduce and prevent the number of falls and number of injuries related to falls for residents. Preventative interventions will include identifying if proper equipment is being used, identifying if other environmental factors place the resident at risk for falls and them implementing interventions based on findings.
Review of Resident 8's Electronic Medical Record (EMR) showed they were admitted to the facility on [DATE] with diagnoses that included low back pain, fracture of lower end of left humerus, difficulty in walking, edema (swelling) on both legs, and a history of left rib fractures of ribs eight to ten.
Review of Resident 8's Morse Fall Scale assessment tool [determines fall risk factors], dated 01/14/2023, showed a score of 65. A score of 45 or higher indicated the resident was considered a high fall risk.
Review of Resident 8's physician notes, dated 01/26/2023 and 04/10/2023, showed the resident had a diagnosis of recurrent falls.
Review of Resident 8's EMR, showed the resident fell on [DATE] which caused a laceration to their forehead that required sutures.
Review of Resident 8's EMR, showed Resident 8 had an unwitnessed fall on 04/07/2023 which resulted in a left arm fracture.
Review of Resident 8's self-care performance care plan, dated 02/07/2023, showed Resident 8 ambulated (walked) independently with a walker.
Review of Resident 8's quarterly Minimum Data Set (MDS, an assessment tool), dated 02/10/2023, showed Resident 8 used a walker for ambulation and required supervision of one person with transfers, supervision with set-up with walking in their room and/or in the corridor, and supervision with set-up with locomotion on unit and off unit.
Review of Resident 8's progress notes, dated 02/27/2023, showed the resident had an unwitnessed fall in the facility's Assisted Living Facility (ALF- located above the nursing facility). Review of Resident 8's Morse Fall Scale assessment, dated 02/27/2023, showed the resident had a fall risk score of 80, a high fall risk.
Review of Resident 8's care plan, showed no additional interventions were implemented for the 02/27/2023 unwitnessed fall or the increase the Morse Fall Scale assessment.
Review of Resident 8's progress noted, dated 03/17/2023, 18 days after the resident fell on [DATE], showed Staff X, former Social Services, and an ALF staff member, showed Resident 8 was spoken to regarding needing an escort (to and from) if they wished to have meals in the ALF. Review of the care plan did not reflect this new intervention.
Review of Resident 8's progress note, dated 04/07/2023, showed Resident 8 was found on the floor by the nurse's station at 7:10 AM. The note showed the resident fell while using their walker and lost their balance. Resident 8 complained of pain and was not able to move their left arm.
Review of Resident 8's physician progress note, dated 04/07/2023, showed the resident had fallen which resulted in a left humerus fracture. The resident was non-weight bearing (to place no weight on the injured arm), precautions to their left upper extremity, and had a splint (device used to protect and support broken or injured bones and joints) in place.
Review of the May 2023 incident report log form showed no documentation or the facility had reported (called) Resident 8's 04/07/2023 fall with injury to the state agency.
Review of Resident 8's fall care plan, initiated on 05/13/2021 and revised on 05/03/2023, showed a goal of will not sustain serious injury through the next review. A care plan intervention directed staff to ensure the resident wore appropriate footwear when ambulating with a walker.
In an interview on 06/16/2023 at 9:29 AM, Staff H, Certified Nursing Assistant (CNA), stated they worked regularly with Resident 8. Staff H stated that prior to Resident 8's fall in April 2023, Resident 8 walked on their own using a walker. Staff H stated they followed the residents' care plan when providing care to residents. Resident 8's care plan was reviewed with Staff H. Staff H showed a charting screen for the staff to chart on how much help the resident needed during care, there were no specifics for how much help Resident 8 required with transfers, bed mobility, toileting, ambulation, and/or eating. Staff H stated they did not know where to look for information on what kind of care they needed to provide to Resident 8. When Staff H was showed Resident 8's care plan, [under the [NAME] tab, a type of care plan-that directs CNA staff on how to provide care to a resident, Staff H stated they did not know if they had access to it.
In an interview on 06/16/2023 at 11:52 AM, Staff G, Licensed Practical Nurse (LPN), stated the amount of assistance Resident 8's required was in their care plan. Staff G accessed Resident 8's fall care plan and stated the CNAs do not have access to that care plan.
In an interview on 06/16/2023 at 12:15 PM, Staff C, Resident Care Manager (RCM)/MDS Coordinator, stated Resident 8's falls should have previous falls with interventions from each fall in it. Staff C stated that there should be a new intervention with each fall placed in the care plan. Staff C stated CNAs do not have access to the care plan, but there was a different care plan available for them to access. Staff C did not know how to access Resident 8's CNA care plan ([NAME]). Staff C stated that CNAs have access to tasks if they were attached to the [NAME] by a K' symbol next to it. Staff C stated that Resident 8's walking and transfers tasks did not have information on how much help Resident 8 needed with transfers or walking. During a joint review of Resident 8's quarterly MDS, dated [DATE], showed that Resident 8 required supervision assist with set up for transfers and ambulation in room/in corridor. Staff C sated that Resident 8 should have had supervision assist with ambulation prior to the fall on 04/07/2023. Staff C stated that supervision assist with ambulation should have been in Resident 8's care plan and that CNAs did not have access to the care plan.
In an interview on 06/16/2023 at 12:58 PM, Staff B, Director of Nursing, stated they expected to see falls included in the resident's care plan with interventions for each fall. Staff B stated, Staff C and RCM's update the resident's care plans. Staff B stated they were still in the learning process and were not able to access the CNAs documentation where they would find the fall interventions for residents.<HOUSEKEEPING STORAGE ROOM>
In an observation on 06/13/2023 at 9:18 AM, 06/13/2023 at 11:48 AM, and 06/13/2023 at 2:21 PM, showed the housekeeping storage room was closed but not locked, the door had a sign posted that stated, This door must always be kept locked. The room was observed with cleaning supplies: One home pest control spray bottle, a high-performance neutral floor cleaner bottle, restroom cleaner spray, all-purpose cleaner spray bottle, vacuum device, batteries, trash bags, wipes, and other items.
In a joint observation and interview with Staff B on 06/13/2023 at 2:21 PM, showed the housekeeping storage room door was closed but not locked and the room was observed with multiple potentially hazardous housecleaning supplies. Staff B stated they expected the housekeeping storage room door to be closed and locked.
Refer to CFR 483.12 (b)(c)(1) - F-609 Reporting of Alleged Violations for additional information.
Refer to CFR 483/12 (C)(2)(3)(4) - F-610 Investigate/Prevent/Correct Alleged Violation for additional information.
REFERENCE: WAC 388-97-1060(3)(g)
This is a repeat citation from 04/27/2022
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
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 complete a self-medication administration assessment ...
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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 complete a self-medication administration assessment for 1 of 1 resident (Resident 6) reviewed for medication at bedside. The failure to complete a self-administration medication assessment placed the resident at risk for medication errors and adverse medication interactions.
Findings included .
Review of the facility's undated policy titled, Self-Administration of Drugs, showed, resident may self-administer drugs so long as they are capable and willing to do so, and it is accomplished in such a way as to assure accurate documentation by the facility and security of the drug supply. The facility will assess the resident's capabilities, provide instructions for administration, monitor compliance with orders and progress, and will provide safe storage of drugs.
Resident 6 admitted to the facility on [DATE].
Resident 6's Medication Administration Records for June 2023 showed the following orders:
-Lidocaine (a substance used to relieve pain) ointment 5% apply to knees/hips topically every 6 hours as needed for pain, can have at bedside and self-apply. Start date 04/12/2023.
-Lidocaine ointment 5% apply to perianal (area around the anus) are topically every 6 hours as needed for pain, may leave at bedside, and self-administer. Start date 10/27/2020.
-Artificial tears solution 1-0.3% instill 2 drops in both eyes every 2 hours as needed for dry eyes. Patient [resident] can have at bedside and self-administer. Start date 06/19/2020.
-Pancrelipase (helps to break down fats, starch, and proteins in food) capsule delayed release particles 25,000-136,000 units give 3 capsules by mouth with meals for dietary supplement, okay to have pills at bedside. Start date 01/26/2023.
Review of Resident 6's medical records showed there was no assessment of self-administration medications and/or documentation of refusal prior to self-administration of medication was ordered. Further review showed that the facility completed an assessment of self-administration of medication for Resident 6 on 06/14/2023, results showed that approval granted to self-administer was checked no . resident refused to participate.
On 06/12/2023 at 12:06 PM, Resident 6 was observed preparing to eat lunch and had 2 blue capsules in a medication cup.
On 06/12/2023 at 2:31 PM, Resident 6 stated that the blue and white capsules were their pancreas (an organ located in the abdomen) medication.
On 06/15/2023 at 10:12 AM, Resident 6 stated that they did not keep the Lidocaine cream and the artificial tears in the room.
On 06/15/2023 at 11:32 AM, Staff I, Licensed Practical Nurse, stated that Resident 6 took the Pancrelipase medication on their own with meals and had an order that it was okay to leave at bedside.
On 06/15/2023 at 12:10 PM, Staff C, Resident Care Manager/Minimum Data Set - an assessment) Coordinator, stated that assessment of self-administration of medication should have been completed every 3 months and that Resident 6 had refused multiple times before. Staff C also stated that they kept the medication at the resident's bedside or drawer.
On 06/15/2023 at 2:23 PM, Staff B, Director of Nursing, stated that according to the pharmacy the self-administration of medications should be evaluated every quarter. Staff B acknowledged that they were not able to find a self-administration medication assessment for Resident 6 prior to starting self-administration of medications.
Reference: (WAC) 388-97-0440,1060 (3)(L)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 9
Resident 9 admitted to the facility on [DATE].
Review of Resident 9's Electronic Health Record on 06/14/2023, showed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 9
Resident 9 admitted to the facility on [DATE].
Review of Resident 9's Electronic Health Record on 06/14/2023, showed no documentation of the resident requesting or declining completion of an Advance Directives.
An interview on 06/15/2023 at 8:37 AM, Staff D stated that they could not find any record of Resident 9's Advance Directives in their file and that they have called the family for follow up but received no response yet. Further stated that the Advance Directive was part of the admission process for all residents coming to the facility.
On 06/15/2023 at 3:57 PM, Staff B, Director of Nursing, stated that they expected for all residents to have Advance Directive per facility policy.
Reference: (WAC) 388-97-0280 (3)(a)
Based on interview and record review, the facility failed to ensure a copy of the Advance Directives was obtained from the residents/representatives who have an Advanced Directives in place and ensure a copy was readily available in the medical records for 2 of 4 residents (Residents 10 and 9) reviewed for Advance Directives. This failure placed the residents at risk of losing their right to have their preferences and choices honored regarding emergent and end-of-life care situations.
Findings included .
An advance Directives is a written instruction, such as a Living Will or Durable Power of Attorney (DPOA), relating to the provision of health care when an individual is incapacitated.
Record review of the facility's policy titled, Resident Rights: Advanced Directives, revised on 01/01/2023, showed that each new admission will be informed of and educated regarding their right to execute Advanced Directives (i.e., Living will, DPOA, and DPOA with Health Care Provision and if necessary, have these same Directives explained to them. Residents will be informed orally and in writing of their right to execute Advance Directives.
RESIDENT 10
Resident 10 admitted to the facility on [DATE].
On 06/13/2023 at 2:43 PM, Staff D, Medical Records Coordinator, stated that Resident 10 did not have an Advanced Directives document in their medical file.
On 06/13/2023 at 3:22 PM, Resident 10's Representative (RR2) stated they were the power of attorney and had provided a copy to the facility.
On 06/15/2023 at 8:39 AM, Staff D, stated that RR2 had provided a copy of the Physician Orders for Life Sustaining Treatment (POLST) and not an Advanced Directive document. However, there was no Advanced Directives document in the resident's clinical record.
On 06/15/2023 at 3:44 PM, Staff A, Administrator, stated that Resident 10 had no Advanced Directives in their clinical record and that Advanced Directives should have been offered to Resident 10 on admission and documented in the resident's clinical record.
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 Skilled Nursing Facility - Advance Beneficiary Notices (SNF...
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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 Skilled Nursing Facility - Advance Beneficiary Notices (SNF- ABN) to 2 of 3 residents (Residents 10 & 168) reviewed for beneficiary notifications. The failure to provide residents the information regarding changes in their Medicare services, including potential financial liability and appeal rights, deterred residents from exercising their right to decide on continuation of skilled services and costs associated, as required by the Medicare Program.
Findings included .
Record review of the facility's policy titled, Beneficiary Notice Policy, revised on [DATE], showed that it is the facility's policy to notify and explain that the individual is no longer receiving Medicare Part A services on the facility belief that Medicare A will not pay for the resident's stay.
RESIDENT 10
Review of Resident 10's undated SNF Beneficiary Protection Notification Review, completed by the facility staff showed Medicare Part A services started on [DATE], and an end of coverage on [DATE]. The form showed the SNF-Advance Beneficiary Notice was not provided to Resident 10 or their representative as stated, Pt (patient [resident]) was supposed to discharge (DC) to Assisted Living (AL) and decided to stay.
Review of Resident 10's medical record showed they remained in the facility after Medicare benefits ended and continued to stay at SNF for long term care. The medical record did not contain a SNF-Advance Beneficiary Notice issued or signed by Resident 10 or their representative to inform of financial liability for non-covered services.
RESIDENT 168
Review of Resident 168's undated SNF Beneficiary Protection Notification Review completed by the facility staff showed Medicare Part A services started on [DATE], and the end of coverage was on [DATE]. The form showed that SNF-Advanced Beneficiary Notice was not provided to Resident 168 or their representative.
Review of Resident 168's medical record showed that resident remained in SNF/facility after the end of their last covered day and died in facility on [DATE]. Further review showed that no SNF-Advance Beneficiary Notice were issued or signed by Resident 168 or their representative to inform of financial liability for non-covered services.
During an interview on [DATE] at 1:21 PM, Staff D, Medical Records Coordinator, stated that the social worker was responsible for issuing the SNF-Advance Beneficiary Notice. The facility currently had no Social Worker available to be interviewed. Staff D stated that no SNF-Advance Beneficiary Notice issued by the facility during the change in coverage for both residents, Resident 10 and/or their representative and Resident 168 and/or their representative.
On [DATE] at 3:40 PM, Staff A, Interim Director of Health Services, stated that a SNF-Advance Beneficiary Notice should be given for residents who remained in the facility after their skilled coverage ends. Staff A stated that a SNF-Advance Beneficiary Notice should have been issued for Resident 10 and Resident 168 after the end of their skilled nursing coverage.
Reference: (WAC) 388-97-0300 (1)(e)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report a fall with substantial injury to the State agency within 24...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report a fall with substantial injury to the State agency within 24 hours for 1 of 1 (Resident 8) reviewed for reporting. This failure placed the residents at risk for abuse and neglect.
Findings included .
Review of the facility policy titled, Abuse/Neglect, revised on 12/08/2023, showed that all suspected abuse, alleged, or actual cases of resident abuse, including injuries of unknown origin, shall be thoroughly and completely investigated, and reported according to the State and Federal regulations.
According to the Nursing Home Guidelines The Purple Book, dated October 2015, in the Reporting Guidelines for Nursing Homes, showed that injuries of unknown source such as substantial, substantial reasonable related, and unknown superficial injuries should be reported to the Department of Social and Health Services (DSHS) Hotline and require DSHS Log within 5 days. Repeated injuries, even when related to condition, may become abuse or neglect if preventive measures are not taken. All incidents require thorough investigation and reporting, as necessary, according to state and federal regulations. All such investigations attempt to determine if such injury or allegation of injury results from abuse or neglect.
Resident 8 admitted to the facility on [DATE].
Review of Resident 8's Electronic Medical Records showed that Resident 8 had a fall on 04/07/2023 that caused them a broken left humerus (long bone in the arm that runs from the shoulder to the elbow).
Review of the May 2023 incident reporting log form showed no documentation of Resident 8's fall with injury on 04/07/2023.
On 06/15/2023 at 4:23 PM, Staff B, Director of Nursing, stated that they follow the purple book for incident completion and reporting. Staff B stated that Resident 8's fall incident was not logged in the incident reporting log form within five days of its occurrence and that it should have been reported to the State since Resident 8 had a fall with injury.
Refer to F610 Investigate/Prevent/Correct Alleged Violation for additional information.
Reference: (WAC) 388-97-0640 (5)(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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a thorough investigation for a fall with substantial injur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a thorough investigation for a fall with substantial injury for 1 of 1 (Resident 8) reviewed for falls. This failure placed the residents at risk for abuse and neglect.
Findings included .
Review of the facility policy titled, Abuse/Neglect, revised on 12/08/2023, showed that all suspected abuse, alleged, or actual cases if resident abuse, including injuries of unknown origin, shall be thoroughly and completely investigated, and reported according to the State and Federal regulations.
The Nursing Home Guidelines, The Purple Book, dated October 2015, showed that facilities are required to report substantial injuries to the State Agency within 24 hours and that substantial injuries of unknown source must be thoroughly investigated. Injuries of unknown source means any injury sustained by a resident where the source of the injury was not observed directly by a staff person. Substantial injuries of unknown source include injuries that are more than superficial. Substantial injuries require more than first aid and may require close assessment and monitoring by nursing or medical staff.
Resident 8 admitted to the facility on [DATE]. Review of Resident 8's Electronic Medical Records showed that Resident 8 had a fall on 04/07/2023 that caused them a broken left humerus (long bone in the arm that runs from the shoulder to the elbow).
Review of the facility document titled, Reporting Log Form, from January 2023 to June 2023, showed that Resident 8's fall that occurred on 04/07/2023 was not logged, nor that it was reported to the State authorities as required.
On 06/15/2023 at 4:23 PM, Staff B, Director of Nursing (DON), stated that they follow the purple book for incident completion and reporting. Staff B stated that Resident 8's fall incident was not investigated and/or completed. Additionally, Staff B stated that they had not been the DON at that time.
Refer to F609 Reporting of Alleged Violations for additional information.
Reference: (WAC) 388-97-0640 (6)(a)(b)
.
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 conduct a timely Significant Change in Status Assessment (SCSA) Min...
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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 timely Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) assessment for 1 of 2 residents (Resident 5) reviewed for significant change in status assessment. The failure to complete a significant change in status assessment within 14 days placed the resident at risk for unmet care needs and a diminished quality of life.
Findings included .
Review of the Long-Term Care Resident Assessment Instrument (RAI) dated October 2019, under Section 5.2 Timeliness Criteria, showed Significant Change in Status Assessment must be completed no later than 14 days from the determination date of the significant change in status. A significant change means a major decline in status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident(s) health status.
An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) 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.
RESIDENT 5
Resident 5 admitted to the facility on [DATE].
Review of Resident 5's Electronic Health Records (EHR) showed Resident 5 admitted to hospice services on 03/27/2023. Further review of Resident 5's SCSA MDS assessment dated [DATE], showed it was completed on 04/11/2023 (1 day late).
On 06/14/2023 at 3:45 PM, a joint record review of Resident 5's SCSA MDS assessment with Staff C, showed it was completed on 04/11/2023. Staff C stated that Resident 5's SCSA MDS assessment was not completed timely.
Reference: (WAC) 388-97-1000(3)(b)
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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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 5
Resident 5 admitted to the facility on [DATE].
Review of Resident 5's EMR showed that they had a significant change ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 5
Resident 5 admitted to the facility on [DATE].
Review of Resident 5's EMR showed that they had a significant change in status MDS assessment dated [DATE] was completed on [DATE] (1 day late), and it transmitted on [DATE] (6 days late).
On [DATE] at 3:45 PM, a joint record review of Resident 5's significant change in status MDS assessment with Staff C showed that it was completed and transmitted late. Staff C stated that Resident 5's MDS assessment was not transmitted timely.
Reference: (WAC) 388-97-1000 (5)(a)(e)(iii)
Based on record review and interview, the facility failed to complete and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframes for 2 of 11 residents (Residents 2 & 5) whose Minimum Data Set (MDS - an assessment tool) were reviewed for timeliness in completion and transmission/submission. The failure to ensure timely completion and transmission of MDS assessments and tracking records placed the residents at risk for unmet care needs and a diminished quality of life.
Findings included .
According to the Resident Assessment Instrument (RAI)/Minimum Data Set (MDS) Manual, dated [DATE], All Medicare [national health insurance program] and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS's Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. Required MDS records are those assessments and tracking records that are mandated under OBRA [Omnibus Budget Reconciliation Act - a federal law, also known as Nursing Home Reform Act] and SNF [Skilled Nursing Facility] PPS [Prospective Payment System - payment methodologies for insurance reimbursement].
Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days), as required. All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days).
Death in Facility tracking records, information must be transmitted within 14 days of the Event Date (A2000 + 14 days for Death in Facility records).
RESIDENT 2
Resident 2 admitted to the facility on [DATE].
Review of Resident 2's Electronic Medical Record (EMR) showed the resident died in the facility on [DATE]. Review of the MDS tab - tracking report, showed that Resident 2 had a completed Death in Facility (DIF) MDS assessment with an ARD of [DATE]. The DIF tracking record was not submitted to the CMS System within 14 days as required.
During an interview on [DATE] at 3:25 PM, Staff C, Resident Care Manager/MDS Coordinator, stated that Resident 2's DIF MDS assessment was not transmitted timely as required.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 13
The RAI Manual defined pressure ulcer stage 2 as partial thickness loss of dermis (thicker layer of the skin - layer...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 13
The RAI Manual defined pressure ulcer stage 2 as partial thickness loss of dermis (thicker layer of the skin - layer underneath the outermost layer of skin) presenting as a shallow open ulcer with a red or pink wound bed, without a slough (a layer of dead tissue separated from surrounding living tissue). May also present as an intact or open/ruptured blister.
Resident 13 admitted to the facility on [DATE] with hospice services and a primary diagnosis of malignant neoplasm of right kidney (cancer of the right kidney).
PRESSURE ULCER
Review of Resident 13's skin assessment tools dated 05/22/2023, documented an ulcer to the sacrum (bony area of the lower back) staged as 2, and the 05/29/2023 skin assessment, showed the following notes, open area measured, 3.5 cm [centimeter] x 1.5 cm. Wound bed with 100% slough. Redness around open area appears to be from incontinence.
On 06/14/2023 at 3:25 PM, a joint record review with Staff C, of Resident 13's admission MDS assessment dated [DATE], showed that Section M0300B (number of unhealed pressure ulcer/injury stage 2) was coded as 1 (one) indicating that the resident had a stage 2 pressure ulcer. Staff C stated that the pressure ulcer should have been coded as stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present) and that Resident 13's MDS was inaccurate.
On 06/14/2023 at 3:32 PM, a joint record review and interview, Staff B, Director of Nursing, stated that upon admission, Resident 13 was assessed for any wounds or pressure ulcers. Staff B stated that they used the skin tool assessment and that a registered nurse did the wound staging. Staff B reviewed the skin tool assessment note dated 05/29/2023, which stated, wound bed has 100% slough. Staff B further stated that the definition of a stage 2 pressure ulcer indicated without slough and that Resident 13's MDS was inaccurate based on the documentation reflected in the skin tool assessment dated [DATE].
PASRR
Review of Resident 13's EMR did not show PASRR documentation.
On 06/16/2023 at 11:48 AM, a joint record review with Staff C, showed Resident 13's admission MDS assessment dated [DATE], showed Section A1500 (PASRR) was coded 0 (No- [was asking] if the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition?) Staff C stated that Resident 13 had no PASRR documentation and that the MDS was inaccurate.
Reference: (WAC) 388-97-1000(1)(b)
Based on interview and record review, the facility failed to accurately assess 2 of 11 residents (Residents 5 and 13) reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding prognosis of life expectancy of less than 6 months, pressure ulcer/injury (to skin and underlying tissue resulting from prolonged pressure on the skin), and Preadmission Screening and Resident Review (PASRR) placed the residents at risk for unidentified 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, Version 1.17.1, revised in October 2019 showed: Accuracy of Assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate RAI (i.e., comprehensive, quarterly, annual, significant change in status).
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 assessment and ends at 11:59 PM on the day of the Assessment Reference Date (ARD). Different items on the MDS have different Observation Periods. When the MDS is completed, only those occurrences during the observation period will be captured on the assessment. In other words, if it did not occur during the observation period, it is not coded on the MDS.
HOSPICE SERVICES - A program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. Under the hospice program benefit regulations, a physician is required to document in the medical record a life expectancy of less than 6 months, so if a resident is on hospice the expectation is that the documentation is in the medical record.
RESIDENT 5
Resident 5 admitted to the facility on [DATE] with diagnoses that included neurocognitive disorder (disorders that affect the brain) with Lewy bodies (nervous system disorder characterized by a decline in intellectual function).
Review of Resident 5's significant change in status MDS assessment dated [DATE], showed Section J (Health Conditions for prognosis of life expectancy of less than months) was marked as Yes. Prognosis in Section J should have been coded No as there was no physician documentation stating and/or signed that resident had life expectancy of less than 6 months.
Review of Resident 5's Electronic Medical Records (EMR) from 03/27/2023 to 04/03/2023 did not show a physician's document that stated Resident 5 had life expectancy of less than 6 months.
On 06/14/2023 at 4:01 PM, during a joint record review of Resident 5's significant change is status MDS assessment with Staff C, Resident Care Manager/MDS Coordinator, showed Resident 5's prognosis was coded yes. Staff C stated that Resident 5's prognosis during the MDS period should had been coded No, as there was no physician documentation for it and that the MDS was not accurate.
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 a Preadmission Screening and Resident Review (PASRR) was com...
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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 Preadmission Screening and Resident Review (PASRR) was completed for 1 of 5 residents (Resident 13) reviewed for PASRR. This failure placed the resident at risk for unmet care needs.
Findings included .
Review of the facility policy titled, PASRR Policy, revised on 04/01/2023, showed that if a PASRR level 1 was not completed, the facility Social Service team member or designee will complete it.
Resident 13 was admitted to the facility on [DATE].
Review of Resident 13's electronic medical records did not show that a PASRR document was completed.
On 06/15/2023 at 3:57 PM, Staff B, Director of Nursing, stated that newly admitted residents were reviewed for PASRR and that the social worker or staff in the facility usually follows-up with the place where the resident came from if they came without a PASRR. Staff B further stated that Resident 13 had no PASRR screening completed at time of admission.
Reference: (WAC) 388-97-1915(1)
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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 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/or to ensure a summary/copy of the baseline care plan was provided to the residents and/or their representatives for 2 of 3 residents (Residents 166 & 116) reviewed for baseline care plan. This failure resulted in the residents not being informed of their initial plan for delivery of care services and placed the residents at risk for unmet care needs.
Findings included .
Record review of the facility's policy titled, Baseline Care Plan, revised on 01/31/2023, showed that a baseline care plan will be developed for all newly admitted resident within 48 hours of admission. The facility will provide the resident and their representative with the summary of the baseline care plan that includes and is not limited to the following: The initial goals of the resident, a summary of medications and dietary restrictions, any services and treatment to be administered by the facility and personnel actin g on behalf of the facility, and any updated information based on the details of the comprehensive care plan as necessary.
RESIDENT 166
Resident 166 admitted to the facility on [DATE].
Review of Resident 166's clinical record, showed no documentation that the care plan was reviewed, and a summary was given to the resident and/or representative within 48 hours of admission.
On 06/12/2023 at 3:41 PM, Resident 166's Representative (RR1) stated that no care plan summary was given by the facility within two days of admission.
On 06/15/2023 at 9:48 AM, Staff B, Director of Nursing, stated that the facility has not been giving the resident and their representative the baseline care plan summary. Staff B acknowledged that no summary of the baseline care plan was documented as given during the care conference held on 06/14/2023. Staff B stated that the base line care plan summary should have been given to Resident 166 and/or their representative.
RESIDENT 116
Resident 116 admitted to the facility on [DATE] rehab services.
Review of the clinical record showed no documentation that the baseline care plan was reviewed with Resident 116 and/or a summary was given to the resident and/or their representative within 48 hours of admission.
On 06/14/2023 at 10:08 AM, Resident 116 stated that the facility did not review baseline care plan and/or receive summary of care plan since time of admission.
Joint interview and record review on 06/14/2023 at 3:08 PM, with Staff C, Resident Care Manager/ MDS (Minimum Data Set - an assessment) Coordinator, showed that baseline care plan for Resident 116 was not done. Staff C stated that the baseline care plan should have been done on 06/11/2023, but it was not completed. Staff C stated that they did not have a process where they reviewed and gave a copy of the baseline care plan with the resident or their representatives within 48 hours.
Reference: (WAC) 388-97-1020(3)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revise Care Plans (CPs) for 1 of 8 residents (Residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revise Care Plans (CPs) for 1 of 8 residents (Residents 8) reviewed for care planning. The failure to review and revise care plans by the interdisciplinary team after each assessment placed the residents at risk for unidentified/unmet care needs and a diminished quality of life.
Findings included .
Review of the facility policy titled, Assessment and Plans of Care, revised on 04/01/2023, showed that each resident's plan of care shall be reviewed and revised by an interdisciplinary team after each comprehensive assessment is conducted.
Review of the facility policy titled, Fall Management, reviewed on 04/01/2023, showed that revision to the care plan will be documented in the chart and communicated to caregivers. The facility will have in place a fall management protocol utilizing assessments and interventions to minimize the risk of falling for residents to reduce and prevent the number of falls and number of injuries related to falls for residents. Preventative interventions will include identifying if proper equipment is being used, identifying if other environmental factors place the resident at risk for falls and then implementing interventions based on findings.
RESIDENT 8
Resident 8 admitted to the facility on [DATE].
Review of Resident 8's Electronic Medical Records (EMR) showed that Resident 8 had a history of recurrent falls. Further review of Resident 8's EMR showed that the resident had falls in the last 12 months including, 06/14/2022 with laceration on the head that needed stitches, 02/27/2023 that caused left flank (side of the body between the ribs and the hip) pain, and 04/07/2023 with left arm fracture.
Review of Resident 8's fall care plan printed on 06/12/2023 did not mention the previous falls or most current falls or new interventions after each fall.
On 06/16/2023 at 12:15 PM, a joint record review of Resident 8's EMR with Staff C, Resident Care Manager/Minimum Data Set (MDS-an assessment tool) Coordinator, showed that the resident had falls on 06/14/2022, 02/27/2023, and on 04/07/2023. Further joint review of Resident 8's fall care plan did not show that the falls or new interventions after each fall were documented in the care plan. Staff C stated that they expected to see each fall mentioned in the fall care plan with new interventions after each fall.
On 06/16/2023 at 12:58 PM, Staff B, Director of Nursing, stated that their expectation was to see all falls in residents' plan of care [care plan] and interventions for each fall in the residents' CP.
Reference: (WAC) 388-97-1020 (5)(b)
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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** HOSPICE SERVICES
Review of the facility policy titled, Nursing Services - Hospice, revised on 08/01/2022, showed that the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** HOSPICE SERVICES
Review of the facility policy titled, Nursing Services - Hospice, revised on 08/01/2022, showed that the facility will ensure all documentation of hospice visits are complete according to the state and federal regulations.
RESIDENT 5
Resident 5 admitted to the facility on [DATE].
Review of Resident 5's progress notes dated 03/27/2023 at 11:59 AM showed that resident admitted to hospice services.
Review of Resident 5's Electronic Medical Records (EMR) did not show documentation of hospice services or hospice visit notes.
On 06/12/2023 at 3:15PM, Staff D, Medical Records Coordinator, stated that Resident 5 admitted to hospice services on 03/27/2023. A joint review of Resident 5's EMR with Staff D, showed that there was no documentation of hospice services admission paperwork and/or hospice visit notes.
On 06/15/2023 at 10:06 AM, Staff B, stated that it was challenging to get hospice visit notes from the hospice provider. Staff B stated that they expected to have good communication between hospice services and the facility. Additionally, Staff B stated that hospice notes should be sent to the facility within 24 hours of their visit to the hospice residents.
Reference: (WAC) 388-97-1060 (1)
Based on observation, interview, and record review, the facility failed to ensure resident-centered care and treatment were provided in accordance with professional standards of practice when facility staff failed to do skin evaluations, implement monitoring and interventions for skin care for 2 of 3 residents (Residents 7 & 166) reviewed for skin conditions. Additionally, the facility failed to ensure consistent communication and collaboration of care occurred between the facility and hospice care for 1 of 2 residents (Resident 5) reviewed for hospice services. These failures placed the residents at risk for wound infection, not receiving the necessary wound/skin treatments, not receiving necessary comfort care services, unmet care needs, and a diminished quality of life.
Findings included .
Review of the facility's policy titled, Skin Care Policy, dated 10/25/2017, showed that residents will be assessed on admission; residents will have weekly skin checks and will have additional interventions as per assessment. All identified wounds will be assessed weekly to identify progress towards healing and new treatments needed. Active skin areas will have treatments ordered by the physician, documentation will occur weekly and consist of site, size, type, drainage, and current status.
RESIDENT 7
Resident 7 admitted to the facility on [DATE].
BRUISE
On 06/12/2023 at 2:35 PM, Resident 7 was observed with purplish blue discoloration to their left index (pointer) finger. Resident 7 stated that the door came back and hit their left hand about 3 to 4 weeks ago.
In a joint skin observation with Staff I, Licensed Practical Nurse, on 06/14/2023 at 1:54 PM, Staff I stated, probably a new bruise to their left index finger, it is my first time to see it.
Review of Resident 7's June 2023 Treatment Administration Record (TAR) showed that a skin check was completed on 06/05/2023 and 06/12/2023 with Intact skin. Skin tool assessments showed that no change in condition were completed for Resident 7's left index finger bruise in the last 30 days.
CHEST
Review of Resident 7's Medical Provider (MP) notes dated 06/05/2022 showed that Resident 7 admitted to the facility with an open area to the chest related to Basal Cell Carcinoma (BCC- type of cancer, painless raised area of skin).
Review of Resident 7's June 2023 TAR showed directions for staff to perform weekly skin checks per house protocol, complete skin tool assessment, and document all findings in the evening of every Monday. TARs completed in April 2023, May 2023, and June 2023 indicated intact skin.
Further review of Resident 7's clinical records including, skin tool assessments and nurse progress notes showed no weekly documentation consistent with Resident 7's chest wound, type, size, drainage, and status in the last 90 days.
LEFT & RIGHT TOES
Review of Resident 7's annual Minimum Data Set (MDS - an assessment tool), dated 04/05/2023, showed that Resident 7 had no Unhealed Pressure Ulcers/Injuries and received dressings to feet.
Review of Resident 7's MP notes dated 11/29/2022, showed a left second toe ulcer, likely developed in setting of pressure from shoe wear. Further review of the MP notes dated 06/05/2023 showed left second toe and right first hallux (big toe) ulceration.
Review of Resident 7's May 2023 and June 2023 skin tools, showed that skin assessments were not consistently completed weekly with wound type, stage, site, size, drainage, and status for both left and right toes.
STOCKINGS
Review of Resident 7's physician orders dated 05/26/2023, showed to hold compression stockings due to pressure sores on right foot.
During a joint observation on 06/15/2023 at 8:24 AM, Staff J, Certified Nursing Assistant, showed that Resident 7 was wearing compression stockings and that Staff J applied the stockings during Resident 7's morning care.
On 06/15/2023 at 8:35 AM, Staff B, Director of Nursing, (DON), confirmed that Resident 7 was wearing stockings and that they should have been placed on hold at this time. Staff B acknowledged that care was not consistent with the care-planned interventions. Staff B stated that it was expected that staff followed the plan of care.
On 06/16/2023 at 9:36 AM, Staff C, Resident Care Manager (RCM)/MDS Coordinator, stated that their process was to complete skin assessment on admission and weekly skin assessments thereafter for active skin issues with site, size, type, drainage, and status. Staff C stated that the expectation was that if skin issues were observed, the Licensed Nurse (LN) was to complete a change of condition skin tool assessment and notify the provider. Staff C stated that a weekly skin tool assessment should have been completed for Resident 7's chest, right and left toes. Additionally, Staff C stated that a change in condition skin tool for Resident 7's right index finger bruise should have been completed.
RESIDENT 166
Resident 166 admitted to the facility on [DATE].
An observation on 06/12/2023 at 8:36 AM, showed Resident 166 with bruising (purplish blue discoloration of skin) to their left and right arms.
Review of the Resident 7's admission skin assessment dated [DATE], showed extensive bruising on upper extremities bilaterally (both sides). A review of Resident 7's physician orders printed on 06/13/2023, showed no monitoring for bilateral arm bruises.
In a joint skin observation with Staff C on 06/16/2023 at 2:46 PM, they stated that Resident 166's extensive upper extremities bruise noted on admission should have been monitored weekly and care planned.
In a phone interview with Staff B on 06/16/2023 at 1:12 PM, they stated that they expected staff to complete residents' weekly skin monitoring and that if staff found any skin issues they would notify the provider, DON, and the resident's representative. Additionally, Staff B stated that there should have been consistent weekly assessments for Resident 7's active skin issues and weekly monitoring ordered for Resident 166's bilateral upper extremities bruises.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident receive necessary treatment, consisten...
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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 resident receive necessary treatment, consistent with professional standards of practice to an existing pressure ulcer ( also known as pressure sores, are localized damage to the skin and/or underlying tissue that usually occur over bony parts of the body) for 1 of 1 resident (Resident 13) reviewed for pressure ulcer. This failure placed the resident at risk of worsening pressure ulcer.
Findings included .
Review of facility's policy, titled, Assessment and Treatment Service to Wound, revised on 04/12/2023, stated that resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Review of facility's policy, titled, Skin Care Policy, stated that facility suggested skin protocols for care and treatment of open areas will be followed unless otherwise ordered by the physician. All treatments will be ordered by the physician.
Resident 13 was admitted on [DATE] to the facility as hospice (sick or terminally ill) with a primary diagnosis of malignant neoplasm of right kidney (cancer of the right kidney).
During wound care on 06/14/2023 at 11:32 AM, observed Staff I, Licensed Practical Nurse (LPN) sprayed wound cleanser Anasept (a brand name), an antimicrobial agent (destroys or inhibits growth of bacteria) over Resident 13's pressure ulcer on sacrum/coccyx (bony prominence near the tail bone), and pat dried the area with gauze dressing for three times. Staff I then, measured wound (2.1 centimeter (cm) x 1.5cm x 0.5cm). Noted pressure ulcer had no drainage or signs of infection but with redness around area measured as 7cm x 7cm in circumference. Staff I then, applied Triad Hydrophilic wound dressing cream (zinc-oxide based cream) over wound area and finally covered the wound with a bordered foam dressing.
A joint interview and record review of Resident 13's Treatment Administration Records (TAR) on 06/14/2023 at 11:58 AM, Staff I stated that the wound order read, Sacral wound care, cleanse, apply skin prep (a water-proof liquid which forms a transparent layer over the skin to protect it against irritation) and cover with adhesive foam dressing. When asked the reason for not following the prescribed physician's order, Staff I stated that they were using the same dressing supplies as provided and instructed by the hospice nurse. Furthermore, Staff I stated that the wound order in the resident's TAR was not the same as the ones they used for Resident 13's wound treatment.
On 06/14/2023 at 1:18 PM, Staff B, Director of Nursing stated that staff was expected to follow the physician's order and any order by hospice must go through our physician in this facility before it is implemented.
Reference: (WAC) 388-97-1060(3)(b)
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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 provide necessary foot care in accordance with profess...
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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 foot care in accordance with professional standards for 1 of 1 resident (Resident 7) reviewed for ADLs (ADLs-Activities of Daily Livings) and foot care. This failure placed the resident at risk for pain/discomfort and diminished quality of life.
Findings included .
Resident 7 admitted to the facility on [DATE] with diagnoses of Peripheral Neuropathy (damaged end nerves causing loss of sensation and weakness to the lower extremities) and hammer toe deformity (a change from the normal shape of the second, third, fourth, or fifth toe).
Review of the medical practitioner notes dated 04/24/2023 showed, Referral to podiatry (treating feet problems, foot doctor) for regular foot care.
On 06/14/2023 at 10:00 AM, Review of the June 2023 task list showed direction for Certified Nursing Assistant, Licensed Nurse (RN -Registered Nurse/LPN- Licensed Practical Nurse) to complete nails and pedicure as needed. According to the task list, no nail care was done in the month of June 2023 and no documentation in Resident 7's electronic medical record that Resident 7 refused nail care in the month of June 2023. Further review showed no notification to the medical practitioner and/or Resident's Representative that Resident 7 was not seen by Podiatry in May 2023.
On 06/14/2023 at 1:26 PM, Resident 7 was lying in bed during a wound care observation. Staff I, Licensed Practical Nurse (LPN), removed Resident 7's socks on the right foot, and confirmed that the resident's right toenails were long, thick, and yellowing. Furthermore, the thick nail from the right big toe were pressing on the second toe causing new skin issue.
During an interview on 06/15/2023 at 9:58 AM, Staff B, Director of Nursing Services, stated that Resident 7 was not seen by the podiatrist on the last Podiatry visit due to an issue with the insurance authorization. The next podiatry visit was scheduled for August 2023.
Review of the undated facility provided hadnwritten document/note from Staff B showed that Resident 7 was placed on the Podiatry list for May 2023. Further review of the document showed that Podiatry services were not authorized by Resident 7's insurance and that Resident 7 was not seen by the podiatrist since the referral made in April 2023.
On 06/16/2023 at 9:50 AM, Staff C, Resident Care Manager, stated that the facility sends referral to podiatry pending authorization. Staff C stated that they would have to find out the reason for Resident's 7 denial from insurance and that Resident 7 needs podiatry services due to long right toenails and risks for further skin issues.
Reference: (WAC) 388-97-1060(3)(j)(viii)
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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** OXYGEN THERAPY TUBING
Review of the facility policy titled, Oxygen Administration, revised on 05/20/2021, showed that oxygen tub...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** OXYGEN THERAPY TUBING
Review of the facility policy titled, Oxygen Administration, revised on 05/20/2021, showed that oxygen tubing should be changed every week with new cannula (flexible tubing) or mask.
Review of the facility policy titled, Physician Order Procedure, revised on 02/07/2023, showed that oxygen orders should include changes of tubes and filters.
RESIDENT 13
Resident 13 admitted to the facility on [DATE] with a diagnosis of secondary neoplasm (cancer) of the right and left lungs.
Review of Resident 13's Medication Administration Record and Treatment Administration Record from 05/22/2023 to 06/14/2023, showed no written order for changing oxygen tubing.
Review of Resident 13's oxygen therapy care plan initiated on 05/24/2023 and revised on 06/08/2023, showed no written intervention about changing or maintaining oxygen tubing.
Multiple observations on 06/12/2023 at 10:29 AM, 06/13/2023 at 8:25 AM, and 06/14/2023 at 10:29 AM showed that Resident 13's oxygen tubing was not dated.
On 06/14/2023 at 11:14 AM, Staff I stated that they monitored oxygen therapy every shift and that there was no order about changing Resident 13's oxygen tubing. Furthermore, Staff I stated that they were not aware of any policy about maintaining or changing oxygen tubing.
On 06/14/2023 at 11:20 AM, joint observation with Staff I, showed that Resident 13's oxygen tubing was not dated.
On 06/14/2023 at 11:28 AM, Staff B stated that Resident 13's oxygen tubing was expected to be changed every week and that it should have been included in their care plan. Staff B stated that there was no order to monitor or change oxygen tubing and that there was no documentation by staff to show that oxygen tubing was cleaned or changed since Resident 13's date of admission.
Reference: (WAC) 388-97-1060 (3)(j)(vi)
Based on observation, interview, and record review, the facility failed to ensure proper care of a suction machine (a medical device used to remove mucus/saliva secretions/blood obstruction from a person's airway) including the suction tubing and suction canister for 1 of 2 crash cart (a medical device containing necessary equipment and supplies for use during emergencies) (Suction Machine in Second Floor Dining Room/Solarium). Additionally, the facility failed to ensure oxygen (O2) therapy was given according to standards of practice for 1 of 1 resident (Resident 13) reviewed for respiratory care. These failures placed the residents at risk for unmet care needs, respiratory infections, and related complications.
Findings included .
Review of the facility policy titled, Care of Suctioning Equipment, revised on 04/01/2023, showed that nursing and designated personnel will change supplies and disinfect and/or prepare equipment for sterilization according to the procedures to prevent the incubation and/or transmission of infectious organisms to residents being suctioned orally or tracheally (windpipe - tube-like structure in the neck and upper chest than stretches from the larynx [hollow, tubular structure connected to the top of the windpipe] to the bronchi [main airways into the lungs] and transports air to and from the lungs). All connecting tubing will be changed weekly or when visibly soiled. Sterile catheters will be disposed of after each use. Oral catheters will be disposed of after 24 hours. Reusable glass suction containers will be emptied of secretions after each shift and cleaned with soap and water.
SUCTION MACHINE IN SECOND FLOOR SOLARIUM/DINING ROOM
On 06/15/2023 at 9:29 AM, observation showed a red suctioning machine in the 2nd floor dining room/solarium that had a suction cannister (plastic container that collects body fluids) had 90 milliliters (ml) of clear fluid in it. Further observation of the suctioning machine showed that there were clear tubes attached and were loose around the crash cart and the tubing had dust on it.
On 06/15/2023 at 9:50 AM, Staff I, Licensed Practical Nurse, stated that they had used the suctioning machine from the 2nd floor dining room a couple months ago. Staff I stated that the suction machine should be ready with the supplies for use in case of an emergency.
During a joint observation and interview with Staff B, Director of Nursing, on 06/15/2023 at 10:38 AM, showed the suction machine cannister in the 2nd floor dining room had clear liquid in it and that the tubing connected to the suction machine had dust on it. Staff B stated that they expected the suction cannister to be empty and that they did not know the suction machine was used. Staff B stated that the suction cannister and tubing should have been replaced after being used. Staff B stated that they expected the suction machine to be ready if needed for emergency. Staff B stated that the facility did not currently have a log to check the suction machine and its supplies.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure monthly pharmacy recommendations were followed up on for 1 o...
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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 monthly pharmacy recommendations were followed up on for 1 of 5 residents (Resident 6) reviewed for unnecessary medications. This failure placed the resident at risk of receiving unnecessary medications, medication-related adverse consequences, and a diminished quality of life.
Findings included .
Review of the facility's policy titled Consultant Pharmacist Reports, revised on 01/01/2023, showed that the facility should present the provider with recommendations and obtain follow up within 30 days or based on urgency of recommendation. A designated facility staff member should monitor for weekly reports to ensure recommendations are completed in a timely manner ., the administer and/or director of nursing will contact the providers who fail to respond to recommendations in a timely manner . Recommendation are acted upon and documented by facility staff and or prescriber.
Resident 6 admitted to the facility on [DATE].
Resident 6's Medication Administration Records (MAR) for June 2023 showed the following orders:
-Lidocaine (a substance used to relieve pain) ointment 5% apply to knees/hips topically every 6 hours as needed for pain, can have at bedside and self-apply. Start date 04/12/2023.
-Lidocaine ointment 5% apply to perianal are topically every 6 hours as needed for pain, may leave at bedside and self-administer. Start date 10/27/2020.
-Artificial tears solution 1-0.3% instill 2 drops in both eyes every 2 hours as needed for dry eyes. Patient can have at bedside and self admin. Start date 06/19/2020.
-Pancrelipase (helps to break down fat, starch or protein in food) capsule delayed release particles 25,000-136,000 unit give 3 capsules by mouth with meals for dietary supplement, ok to have pills at bedside so patient can take them with her meals. Start date 01/26/2023.
Review of Resident 6's pharmacy Medication Regimen Review (MRR) documents dated 12/20/2022, 03/22/2023, 04/21/2023 and 05/30/2023 showed that Resident 6 had an order to self-administer the following medications: artificial tear eye drops and lidocaine ointment. Further review of the document showed that per the MAR Resident 6 keeps these medications at her bedside and is allowed to self-administer. Recommendations: please make sure the self-administration of medication assessment is up-to-date. It is recommended for the assessment to be completed quarterly. There was no indication on documents that follow up was completed by the facility.
Review of Resident 6's medical records showed that there was no evaluation/assessment of self-administration medications and or documentation of refusal for the month of December 2022, January 2023, March 2023, April 2023 and May 2023. Further review showed that the facility completed an evaluation or assessment of self-administration of medication for Resident 6 on 06/14/2023, results showed that approval granted to self-administer was checked no . resident refused to participate.
On 06/15/2023 at 12:10 PM, Staff C, Resident Care Manager/MDS (Minimum Data Set - an assessment) Coordinator, stated that self-medication assessment should be completed every 3 months and that Resident 6 had refused multiple times before. Staff C also stated that they reviewed and processed the recommendations for the MRR's right away, as soon as I get it.
On 06/15/2023 at 2:23 PM, Staff B, Director of Nursing, stated that according to the pharmacy the self-administration of medications should be evaluated every quarter. Staff B acknowledged that they were not able to find a self-administration medication evaluation/assessment for Resident 6 and there was no follow up on the pharmacy's MRR recommendations for the month of December 2022, January 2023, March 2023, and April 2023.
Reference: (WAC) 388-97-1300 (4)(c).
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to properly label and store medications (no open date or not dating medications after opening it) and failed to ensure expired m...
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Based on observation, interview, and record review, the facility failed to properly label and store medications (no open date or not dating medications after opening it) and failed to ensure expired medications were disposed of timely in accordance with current accepted professional standards for 1 of 1 medication storage room and 1 of 2 medication carts (Cart 2) reviewed for medication storage. Additionally, the facility failed to maintain proper temperature for 1 of 2 refrigerators in the medication storage room (Refrigerator 1 for medication). This failure placed the residents at potential risk to receive expired medications and to receive compromised or ineffective medications with unknown potency.
Findings included .
Review of the facility policy titled, Temperature Fridge Log, revised on 04/12/2023, stated that the facility will monitor and make steps to keep refrigerator temperature according to the pharmacy recommendation: medical fridges have the latest thermometers that continuously monitor and record temperatures for reassurance. They also are fitted as standard with alert notifications if the temperature inside the fridge falls below, or rises above, the prescribed level. This allows staff to react immediately and take preventive steps to prevent mishaps. The recommended temperatures for medical refrigerators, typical prescribed level of the unit's temperature range between 36 degrees Fahrenheit (°F) and 46°F.
On 06/13/2023 at 11:26 AM, a joint observation and interview with Staff G, Licensed Practical Nurse, showed the following:
MEDICATION STORAGE ROOM
-three bottles of Milk of Magnesia (a medication to reduce stomach acid and helps to increase bowel movement), each labeled with an orange tag 05/31/2023 exp date,
-a bottle of stool softener (a medication to make stool soft and easier to pass) with expiration date of 05/31/2023 and,
-a bottle of Loratadine (a medication to prevent or reduce allergy) tablet with no open date.
On 06/13/2023 at 11: 28 AM, Staff G stated that these medications needed to be discarded and proceeded to pour tablets into a chemical container labeled as drug buster. Staff G stated that the pharmacy staff came in and applied a tag- labelled expired medications. Staff G further stated that the facility nurse was responsible for disposing them off at expiration date.
REFRIGERATOR 1 (MEDICATION)
On 06/13/2023 at 11:35 AM, joint observation with Staff G showed that refrigerator 1 had the following findings:
-an unopened vial of Tubercullin Purified Protein Derivative (used in a skin test to help diagnose for tuberculosis infection) with expiration date of 05/15/2023.
-insulin (a type of hormone that helps to regulate blood sugar level in the body) pen
- Enbrel (medication to treat rheumatoid arthritis [a condition affecting the joints of the body])
-an Influenza vaccine (vaccine used to protect against influenza viruses)
-one round-shaped portable thermometer at 49 °F
-rectangular-shaped portable thermometer at 50 °F
On 06/13/2023 at 11:35 AM, Staff G had confirmed both temperature readings and they stated that the ideal temperature for the refrigerator should be at least between 38 °F to 40 °F.
CART 2
On 06/13/2024 at 2:34 PM, Staff G showed a bottle of Guaifenesin (a medication to help clear mucus or phlegm during cough or colds) syrup with no opened date. Staff G stated that bottles should be dated once opened and initialed with their names.
On 06/13/2023 at 2:58 PM, Staff B, Director of Nursing, stated that a pharmacy nurse comes every quarter, reviews all medications and labels expired medications. Staff B further stated that the facility staff was expected to dispose off expired medications immediately within a day or two.
On 06/13/2023 at 3:10 PM, in a joint observation and review, Staff B stated that there were two refrigerators, one for medication (refrigerator 1) and the other for supplements (refrigerator 2). Staff B showed a temperature log (refrigerator 1) kept at the medication storage room dated June 2023 with entries from day 1 to day 13. Staff B then opened refrigerator 1 and showed two portable thermometers (one round-shaped and another rectangular-shaped) with temperature of 55 °F and 56 °F, respectively. Observed Staff G went in the medication storage room and stated, the temperatures were already above 40 °F this morning. Further, review of the temperature log showed that refrigerator 1 were checked twice on 06/13/2023 at 00:30 AM and 5:00 AM with temperatures recorded as 38/40 [38 °F/40 °F]. Staff B stated that the night staff was responsible for checking and monitoring the temperature during their shift. Staff B showed one of the medications inside refrigerator 1 was an influenza vaccine which Staff B stated, needed to be maintained within 38 °F to 40 °F. Furthermore, Staff B stated that staff was expected to make sure that refrigerator temperature was maintained at 40 °F and any discrepancy on recorded temperature must be reported to the supervisor.
Reference: (WAC) 388-97-1300 (2)
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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** RESIDENT 4
Resident 4 admitted to the facility on [DATE] with a diagnosis of generalized anxiety (a mental disorder characterize...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 4
Resident 4 admitted to the facility on [DATE] with a diagnosis of generalized anxiety (a mental disorder characterized by significant and uncontrollable feelings of anxiety and fear that interfere with daily activities) and unspecified recurrent major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
Review of Resident 4's physician orders dated January 2021 showed that an antidepressant (medication to treat depression and anxiety) was ordered for Resident 4's bedtime anxiety.
Review of Resident 4's antidepressant care plan, reviewed on 04/24/2023 did not include non-pharmacological interventions to address Resident 4's bedtime anxiety.
On 06/15/2023 at 3:57 PM, Staff B stated that they monitored possible adverse side effects of psychotropic (any drug that affects behavior, mood, thoughts, or perception) medication and that non-pharmacological interventions should be included in Resident 4's care plan.
SELF-ADMINISTRATION OF MEDICATION
Review of the undated facility policy, titled, Self-Administration of Drugs, showed that if the interdisciplinary team determines that residents can safely self-administer drugs, he/she is assigned to one of the self-administration levels and an appropriate care plan is written.
Review of June 2023 MAR showed that Resident 4 had two topical medications, Aspercreme (a medication used for relief of minor aches such as muscle and joint pains) lotion and Diclofenac Sodium (a medication used to treat joint pain) Gel, both could be self-administered by Resident 4.
Review of Resident 4 EMR showed that they were evaluated for self-administration of medication on 11/08/2021and no self-administration care plan was written.
On 06/15/2023 at 4:09 PM, Staff B stated that Resident 4 had no care plan for self-administration of medication.
RESPIRATORY CARE
Review of the facility policy, titled, Oxygen Administration, revised on 05/20/2021, stated that oxygen (O2) tubing should be changed every week with new cannula (flexible tubing) or mask.
RESIDENT 13
Resident 13 admitted to the facility on [DATE] with a diagnosis of secondary neoplasm (cancer) of the right and left lungs.
Review of Resident 13's oxygen therapy care plan initiated on 05/24/2023 and revised on 06/08/2023, showed no written intervention about changing or maintaining oxygen tubing.
On 06/14/2023 at 11:14 AM, Staff I stated that they monitored oxygen therapy every shift and that there was no order about changing Resident 13's oxygen tubing. Furthermore, Staff I stated that they were not aware of any policy about maintaining or changing oxygen tubing.
On 06/14/2023 at 11:28 AM, Staff B stated that Resident 13's oxygen tubing was expected to be changed every week and that it should be included in the plan of care. Additionally, Staff B stated that there was no order to monitor or change oxygen tubing and that there was no documentation by staff to show that oxygen tubing was cleaned or changed since Resident 13's admitted to the facility.
PSYCHOTROPIC NON-PHARMACOLOGICAL INTERVENTION
Review of the physician orders dated May 2023 showed that an anti-anxiety medication (medication to treat anxiety) was ordered for Resident 13.
Review of Resident 13's care plan initiated on 05/23/2023 did not include non-pharmacological interventions to address Resident 13's anxiety.
On 06/15/2023 at 3:57 PM, Staff B stated that they monitored possible adverse side effects of psychotropic medications and that non-pharmacological interventions should be included in Resident 13's care plan.
Reference: (WAC) 388-97-1020 (1) (2)(a)
RESIDENT 8
Resident 8 admitted to the facility on [DATE] with diagnoses that included edema (swelling) on both legs.
Review of Resident 8's care plan printed on 06/12/2023 did not show a care plan for edema.
On 06/15/2023 at 10:32 AM, a joint review of Resident 8's Electronic Medical Records with Staff B, showed that Resident 8 had daily compression stockings donned (put on) on both legs for edema. Staff B stated that they did not see an edema care plan for Resident 8 and that Resident 8 should have had an edema care plan in place.
Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan (CP) for 6 of 8 residents (Residents 7, 8, 6, 4, 9 & 13) reviewed for comprehensive person-centered care plan. The failure to develop CPs for residents' skin condition, edema (swelling), pain, self-administration of medications, walker, behavior, and respiratory 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, Assessment and Plans of Care: Comprehensive Care Planning, revised on 04/01/2023, showed that a comprehensive care plan for each resident used the results of the comprehensive assessment. Each resident's care plan shall include measurable objectives and timetables to meet all resident needs identified in the comprehensive assessment. All items or services ordered to be provided or withheld shall be included in each resident's plan of care. The comprehensive care plan will describe services furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. Residents' right to refuse care and treatment shall also be included in the comprehensive care plan.
RESIDENT 7
Resident 7 admitted to the facility on [DATE].
CHEST WOUND
Review of the Medical Provider (MP) notes dated 06/06/2022, showed that Resident 7 had a Basal cell carcinoma (BCC- type of cancer, painless raised area of skin) to the chest.
Review of Resident 7's physician order, dated 04/21/2023, showed a wound care order to anterior (front) chest for nonhealing skin ulceration (open sore).
Review of Resident 7's CP revised on 04/12/2023, showed that Resident 7 had impaired skin integrity of the chest with no measurable goals and/or interventions.
LEFT & RIGHT TOES
Review of Resident 7's annual Minimum Data Set (MDS - an assessment tool), dated 04/05/2023, showed that Resident 7 received dressings to feet. Review of the MP notes dated 11/29/2022, showed a left second toe ulcer, Likely developed in setting of pressure from shoe wear. Further review of the MP notes dated 06/05/2023 showed left second toe and right first hallux (big toe) ulceration.
Review of Resident 7's CP revised on 04/12/2023, showed that Resident 7 had no problem, goal, and/or interventions for left and right toe ulcerations.
PODIATRY
Review of Resident 7's active physician orders dated 3/30/2022, showed a referral for podiatry (treating feet problems, foot doctor) as needed.
Review of MP notes dated 04/24/2023, showed, referral to podiatry for regular foot care.
Review of Resident 7's clinical record showed that they had not been seen for podiatry services since the referral in April 2023.
Review of the CP printed on 06/14/2023 showed no podiatry services were included in Resident 7's plan of care.
On 06/16/2023 at 2:46 PM, Staff C, Resident Care Manager (RCM)/MDS Coordinator, stated that CPs are updated by the RCM, Staff B, Director of Nursing, and any nurse on admission, quarterly, annually and for new orders and/or updates. Staff C stated that the expectation was that each skin alteration present must have a CP. Staff C stated that Podiatry service referred by MD should have been in Resident 7's CP.
In a Phone interview on 06/16/2023 at 1:15 PM, Staff B stated that Resident 7's active wounds, chest ulceration, left and right toe ulceration and podiatry should have been care planned with specific problems, goals, and interventions.
PAIN MANAGEMENT - NON-PHARMACOLOGICAL INTERVENTIONS
According to [NAME] Medicine's website reviewed on 06/27/2023 showed, non-pharmacological pain management is the management of pain without medications. This method utilizes ways to alter thoughts and focus concentration to better manage and reduce pain.
RESIDENT 6
Resident 6 admitted to the facility on [DATE] with diagnoses including chronic pain syndrome (a condition where pain lasts longer than 3 months and negatively affects physical, mental, and emotional well-being) and pelvic (lower part of the trunk, between the abdomen and the thighs) and perineal (between the genitals and anus) pain.
Review of Resident 6's physician orders dated 6/14/2023 showed the following orders:
-Acetaminophen (medication to treat pain) 325 milligram (mg) give 2 tablets every 4 hours as needed for pain. Start date 03/13/2021.
-Hydromorphone (medication to treat moderate to severe pain) 2 mg give 1 tablet four times a day for pain. Start date 07/28/2021.
-Gabapentin (medication to relieve nerve pain) 300 mg three times a day for pain. Start date 09/21/2022.
-Lidocaine (a substance used to relieve pain) ointment 5% apply to knees/hips topically every 6 hours as needed for pain, can have at bedside and self-apply. Start date 04/12/2023.
-Lidocaine ointment 5% apply to perianal (area around the anus) topically every 6 hours as needed for pain, may leave at bedside and self-administer. Start date 10/27/2020.
-Acetaminophen 325 mg give 2 tablets three times a day for pain. Start date 07/15/2022.
Review of Resident 6's pain care plan with Last care plan review completed: 4/5/2023 showed that Resident 6 had chronic pain related to chronic opiate (a substance used for pain relief) dependent with severe perineal/pelvic pain. Further review showed that interventions did not include non-pharmacological interventions to manage pain.
Review of Resident's 6's Medication Administration Record (MAR) for April 2023, May 2023, June 2023 showed that the facility did not include non-pharmacological interventions to manage pain.
On 06/15/2023 at 2:23 PM, Staff B stated that their staff would try non-pharmacological interventions for pain management. Staff B acknowledged that there was no documentation indicating that non-pharmacological interventions were offered for Resident 6. Staff B stated that they would document it in the care plan.
SELF-ADMINISTRATION OF MEDICATION
Resident 6's June 2023 MAR showed the following orders:
-Lidocaine (a substance used to relieve pain) ointment 5% apply to knees/hips topically every 6 hours as needed for pain, can have at bedside and self-apply. Start date 04/12/2023.
-Lidocaine ointment 5% apply to perianal are topically every 6 hours as needed for pain, may leave at bedside, and self-administer. Start date 10/27/2020.
-Artificial tears solution 1-0.3% instill 2 drops in both eyes every 2 hours as needed for dry eyes. Patient can have at bedside and self admin. Start date 06/19/2020.
-Pancrelipase (helps to break down fats, starch, and proteins in food) capsule delayed release particles 25,000-136,000 unit give 3 capsules by mouth with meals for dietary supplement, ok to have pills at bedside so patient can take them with meals. Start date 01/26/2023.
Review of Resident 6's medical records showed that there were no assessments of self-administration medications and/or documentation of refusal prior to self-administration of medication was ordered. Further review showed that the facility completed an assessment of self-administration of medication for Resident 6 on 06/14/2023. The results showed that approval granted to self-administer was checked no . resident refused to participate.
Review of Resident 6's refusal care plan with Last care plan review completed: 4/5/2023 showed that there was no documentation that resident had refused self-administration medication assessment.
On 06/12/2023 at 12:06 PM, Resident 6 was observed preparing to eat lunch and had 2 blue capsules in a medication cup at their side table.
On 06/15/2023 at 10:12 AM, Resident 6 stated that they did not keep the Lidocaine cream and the artificial tears in the room.
On 06/15/2023 at 11:32 AM, Staff I, Licensed Practical Nurse, stated that Resident 6 took the Pancrelipase medication on their own with meals and had an order that it was okay to leave at bedside.
On 06/15/2023 at 12:10 PM, Staff C stated that assessment of self-administration of medication should have been completed every 3 months and that Resident 6 had refused multiple times before.
On 06/15/2023 at 2:23 PM, Staff B stated that according to the pharmacy, the self-administration of medications should be evaluated every quarter. Staff B stated that the resident refused to do the assessment for self-administration of medications. Staff B acknowledged that they should have updated the care plan for resident's refusal of the assessment.
WALKER
Review of Resident 6's Annual Minimum Data Set (MDS- an assessment) with assessment date 04/07/2023 showed that resident was independent with activities of daily living and further review showed that resident was using a walker.
Review of Resident 6's care plan with Last care plan review completed: 4/5/2023 showed that resident uses a four-wheel walker (FWW) for ambulation or ambulates without device at times, independent with all mobility.
Review of Resident 6's Physical Therapy notes dated 11/21/2022, showed reason for referral: pt [patient] referred for skilled PT [physical therapy] eval [evaluation] to determine need of walker/AD (assistive device) Further review showed that clinical impression indicated that patient would benefit from a four wheel walker.
On 06/12/2023 at 2:31 PM, Resident 6 stated, walker breaks does not work sometimes, they stutter . someone tried to give me a used walker but I want a new walker.
On 06/14/2023 at 2:30 PM, Staff V, Therapy Coordinator, stated that Resident 6 was evaluated and offered a front wheel walker because it was more stable, but resident refused it. Staff V also stated that the current walker does not lock as well.
On 06/15/2023 at 12:10 PM, Staff C stated that if walker was not working properly, they would care plan it and would give Resident 6 a new walker.
06/15/2023 at 02:23 PM, Staff B stated that Resident 6 did not like how the breaks work on their walker and the facility had tried to give them 2 different walkers, but resident had refused. Staff B stated that they should have care planned about the walker.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
HAND HYGIENE
According to the CDC's document titled, When and How to perform Hand Hygiene reviewed on January 8, 2021, it stated to perform hand hygiene immediately after removing gloves.
Review of t...
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HAND HYGIENE
According to the CDC's document titled, When and How to perform Hand Hygiene reviewed on January 8, 2021, it stated to perform hand hygiene immediately after removing gloves.
Review of the facility's policy, titled, Policy and Procedure- Handwashing-Hand hygiene, revised on 03/16/2023 stated that the use of gloves does not replace handwashing.
RESIDENT 13
An observation on 06/14/2023 at 11:32 AM, showed that Staff I, Licensed Practical Nurse, performed handwashing, put on three sets of gloves then assisted Resident 13 to their left side. Staff I removed an incontinent brief and a soiled wound dressing from the resident's lower back. Staff I then wiped off brown material from the resident's buttocks/anal (bottom) area using moist disposable wipes. Then, Staff I removed their two sets of gloves. No hand hygiene was done. Staff I opened three single packs of 4 x 4 gauze dressing and set them aside. Staff I proceeded to remove their remaining set of gloves and pressed the call light to ask for assistance. An aide came and Staff I left the bedside and performed handwashing and put on three set of gloves. Staff I sprayed antimicrobial agent over the wound, pat dried, then applied cream over the wound area. Staff I removed one set of gloves. No hand hygiene was done. Then Staff I covered the wound with a foam dressing. Staff I removed the second set of gloves. No hand hygiene was done. Staff I then provided perineal (private area) care. Staff I removed remaining gloves and performed handwashing.
On 06/14/2023 at 1:04 PM, Staff I stated that it was a personal preference to put on more than one set of gloves to avoid any creams from touching beddings or linens. Staff I further stated that they believed that there was enough barrier between gloves.
On 06/14/2023 at 1:18 PM, Staff B stated that staff was expected to follow proper hand hygiene protocol and that use of gloves did not replace hand washing. Staff B further stated that putting on more than one set of gloves was not part of the facility's policy.
Reference: (WAC) 388-97- 1320 (1)(a)(3)
Based on observation, interview, and record review, the facility failed to ensure clean linens were covered while transported to the second floor for 3 out of 3 linen closets (linen rooms 1, 2 and 3). In addition, the facility failed to consistently ensure policies and procedures (P/Ps) related to infection prevention and control were reviewed annually as required and the facility failed to perform hand hygiene during wound care. These failures placed the residents at risk for facility acquired or healthcare associated infections and related complications.
Findings included .
TRANSPORTING CLEAN LINENS
On 06/13/2023 at 8:32 AM and on 06/16/2023 at 8:46 AM, Staff K, Custodial and Housekeeping Coordinator, was observed pushing an uncovered wheeled laundry cart with clean towels on it, from the elevator down the hallway to three of the linen storage rooms. Half of the towels were covered in a clear plastic wrap and the other half of the towels were not covered or wrapped.
On 06/16/2023 at 8:56 AM, Staff K stated that staff transferred the clean linens in an opened laundry cart with wheels that did not have a cover. Staff K also stated that once the linen that was covered in a clear plastic wrap was opened or unsealed, staff did not cover the clean linen while it was transported down the hallway or to another floor via the elevator.
On 06/21/2023 at 11:28 AM, Staff B, Director of Nursing, stated that the clean linens should be stored in the clean linen closets and staff should maintain cleanliness when linens were transported to the linen closet or to the floor.
INFECTION PREVENTION AND CONTROL P/Ps
Review of the following infection prevention and control P/Ps showed they were not reviewed annually as required:
1. The Antibiotic Stewardship (the effort to measure how antibiotics are prescribed) Policy was last reviewed on 10/25/2017.
2. The Influenza Vaccine Policy was last reviewed on 10/25/2017.
3. The Pneumococcal Policy was last reviewed on 10/25/2017.
4. The Team Member Covid-19 (communicable respiratory disease) Vaccination Policy was last reviewed on 01/21/2022.
On 06/16/2023 at 11:27 AM, Staff B stated that they reviewed their policies annually and updated as needed. Staff B also stated that the policies should have an updated date under the date reviewed/revised if the policy had been reviewed. Staff B acknowledged that they were not aware of the Center for Disease and Control (CDC) Prevention update on pneumococcal vaccination and that the policies above were not updated or reviewed annually.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure that unless the facility employed a full time Registered Dietitian, the director of food and nutrition services had completed an aca...
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Based on interview and record review, the facility failed to ensure that unless the facility employed a full time Registered Dietitian, the director of food and nutrition services had completed an academic program in nutrition or dietetics (the application of the science of nutrition to the human being in health and disease) accredited (officially recognized or authorized) by an appropriate national accreditation organization. This failure placed residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services management.
Findings included .
Review of the facility's undated document titled, Facility Assessment, showed that the facility had a dietitian or other qualified nutrition professional to serve as the director of food and nutrition services. Further review showed that one Certified Dietary Manager (CDM) was required as full-time personnel to meet the needs of the residents.
On 06/14/2023 at 11:44 AM, Staff W, Registered Dietitian, stated that they did not work for the facility as full-time or part time staff, but as a consultant as needed.
On 06/15/2023 at 2:58 PM, Staff M, Executive Chef, stated that there was not a CDM for the facility. Staff M stated that the staff who was a CDM left the facility over a month ago and was the only CDM staff in the facility.
Reference: (WAC) 388-97-1160 (2)(3)(b)(i)(ii)
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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
Based on observation, interview, and record review, the facility failed to ensure the foods stored in the kitchen were labeled/dated when first opened and ensure thermometers were properly sanitized b...
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Based on observation, interview, and record review, the facility failed to ensure the foods stored in the kitchen were labeled/dated when first opened and ensure thermometers were properly sanitized between use for 2 of 2 kitchen (Main Kitchen and Second Floor Kitchen). In addition, the kitchen staff failed to put on hair restraints while preparing/cooking foods in the Main Kitchen. These failures 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 policy titled, Labeling - Dining Services, dated 10/01/2019, showed that food products must be labeled and dated with product name, date the food was produced, and employee initials. Food products that are left in their original containers must be labeled with a date they were opened.
Review of the facility policy titled, Food Cooking and Holding Temperatures, dated 05/16/2014, showed that foods must be properly covered, dated, and rotated. All opened containers must have the initial opened date listed on the label.
FOOD ITEMS IN THE MAIN KITCHEN
On 06/12/2023 at 8:35 AM, a joint observation of the walk-in refrigerator in the main kitchen with Staff M, Executive Chef, showed one undated gallon container of mayonnaise that was two thirds of a gallon full.
On 06/12/2023 at 8:51 AM, a joint observation of the walk-in dry goods room in main kitchen with Staff M, showed the following food items were opened and undated.
- One container of Molasses (thick, dark brown syrup used in baking).
- One bottle of sesame seed oil.
- One bottle of rice vinegar.
SECOND FLOOR KITCHEN
On 06/14/2023 at 8:49 AM, a joint observation with Staff P, Dietary Aide, showed that the second-floor kitchen small freezer had one undated container of vanilla bean ice cream and two undated containers of sherbet. Staff P stated that the vanilla bean ice cream and sherbet should have been dated when first opened.
On 06/15/2023 at 2:56 PM, Staff M, stated that the food items should have been dated when they were first opened.
USE OF KITCHEN THERMOMETER IN THE MAIN KITCHEN
On 06/14/2023 at 10:46 AM, Staff N, Sous Chef, was observed taking temperatures of the food items. Staff N placed a kitchen thermometer into the quesadillas, then placed the thermometer on the metal counter table with the metal tip of the thermometer touching the counter table first. Staff N, then proceeded to place the thermometer into the vegetable garden soup without sanitizing the thermometer. Staff N stated that they did not wash or clean the kitchen thermometer between food items when taking the food temperature.
USE OF KITCHEN THERMOMETER IN THE SECOND FLOOR KITCHEN
On 06/14/2023 at 11:17 AM, Staff P, Dietary Aide, was observed taking the temperature of foods prepared for the lunch meal. Staff P poured sink water into a glass cup, placed the kitchen thermometer metal tip in that water, and then dried the thermometer with a paper towel. Staff P took the temperatures of ham, mayonnaise, pickles, red whole onion, salsa, sour cream, and guacamole without sanitizing the thermometer between food items. Staff P rinsed the metal tip of the thermometer into the same cup of water and dried the thermometer with the same paper towels when taking the temperature between food items. Additionally, Staff P rinsed the tip of the thermometer in warm water that read 110 degrees Fahrenheit prior to taking the temperature of hot food items. Staff P took the temperature of garden vegetable soup and quesadillas without sanitizing the thermometer between food items. Staff P rinsed the thermometer in the warm water and dried the thermometer with paper towel when taking the temperature between foods. Staff P stated that they followed that process daily.
On 06/15/2023 at 3:53 PM, Staff O, Sous Chef/Lead Cook, stated that their expectation was for staff to sanitize the thermometer with alcohol wipes between taking the temperature of food items to prevent cross contamination.
USE OF HAIR RESTRAINTS
On 06/14/2023 at 10:31 AM, Staff N, was not wearing a hair covering/restraints in the kitchen while preparing and cutting up quesadillas and when taking the temperatures of the food items for the residents.
On 06/14/2023 at 10:39 AM, Staff Q, Dining Services, was not wearing a hair covering/restraints in the kitchen while cutting up quesadillas.
On 06/14/2023 at 12:07 PM, Staff M, stated that their expectation was that kitchen staff used head covers a hair net or a hat while in the kitchen preparing food for the residents.
Reference: (WAC) 388-97-1100 (3)
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure the facility assessment was updated to accurately determine and identify the resources needed for the facility's resident care needs...
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Based on interview and record review, the facility failed to ensure the facility assessment was updated to accurately determine and identify the resources needed for the facility's resident care needs. This failure had the potential to affect the provision of care and services for the residents who reside in the facility.
Findings included .
Review of the facility assessment provided by the facility showed that it was undated, unable to determine when the facility assessment was updated and/or reviewed. Since the last update there had been significant changes such as:
- The listed name of the social worker was no longer current.
- There was no full-time social services coordinator.
- There was no full-time certified dietary manager (CDM).
These significant changes affected the day to day and emergency operations systems in the facility and required a comprehensive re-assessment of resources and facility capabilities.
Review of the facility assessment provided by the facility showed that assistance with activities of daily living, bowel/bladder status, mental status, special care, medications and other, did not provide accurate and updated information when compared to CMS (Centers of Medicare [government health insurance] and Medicaid [government health insurance] Services) form 672 (a form with resident census and conditions of residents) received by the facility.
Further review of the facility assessment under Other, List contracts, memoranda of understanding, or other agreements with third parties to provide services or equipment to the facility . Use and /or refer to: ., contract book. List of contracts and/or agreements with third parties was not listed in the facility assessment.
On 06/16/2023 at 2:42 PM, Staff A, Health Services Director, stated that they were pursuing updated contracts for hospice (end of life care), staffing agency, pharmacy, rehab, and others. Contract binder was not available to review at time of request. Staff A stated that their CDM and social worker personnel left.
06/16/2023 at 2:42 PM, Staff B, Director of Nursing stated that they were not sure on how to determine acuity (measurement of the level of nursing care required by a patient based on severity of either an illness or mental condition) of the resident population. Staff B acknowledged that the facility assessment was not up to date.
Reference: (WAC) 388-97-1620(2)(b)(i)(ii)
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MINOR
(C)
Minor Issue - procedural, no safety impact
Menu Adequacy
(Tag F0803)
Minor procedural issue · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure pre-planned menu posted in the dining room was accurately posted and updated with the current menu for 1 of 1 dining r...
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Based on observation, interview, and record review, the facility failed to ensure pre-planned menu posted in the dining room was accurately posted and updated with the current menu for 1 of 1 dining room (Second Floor Dining Room). This failure placed the residents, their representatives, and visitors at risk of not being fully informed of the current pre-planned menu.
Findings included .
On 06/13/2023 at 8:30 AM, observed that the menu in the Second Floor Dining Room were dated 04/01/2023 to 04/07/2023 Week 3, and 04/08/2023 to 04/14/2023 Week 4 for lunch and dinner were not current.
On 06/13/2023 at 11:17 AM, a joint record review of the menu posted in the Second Floor Dining room with Staff D, Medical Records Coordinator, stated that the menu were current for that week. Further review with Staff D showed that the lunch menu for Tuesday was vegetarian chili, fresh fruit, turkey & biscuit (with gravy, mashed potatoes, and sauteed spinach), roast and beef sandwich, and a brownie.
On 06/13/2023 at 11:23 AM, Staff D asked Staff P, Dietary Aide, what was in the menu. Staff P stated that they had fried chicken and gravy with mashed potatoes and green beans for lunch that day. Staff D stated that they were going to change the menu and brought a current one and posted it in the Second Floor Dining Room, and the menus brought by Staff D were dated 03/18/2023 to 03/24/2023 (the menu did have the current dates for that week).
On 06/14/2023 at 11:49 AM, Staff M, Executive Chef, stated that they update the menu in the Second Floor Dining Room after the registered dietitian reviewed and approved them. Staff M removed the old menu from the dining room, which dated 03/18/2023 to 03/24/2023 and replaced it with menu dated 06/10/2023 to 06/16/2023 and 06/16/2023 to 06/24/2023.
Reference: (WAC) 388-97-1160 (1)(b)
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Apr 2022
17 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
Based on interview and record review the facility failed to ensure a 1 of 3 residents (Resident 16) reviewed for Advanced Health Care Directive (AD) and/or had an alternate decision maker in place. Fa...
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Based on interview and record review the facility failed to ensure a 1 of 3 residents (Resident 16) reviewed for Advanced Health Care Directive (AD) and/or had an alternate decision maker in place. Failure to ensure Resident 16's decisions for treatment were available and ensure the Durable Power of Attorney (DPOA) was implemented within the guidelines established in the legal document is a violation of resident rights.
Findings included .
On 04/21/2022 at 2:25 PM, Staff M, Social Worker was interviewed about Resident 16. Staff M stated a family member was the DPOA and printed two documents from the emails she had received. The documents showed the resident had both a DPOA and an AD, signed on 01/06/2014.
When asked if anyone had discussed the Physician Orders for Life Sustaining Treatment (POLST) which indicated the resident was comfort care only and a do not resuscitate (DNR) had been signed by the DPOA. Staff M responded stating the physician determined the resident was not competent and needed assistance to make decisions and had signed the POLST.
Review of the DPOA, found it was for financial decisions. The document indicated the DPOA could assume health care decision, If at any time the principal (or resident) was diagnosed in writing to be in a terminal condition, or a permanent unconscious condition by two physicians having direct personal knowledge of the principal's condition (one of whom is a board-certified neurologist) . However, there was no evidence the resident was diagnosed with a terminal condition.
The AD and DPOA, dated 01/06/2014, signed by the resident included limited treatment options which included artificial hydration, and to receive necessary medications to relieve pain and suffering.
When asked about the DPOA, Staff M, said they were not aware of the guidelines established to indicating when the DPOA could make healthcare decisions. When asked why the documents were not in the medical record, Staff M did not provide any clarification.
Not ensuring Resident 16's AD and DPOA were available in the medical record contributed to confusion about what decisions were made for end-of-life treatment by the resident and when healthcare decisions could be made by the DPOA.
Reference: (WAC) 388-97-280 (3)(a)(c)(i-ii)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to report timely for two fall incidents for 1 of 57 residents (Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to report timely for two fall incidents for 1 of 57 residents (Resident 9), reviewed for incidents and/or accidents. This failure prevented the facility from ruling out abuse and/or neglect for a resident who was at high risk of falls.
Findings included .
According to the Nursing Home Guidelines, also known as the Purple Book, revised in October 2015, under the section titled, When to Report showed that allegation of abuse should be documented on the reporting log within 5 days of discovery [of the incident].
RESIDENT 9
Resident 9 was admitted to the facility on [DATE] for multiple care needs and had a re-admission date of 01/08/2022.
Review of the incident report log for January 2022 showed Resident 9 had 3 unwitnessed falls on 01/02/2022, 01/06/2022 and 01/08/2022. The fall for 01/06/2022 showed a logged date of 01/25/2022 on the incident report log, 19 days after the incident date. The fall for 01/08/2022 showed a logged date of 01/25/2022 on the incident report log, 17days after the incident date.
On 04/27/2022 at 9:41 AM, Staff B, Registered Nurse, Director of Nursing Services was asked about the facility's reporting process for incidents and/or accidents. Staff B stated incidents and/or accidents were logged on the incident report log within 5 days of the incident and/or accident. Staff B stated the deadline to log incidents/accidents on the incident report log was 5 days from the incident date.
On 04/27/2022 at 9:42 AM, Staff B reviewed the January 2022 incident log for Resident 9's falls and stated the falls for 01/06/2022 and 01/08/2022 were logged on 01/25/2022. When asked if the accidents were logged or reported timely on the incident report log, Staff B stated it was not timely. Staff B added that last January 2022, she was not aware that incident reports should be logged within 5days of the incident until she had consulted with their resource nurse.
Reference: (WAC) 388-97-0640 (5)(a)(6)(c)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure incident investigation reports were completed thoroughly 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 incident investigation reports were completed thoroughly and accurately for 1 of 7 residents (Residents 9) reviewed for incident investigation related to incidents and/or accidents. This failure prevented the facility from identifying the extent and nature of the accident/incident and placed the resident at risk for unidentified abuse and/or neglect or inappropriate corrective actions or interventions related to accidents and incidents.
Findings included .
Resident 9 was admitted to the facility on [DATE] for multiple care needs and had a re-admission date of 01/15/2022.
Review of the incident report log from November 2021 to April 2022 showed Resident 9 had 2 falls in December 2021 and 3 falls in January 2022. The falls For December 2021 happened on 12/02/2021 and12/27/2021. The falls for January 2022 happened on 01/02/2022, 01/06/2022 and 01/08/2022.
Review of Resident 9's fall incident investigation report (IIR) for 01/08/2022 at 8:25 AM showed under immediate action taken that Resident 9 was sent out to the hospital due to the right hip pain. Under the same section, there was a question if the resident was taken to [the] hospital and it was answered for N [No].
On 04/27/2022 at 9:47 AM, Staff B, Director of Nursing Services stated she was the person responsible for reviewing the accuracy of the incident investigation report to ensure the safety of the resident, the information on the record were accurate, the data gathered were correct on what happened and if the incident or accident was avoidable or not.
On 04/27/2022 at 9:49 AM, a joint record review of the fall IIR for 01/08/2022 was conducted with Staff B. When asked if the fall IIR was reviewed thoroughly and completed accurately, Staff B stated it was not for it was marked N for no and should have been marked as a Y or yes that resident was sent out to the hospital.
Review of Resident 9's fall IIR for 01/02/2022 at 4:00 AM showed under immediate action taken that pressure was applied to the head laceration to stop the bleeding and 911 (emergency alert system) was called and resident was transported to the hospital. Under the same section, there was a question if the resident was taken to [the] hospital and it was answered for N [No]. For the section injuries observed at time of incident, there was documentation that stated, No injuries at time of incident.
On 04/27/2022 at 9:57 AM, Staff B reviewed the fall IIR for 01/02/2022. Staff B stated the IIR was not accurate for resident was sent out to the hospital and there was obvious injury [bleeding to the scalp].
Review of Resident 9's fall IIR for 12/02/2021 at 5:30 AM showed under incident description that Resident 9 was found in the bathroom lying on her right side and had a skin tear to the right elbow and 2 skin tears to the right knee. For the section injuries observed at time of incident, there was documentation that stated, No injuries at time of incident.
Further review of the fall IIR for 12/02/2021 at 5:30 AM showed there was no documentation that notification was made to the provider or the family regarding the fall with skin tears.
Review of the progress notes for 12/02/2021 and 12/03/2021 showed no documentation related to the 12/02/2021 fall incident.
On 04/27/2022 at 9:58 AM, Staff B reviewed the fall IIR for 12/02/2021 and found the no injury documentation. Staff B then discovered that the software would do an automatic entry of No injuries at time of incident if the section for injuries observed at time of incident was not filled out with information or answer. Staff B stated it was her responsibility to fill out the type of injury on the software for the nurses would only describe the incident but not fill out the section type of injury. Staff B stated that even if there was software issue, it was still her responsibility to ensure accuracy of the IIR.
On 04/27/2022 at 10:02 AM, Staff B stated that it was an expectation for notification to be done for any fall incidents. Staff B stated there was no documentation that notification was made to the family or provider regarding the fall for 12/02/2021.
Reference: (WAC) 388-97- 0640 (6)(a)(b)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
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 comprehensive assessments and Care Area Assessments (CAAs) w...
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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 comprehensive assessments and Care Area Assessments (CAAs) were completed timely as required for 1 of 12 residents (Resident 170) reviewed for comprehensive Minimum Data Set (MDS) assessments and CAAs. The facility's failure in ensuring comprehensive assessments and CAAs were completed timely as required placed the residents at risk for delayed or unidentified 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, Version 1.17.1, and dated October 2019, under Section 5.2 Timeliness Criteria, for the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600).
RESIDENT 170
Resident 170 was admitted to the facility on [DATE] for multiple care needs.
Review of the admission MDS Assessment, with Assessment Reference Date (ARD) of 04/06/2022 showed an entry date (A1600) of 03/30/2022 and the MDS completion date (Z0500B) was signed as completed on 04/13/2022, 14 days after the entry date.
On 04/26/2022 at 2:37 PM, Staff B, Registered Nurse, Director of Nursing Services was interviewed about the completion of the MDS. After a review of the admission MDS with an ARD of 04/06/2022, Staff B stated the MDS was completed on 04/13/2022. Staff B stated that the MDS should have been completed on 04/12/2022.
Reference: (WAC) 388-97-1000 (5)(b)
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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 conduct a timely significant change of condition Minimum Data Set (...
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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 timely significant change of condition Minimum Data Set (MDS) assessment for 1 of 1 resident (Resident 4) reviewed for significant change in condition. The failure to complete a significant change of condition assessment within 14 days when there was a decline placed the resident at risk for unmet care needs and a diminished quality of life.
Findings included .
Record review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, and dated October 2019, under Section 5.2 Timeliness Criteria, showed significant Change in Status Assessment must be completed no later than 14 days from the Assessment Reference Date or ARD (A2300) and no later than 14 days from the determination date of the significant change in status. (For purpose of this section, a significant change means a major decline in status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status).
Resident 4 was admitted to the facility on [DATE] for multiple care needs.
Review of Resident 4's clinical records showed that Resident 4 was admitted to hospice care on 10/04/2021.
Review of Resident 4's electronic health records showed a significant change in status MDS assessment was completed with an ARD (A2300) of 10/18/2021. The MDS completion date (Z0500) was signed as completed on 11/22/2021, 35 days after the ARD date.
On 04/22/2022 at 11:24 AM, Staff B, Registered Nurse/Director of Nursing Services was asked regarding the process for MDS completion. Staff B stated comprehensive assessments such as the significant change in status MDS assessments had to be completed 2 weeks (14 days) from the ARD [should be completed within 14 days from the date hospice was initiated]. Following a review of the significant change in status MDS assessment with an ARD date of 0/18/2021, Staff B stated the MDS was completed on 11/22/2021. When asked if the MDS was completed timely, Staff B stated that it was completed timely for it got accepted. Following a discussion regarding the requirement for completing the MDS, Staff B stated that there was an issue with the timeliness of the significant change in status MDS assessment that was completed late on 11/22/2021.
Reference: (WAC) 388-97-1000(3)(b)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 5
Resident 5 was a long-term care resident of the facility with multiple care needs. Review of the resident's quarterl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 5
Resident 5 was a long-term care resident of the facility with multiple care needs. Review of the resident's quarterly MDS dated [DATE] showed Resident 5 needed extensive assistance of one person with toilet use.
Review of the clinical records showed the resident was incontinent of bowel and bladder and was on a toileting program.
Review of Resident 5's quarterly MDS dated [DATE], showed Section H0200A1 (Urinary Toileting Program - has a trial of a toileting program [e.g., scheduled toileting, prompted voiding, or bladder training] been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility) was coded No. Review of Section H0500 (Bowel toileting Program - is a toileting program currently being used to manage the resident's bowel continence) showed it was marked No [indicating the resident was not on bowel toileting program].
On 04/25/22 at 10:40 AM, Staff B, MDS Coordinator stated that Resident 5 was on a bowel and bladder program and Sections H0200A1 and H0500 on the MDS should have been coded Yes.
Reference: (WAC) 388-97- 1000 (1)(b)
Based on interview and record review, the facility failed to accurately assess 2 of 12 residents (Residents 4 and 5 ) for whom Minimum Data Set (MDS) assessments were reviewed. The failure to ensure accurate assessments regarding administered medications and bowel and bladder program placed the residents at risk for unidentified or unmet care needs including potential medication adverse reactions and a diminished quality of life.
Findings included .
Accuracy of Assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument ([RAI] i.e., comprehensive, quarterly, annual, significant change in status).
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 assessment and ends at 11:59 PM on the day of the Assessment Reference Date (ARD). Different items on the MDS have different Observation Periods. When the MDS is completed, only those occurrences during the observation period will be captured on the assessment.
RESIDENT 4
Resident 4 was admitted to the facility on [DATE] for multiple care needs.
Review of the Quarterly MDS assessment with ARD date of 01/18/2022 showed Resident 4 was coded under Section N0410 (Medications Received) to have received 2 days of anti-anxiety medication (Lorazepam, a type of anti-anxiety medication) and 1 day of opioid (a substance used to treat moderate to severe pain) medication (Morphine, a type of opioid medication) during the 7-day look-back period, which was from 01/12/2022 to 01/18/2022).
Review of Resident 4's January 2022 Medication Administration Record (MAR) showed that during the 7-day look back period from 01/12/2022 to 01/18/2022, Resident 4 had received Lorazepam on 01/16/2022, which was only for 1 day. Resident 4 had not received the Morphine during the 7-day look back period from 01/12/2022 to 01/18/2022.
On 04/27/2022 at 8:48 AM, Staff B, Registered Nurse, Director of Nursing was asked regarding the look back period for coding the MDS and stated that the 7day look back period would include from 01/12/2022 to 01/18/2022. Following a record review of the Quarterly MDS with ARD date of 01/18/2022, Staff B stated that Section N0410 showed that Resident 4 was coded to have received 2 days of anti-anxiety medication and 1 day of opioid medication. Following review of the January 2022 MAR, Staff B stated that Section N0410 should have been coded to have received 1 day of anti-anxiety medication (Lorazepam) instead of 2 days and should have been coded 0 (zero) day for use of opioid medication (Morphine). Staff B stated that Section N0410 of the Quarterly MDS was not coded correctly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review, revise or update the care plans and/or conduct care plannin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review, revise or update the care plans and/or conduct care planning conferences for 2 of 12 residents (Residents 9 and 12) reviewed for care planning. The failure to review and revise/update care plans by the interdisciplinary team (IDT) and to conduct care planning conferences to involve resident and/or the resident representative after each assessment and/or when resident care requirements changed placed the residents at risk for unmet care needs and diminished quality of life.
Findings included .
RESIDENT 9
Resident 9 was admitted to the facility on [DATE] for multiple care needs and had a re-admission date of 01/15/2022.
Review of the incident report log from November 2021 to April 2022 showed Resident 9 had 2 falls in December 2021 and 3 falls in January 2022. The falls For December 2021 happened on 12/02/2021 and 12/27/2021. The falls for January 2022 happened on 01/02/2022, 01/06/2022 and 01/08/2022.
Review of Resident 9's clinical records showed a care plan for fall that was created on 06/18/2021 and revised on 12/08/2021, showed a documentation for actual fall for 12/02/2021. The care plan did not list the actual falls that occurred on 12/27/2021, 01/02/2022, 01/06/2022 and 01/08/2022.
On 04/27/2022 at 9:51 AM, Staff B, Registered Nurse, Director of Nurses was asked to review the care plan for risk for falls. Staff B stated the care plan for risk for fall was not updated to reflect the 01/08/2022 fall and the other fall incidents.
RESIDENT 12
Resident 12 admitted to the facility on [DATE] for mulitple care needs.
In an interview with Resident 12 on 04/19/2022 at 10:32 AM, the resident was not able to recall if he had attended a care conference.
Review of the resident's record showed that the resident had a care conference on 12/03/2021 and that the resident was in attendence.
In an interview with Staff E, Social Services Director on 04/27/2022 at 9:50 AM, when asked how often care conferences occurred, she stated quarterly roughly in line with the Minimum Data Set (MDS-an assessment tool) schedule. When asked if Resident 12 had a care conference since December 2021, she repiled no. Staff E stated Resident 12 should have had a care conference in Feburary of 2022.
Reference: (WAC) 388-97-1020 (2) (f)(5)(b)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 3 of 12 residents (Resident 4, 9 and 170) reviewed for physician orders, medication side effects monitoring, and skin treatment. The failure of the nursing staff to follow or review physician's orders and/or ensure wound treatment protocol was followed placed the residents at risk of unidentified side effects to medications, not receiving wound and pain treatment on the correct location and adverse outcomes.
Findings included .
RESIDENT 4
Resident 4 was admitted to the facility on [DATE] with multiple diagnoses including memory loss.
Review of Resident 4's clinical records showed that Resident 4 had physician orders for Quetiapine (an antipsychotic medication or AP, is a medication used to treat mental health problems or behaviors) with a start date of 12/28/2021 and Citalopram (an antidepressant medication or AD, is a medication used to manage mood or emotions) with a start date of 01/26/2022. Resident 4 was not taking any anti-anxiety medication (or AA, medication used to control or manage anxiety).
Review of Resident 4's April 2022 Medication Administration Records (MAR) showed Resident 4 was monitored for side effects related to the use of AA medication and nurses were signing it every shift even if the resident was not taking AA medication.
Further review of Resident 4's April 2022 MAR showed the order for monitoring the side effects related to use of AP and AD medications stated, Document: 'Y' if monitored and any of the above [a list of side effects was listed prior] was observed, select chart code 'other/see nurses notes' and progress note findings. 'N' if monitored and none of the above was observed. The nurses were putting check marks and their initials for monitoring and were not documenting N or Y' if a side effect was observed or not.
On 04/27/2022 at 8:55 AM, Staff B, Director of Nursing Services (DNS) was asked regarding the expectation for following orders in the MAR. Staff B stated that it was the expectation for nurses to read the order, follow the instructions and/or do what the order states. Following a review of Resident 4's April 2022 MAR, Staff B stated that Resident 4 was no longer taking an AA medication and the nurses should have discontinued the monitoring for the side-effects related to use of AA medication for it was no longer needed. Following a review of the nurses' documentation for monitoring of side effects related to use of AP and AD medications where there was no mark for N or Y, Staff B stated the nurses were not reading and following the instructions on the order. Staff B stated that because it was not marked as N for no or Y for yes, there was no way to determine if side effects were observed or not.
NOT FOLLOWING ORDER FOR PAIN PATCH PLACEMENT
RESIDENT 9
Resident 9 was initial admitted to the facility on [DATE] and was re-admitted from the hospital on [DATE]. Resident 9 had multiple diagnoses including pain to the lower back.
On 04/19/2022 at 9:28 AM and on 04/21/2022 at 11:44 AM, Resident was observed to have a Lidocaine patch (pain medication that is administered in the form of a patch) to the right outer thigh.
Review of Resident 9's clinical record showed a physician order for Lidocaine patch, Apply to LOWER BACK topically one time a day for PAIN and remove per schedule with a start date of 06/09/2021.
Review of Resident 9's April 2022 MAR showed the Lidocaine patch was applied and removed from the right thigh daily from 04/01/2022 to 04/07/2022 and from 04/15/2022 to 04/20/2022 and not on the lower back as ordered. On 04/14/2022, it was documented that the Lidocaine patch was administered and removed from the right leg and not on the lower back as ordered.
On 04/22/2022 at 8:00 AM, Staff B was asked where the Lidocaine patch would be applied, and she stated the order was to put it on the lower back.
On 04/22/022 at 11:35 AM, following record review of the April 2022 MAR for the order and application of the Lidocaine patch, Staff B stated that the staff had been putting the patch on the right thigh. Staff B stated that Staff J, Licensed Practical Nurse (LPN) had reported that Resident 9's pain was on the right thigh. Staff B stated that the Lidocaine patch order should have been clarified with the provider if it can be applied to the right thigh instead of the lower back.
SIGNING FOR TREATMENT FOR A PRESSURE INJURY (BEDSORE) THAT HAD HEALED
On 04/19/2022 at 9:58 AM, Resident 9 was observed to have redness to both buttocks.
On 04/21/2022 at 11:43 AM, Resident 9's skin was observed during incontinence care. The skin to the lower back area over the sacral area (large triangular bone at the lower end of the spine) and over the coccyx (tailbone area) and the left buttock was intact and had no redness. The right buttocks had redness that blanches and was not open.
On 04/21/22 at 11:16 AM, a review of Resident 9's April 2022 Treatment Administration record (TAR) showed a treatment order for Stage II [partial-thickness skin loss with exposed dermis (layer of the skin)] to the bilateral buttocks ., with a start date of 01/15/2022. The nurses had been signing that they did the treatment to the pressure injury on the bilateral (both) buttocks, even if there was no pressure injury to the buttocks, only redness to the right buttock.
On 04/27/2022 at 10:08 AM, Staff B reviewed the clinical records for the presence of a pressure injury. Staff B stated that there was no record to show that Resident 9 had an existing pressure injury. Staff B reviewed the order on the April 2022 TAR and stated nurses were signing the treatment order for Stage II pressure injury to bilateral buttocks even if Resident 9 had no presure injury. Staff B stated that the physician order was discontinued on 04/25/2022 for the treatment that was not needed.
RESIDENT 170
Resident 170 was admitted to the facility on [DATE] for multiple care needs.
On 04/22/2022 at 8:43 AM, Staff J, LPN, was observed do a dressing change to Resident 170's right buttock and sacral area (area at the bottom of the spine or lower back, between the upper buttocks). Staff J did not mark the dressing with a date or an initial after applying it.
On 04/22/2022 at 8:55 AM, Staff J was asked regarding their process for doing wound dressing or treatment. Staff J stated that it was an expectation to put the date and initial when doing dressing changes to know when the dressing had been changed. When asked if a date and initial was put on the dressing for Resident 170's wound, Staff J stated she forgot to put the date and initial for she was in a hurry to do other jobs.
Review of Resident 170's clinical records showed an order for use medihoney [a type of wound ointment/treatment] with duaderm [sic] covering [type of wound dressing] until resolved. every 72 hours for bedsore, with a start date of 04/15/2022. The order did not include a site or location for the bedsore that needed treatment.
On 04/26/2022 at 2:45 PM, Staff B was asked to review the treatment orders for Resident 170. Staff B stated the order for the use of the medihoney, with a start date of 04/5/2022, was incomplete for it did not include the site where to apply the treatment or dressing.
Reference: (WAC) 388-97- 620 (2)(b)(i)(ii),(6)(b)(i)
CONCERN
(D)
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 interview, and record review, the facility failed to ensure assistance with activities of daily living (ADL) related to...
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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 assistance with activities of daily living (ADL) related to bathing was provided for 1 of 2 dependent residents (Resident 170) reviewed for activities of daily living. This failed practice placed the resident at risk for unmet care needs and diminished quality of life.
Findings included .
Resident 170 was admitted to the facility on [DATE] for multiple care needs.
On 04/19/2022 at 2:33 PM, Resident 170 stated he had not gotten a shower since admission to the facility.
Review of Resident 170's clinical records showed no bathing information on the [NAME] (a record that provides summaries and overviews of residents' care in long term care facilities) regarding bathing schedule and assistance needed. There was no documentation on the ADL record sheet that bathing was provided. The bathing task list record from 03/30/2022 to 04/20/2022, showed no record found that bathing of any kind was provided. The progress notes from 03/30/2022 to 04/20/2022 did not have any documentation that bathing was provided or was refused by Resident 170.
Further review of the clinical records showed Resident 170 was care planned for ADL. The care plan did not have information related to bathing: bathing preference (shower tub bath or bed bath), bathing schedule (frequency, day of the week and if to be given on day shift or evening shift) and the assistance needed to do the bathing.
On 04/22/2022 at 11:57 AM, Staff B, Director of Nursing Services was asked regarding bathing including documentation. Staff B stated there was a daily shower schedule, showers were done on day shift and evening shift by the Nursing Assistants, and showers/bathing were scheduled to be given 2x/week. Following a record review of the bathing task list record from 03/30/2022 to 04/22/2022, Staff B stated there was no record if bathing was done.
On 04/22/2022 at 12:05 PM, Staff H, Medical Records/admission Coordinator stated that Resident 170 had been refusing shower and documentation for refusal would be on the progress notes. At 12:30 PM, Staff H provided copies of the progress notes from 03/30/2022 until 04/22/2022 and stated that there was no documentation about refusal for bathing or shower.
On 04/26/2022 at 2:30 PM, Staff B stated that it was an expectation for the resident to be asked about his bathing preference and this information would be on the ADL care plan. Following a review of the ADL care plan, Staff B stated that the ADL care plan did not have information regarding bathing.
On 04/27/2022 at 10:54 AM, Staff B reviewed the shower sheets that the Nursing Assistants filled out and stated that Resident 170 had a bed bath on 03/31/2022, a shower on 04/09/2022, and no record of bathing or shower for the week of 04/10/2022 to 04/16/2022. Shower was not provided 2x/week per facility's practice and no documentation of refusal either. Staff B stated that documentation for shower or bathing was a problem for the facility.
Reference: (WAC) 388-97-1060 (2)(c)
.
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** RESIDENT 16
Resident was admitted to the facility on [DATE] with diagnoses that included dementia (memory loss), and abnormaliti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 16
Resident was admitted to the facility on [DATE] with diagnoses that included dementia (memory loss), and abnormalities of gait and mobility.
Review of the resident's admission MDS dated [DATE] showed the resident had severe impaired cognition and needed extensive assistance of 2 persons with bed mobility and transfer.
Multiple observations on 04/20/2022, 04/21/2022, 04/22/2022, 04/25/2022, 04/26/2022 and 04/27/2022, showed Resident 16's had mobility bars in the up position on both the upper sides of the bed.
On 04/27/2022 at 8:05 AM, Staff J, Licensed Practical Nurse (LPN), was asked why Resident 16 had mobility bars and who had implemented its use. Staff J said the resident was using mobility bar to turn from side to side when staff were providing care in bed but could not find who had implemented the use of mobility bars. Staff J was asked what the facility process for safety use of mobility bars, and Staff J said a consent, physician orders, assessment, or evaluation for the mobility bars. In a joint record review of Resident 16's records with Staff J showed there was no consent, physican orders, assessment, or evaluation for the mobility bars. Staff J said there was no consent and physician orders and that assessment should be done initially [prior to installing them in bed], quarterly and annually. Staff J said that assessments could be done by normally by Physical/Occupational therapist and/or the nursing staff.
On 04/27/2022 at 8: 37 AM, Staff B stated that there was no consent, orders, assessment or evaluation for the mobility bar device in the resident's clinical records. When asked what was her expectation, Staff B said that she expected to have orders, consent and an assessment in place.
RESIDENT 18
Resident 18 was admitted to the facility on [DATE] with multiple diagnoses including repeated falls and fracture of the right femur (thigh bone).
On 04/22/2022 at 5:26 AM, Resident 18 was observed in bed, the bed was on low position, a fall mat on the floor on each side of the bed, and a personal caregiver at bedside.
Review of the incident report log for April 2022 showed Resident 18 had a fall on 04/20/2022 and 04/05/2022, and both falls happened on the night shift. Review of the fall incident investigation report (IIR) for 04/03/2022 showed that neurological exam would be done.
Review of the fall IIR for 04/05/2022 showed no documentation that the provider [MD - Medical Doctor] and family were notified.
Review of Resident 18's clinical records showed no record that vital signs such as temperature, blood pressure, respiration and pulse were checked on 04/04/2022, as part of the neurological exam following the 04/03/2022 fall incident. There was no documentation that the provider or family was notified of the 04/05/2022 fall incident. There was no record that a post fall assessment was done following the fall on 04/05/2022.
Review of the Resident 18's Care Area Assessment (CAA) summary dated 04/05/2022, showed that Resident 18 was a high fall risk, and the fall risk would be addressed in the care plan.
Further review of Resident 18's clinical record showed there was no care plan created related to high fall risk or history of repeated falls prior to admission. There was no care plan in place related to use of a low bed and fall mat. There was no record that an assessment and evaluation was done prior to the use of a fall mat or low bed.
On 04/27/2022 at 10:15 AM, Staff B was interviewed regarding their process related to post fall care and management. Staff B stated that it was an expectation for a resident that had a fall to have a post-fall assessment and a care plan for fall especially if it were a high risk so everyone would know what kind of care and interventions in place to address the risk for fall or history of falling. Following a record review of the clinical records related to fall, Staff B stated there was no initial or comprehensive care plan for fall and no post-fall assessment after the 04/05/2022 fall incident. Staff B stated that it was an expectation to have an assessment, evaluation, and care plan for use of the fall mat and low bed. Staff B stated there was no record of an assessment, evaluation, or care plan regarding use of low bed and fall mat. Staff B stated they have no form for the interdisciplinary team to fill out for the use of devices such as fall mat or low bed.
On 04/27/2022 at 10:24 AM, Staff B stated that if the fall was unwitnessed, the expectation was to do a neurological exam and alert charting. Following a review of Resident 18's clinical records. Staff B stated there was no documentation for alert charting, neurological exam, and vital signs for 04/04/2022 that should have been done every shift. Staff B provided a copy of the neurological assessment for the 04/03/2022 with a completed date of 04/20/2022, which was 17 days after the fall incident of 04/03/2022.
Reference: (WAC) 388-97-1060 (3)(g)
Based on observation, interview, and record review, the facility failed to consistently ensure safety assessments and/or evaluations were completed for the use of transfer pole, mobility bars and fall mat for 2 of 7 residents (Residents 10 and 16) reviewed for accidents and hazards. This failure placed the residents at risk for increased potential for a device-related incidents or accident.
Additionally, the facility failed to provide care and services for fall prevention and management including care planning for 1 of 7 residents (Resident 18) reviewed for accidents. These failures placed the resident who was identified as a high fall risk on admission at risk for more falls with potential for injury.
Findings included .
RESIDENT 10
Resident 10 admitted to the facility on [DATE] for multiple care needs.
Review of the resident's most recent quarterly Minimum Data Set (MDS), dated [DATE], showed the resident required the assistance of one staff for transfers.
Observation of the resident's room on 04/26/2022 at 11:27 AM, showed two transfer poles (one next to the bed and one next to the recliner chair).
In an interview with the resident on 04/26/2022 at 11:27 AM, when asked if she used the transfer poles for transfers, she stated sometimes but not very often. She stated that she recently had been using the sit to stand machine for transfers because it was easier.
In an interview with Staff G, Physical Therapist/Rehab Director, on 04/26/2022 at 1:47 PM, Staff G was asked who had implemented the use of the transfer pole for Resident 10. She stated it was a therapy intervention that had been put into place for the resident to be able to stay as independent as possible with transfers. Staff G stated Resident 10 had recently been on therapy, discharged from services on 02/02/2022, and it was reccomended to use the sit to stand for transfers because the resident's capabilities varied from time to time. The other reason for the sit to stand recommendation was that in the bathroom the resident had a hard time standing with the grab bars but if the resident and staff felt she was safe to use the transfer pole then it could be used.
In an interview with Staff B, Director of Nursing Services (DNS) on 04/26/2022 at 2:51 PM, when asked what evaulation and consents need to be in place for use a transfer pole, Staff B stated a consent, nursing evaluations (initial and quarterly), a physician order, and it should be on the care plan.
Further review of the resident's record did not include a consent, an order, a nursing evaluation or the use of the transfer pole on the resident's care plan. Staff B stated there was no consent, physician order, nursing evaluation or care plan for the use of the transfer pole.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with indwelling foley catheter (a 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 ensure a resident with indwelling foley catheter (a flexible tube that a clinician passes into the bladder and connected to a bag to drain urine) received appropriate care and services for 2 of 3 residents (Resident 3 &12) reviewed for foley catheter care. This failure placed the resident at risk for urinary catheter related infections and/or complications.
Finding included .
RESINDENT 3
Resident 3 was admitted to the facility on [DATE] with diagnoses that includes Benign Prostatic hyperplasia (BPH- an enlarged prostate blocking urine stream) and Urinary Tract Infection (UTI- bladder infection).
Review of resident's quarterly Minimum Data set (MDS), an assessment tool, dated 01/13/2022 showed the resident was alert and oriented and needed extensive assistance of 1 person with activities of daily living. Further review of the MDS showed the resident had an indwelling foley catheter.
On 04/19/2022 at 2:45 PM, the resident was observed seated in a recliner chair watching TV and had an indwelling catheter connected to a leg bag.
Review of the clinical records showed the resident has had recurring UTI's and no documentation of catheter care.
RESIDENT 12
Resident 12 was long-term care resident at the facility with diagnoses that included phimosis (a condition in which tight foreskin cannot be pulled back over the head of the penis resulting to urinary obstruction).
Review of the resident's quarterly MDS dated [DATE] showed the resident was alert and oriented, needed limited assistance of 1 person with activities of daily living, and had an indwelling foley catheter.
Review of the clinical records showed the resident was diagnosed with phimosis that resulted to urinary obstruction and underwent a surgical procedure in October 2022 that resulted to scarring, and Resident 12 elected to have a chronic indwelling catheter.
Further review of clinical records showed the resident was taking Ciprofloxacin (an antibiotic medication) on 07/01/2021 for UTI.
On 04/19/2022 at 11:22 AM, the resident was observed sitting in a recliner chair, and had a indwelling foley catheter connected to a leg bag.
On 04/21/2022 at 2:12 PM, Staff J, Licensed Practical Nurse, was asked who was responsible to perform catheter care and where was it being documented. Staff J said the nurses and the nursing aides were responsible and they were being done daily and recorded in the task under catheter care. During a joint record review, Staff J could not find the urinary catheter care documentation for both Resident 3 and Resident 12.
On 04/21/2022 at 2:38 PM, Staff B, Director of Nursing Services, stated that both Resident 3 and Resident 12 had indwelling catheters, but the urinary catheter cares tasks had been discontinued. Staff B did not know why and there was no documentation that catheter care was being done and that catheter care should be done daily to prevent UTI, and it should be documented under catheter care task and/or in the nursing progress notes.
Reference: (WAC) 388-97-1060 (3)(c)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure staffing hours were accurately posted and updated daily for 7 days when reviewing for sufficient staffing. This failur...
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Based on observation, interview, and record review, the facility failed to ensure staffing hours were accurately posted and updated daily for 7 days when reviewing for sufficient staffing. This failure placed the residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels and census information.
Finding included .
Review of the facility nursing staff posting on 04/19/2022, 04/20/2022, 04/21/2022, 04/22/2022, 04/25/2022, 04/26/2022, 04/27/2022 for the period of survey, showed no actual hours was posted for the nursing staff.
On 04/27/2022 at 8:42 AM, during a joint record review and interview, Staff B, Director of Nursing Services was asked if the staffing hours were posted at the nurses' station, the DNS said No, but it is supposed to have staffing hours.
No Reference WAC.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 04/22/2022 at 6:07 AM, in an observation with Staff J and Staff K, Registered Nurse, were performing controlled medication (m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 04/22/2022 at 6:07 AM, in an observation with Staff J and Staff K, Registered Nurse, were performing controlled medication (medication that is regulated by the government) count, at the change of shift for refrigerated controlled medications in the medication room in the skilled nursing floor. A bottle of liquid Ativan (Lorazepam -an antianxiety medication) was stored in a locked box in the refrigerator of the medication room. Staff J removed the locked box from the refrigerator and lifted the lid to the lock box without inserting the key to unlock the box. Staff J then closed the lid, inserted the key into the lock, attempted to lock and unlock the box, and stated that the lock was broken.
On 04/22/2022 at 6:10 AM, Staff K was asked if the lock was working when she performed the controlled medication count, at the beginning of her shift on 04/21/2022. Staff K stated that the lock was broken when she began her shift and stated that she did not know how long the lock had been broken. Staff K was asked who she notified that the lock was broken. Staff K stated that she did not notify anyone.
Staff K and Staff J were asked what the facility policy was for securing controlled medications. Staff K and Staff J stated that the policy was that all controlled medications need to be secured with 2 locks and counted at each shift change.
Reference: (WAC) 388-97-1300 (2)
Based on observation, interview, and record review, the facility failed to ensure medications were properly secured/stored for 1 of 19 residents (Resident 12) and ensure controlled medication was properly locked in permanent affixed compartment for 1 of 2 medication cart (Cart 2) reviewed for medication storage. These failure placed the residents at risk for unauthorized access to medications and for the potential abuse of controlled medication.
According to the facility policy revised on 05/15/2018, showed:
1. Medication storage in the facility: Self-administered bedside medication storage: Medications and biologics are to be stored safely, securely, and properly in the medication room, cart, and medication supplies. Beside medication storage is permitted for residents who wish to self-administer medication, upon the written order of the prescriber once self-administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team.
2. Medication storage for controlled substance: Medication classified as schedule II-V (controlled substance) should be in a double locked compartment separate from all other medication.
Finding included .
MEDICATION AT BEDSIDE
RESIDENT 12
Resident 12 was admitted to the facility on [DATE] with diagnoses that included Gastro Esophageal Rreflex Disease (GERD - Acid Reflux).
Review of the resident's Medication Administration Record for March 2022 showed an order for Tums Tablet Chewable 500 MG (Milligram) (Calcium Carbonate - an antacid). Give 2 tablet by mouth every 6 hours as needed for GERD.
Observation on 04/25/22 at 9:05 AM, showed Resident 12 had unlabeled bottle of Calcium Carbonate (Tums) 500 MG at bedside. The resident stated he normally keeps his bottle of Tums at bedside and takes it when he needs it.
On 04/25/2022 at 9:16 AM, a joint observation with Staff J, Licensed Practical Nurse (LPN), showed a bottle of Tums at the bedside and stated that the medication was supposed to be stored in the medication cart and not at the resident's room.
On 04/25/2022 at 11:47 AM, Staff B, Director of Nursing Services, stated that it was her expectation that all medications are to be stored in a medication cart and not in the resident's room. Staff B said for a resident to keep medications at bedside or self-administer medication, they need to have medication administration assessment and approval from their primary care provider. When asked if Resident 12 had been assessed or had an approval to keep or self-administer medication, Staff B said no.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP- person who make sure healthcare workers and residents were doing all the things they should to prev...
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Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP- person who make sure healthcare workers and residents were doing all the things they should to prevent infections) had the training and certificate in place to do the role. This failure placed the residents at risk for unmet infection control issues or care needs.
Findings included .
On 04/19/2022 at 8:25 AM, Staff A, Administrator, during the entrance conference, he stated that Staff B, Registered Nurse (RN) was the Infection Preventionist at the facility.
On 04/21/2022 at 2:43 PM, Staff B, RN, Director of Nursing Services was asked for a copy of the Infection Preventionist Certificate and the roles she had at the facility. Staff B stated that she does the role of the DNS, Staff Development Coordinator, and the IP. Staff B stated she did not have the training as an Infection Preventionist and had no Infection Preventionist Certificate.
No reference WAC.
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LACK OF ORDER FOR COLOSTOMY CARE
RESIDENT 12
Resident 12 was admitted to the facility on [DATE] with diagnoses that included div...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LACK OF ORDER FOR COLOSTOMY CARE
RESIDENT 12
Resident 12 was admitted to the facility on [DATE] with diagnoses that included diverticulitis (an inflammation or infection in one or more pouches in the digestive tract).
Review of the resident's quarterly Minimum Data Set (MDS- an assessment tool) dated 01/13/2022 showed the resident was alert and oriented, needed limited assistance of 1 person with activities of daily living, and had a colostomy (an operation that redirects the colon to anew opening thru the abdominal wall to excrete waste material).
On 04/22/2022 at 9:43 AM, the resident was observed to have a colostomy bag and a belt to hold peristomal hernia (when a loop of bowel bulges through an opening in the muscle that was made by the surgeon for the stoma (opening) to pass through).
On 04/22/2022 at 9:51 AM, Staff J, Licensed Practical Nurse (LPN), was asked how they were managing the resident's colostomy. Staff J said they emptied the colostomy bag every day and change the bag every 4 days. Staff J was asked where one would get the order for colostomy care/management and the required supplies. Staff J said the order would be found in the physician orders and in the TAR. A joint record review was conducted and Staff J stated there was no order for the management of colostomy care and/or its supply material.
On 04/25/2022 at 3:23 PM, Staff B stated that there were no orders for the colostomy care and colostomy supplies. Staff B said it was her expectation that the order should be in place.
Reference: (WAC) 388-97-1060(1)
Based on observation, interview, and record review, the facility failed to ensure skin assessments were conducted and documented thoroughly, skin issues and/or pressure injuries (PI, or bedsores) were monitored and treated timely, and care plans were developed and/or updated for 4 of 6 residents (Residents 4, 18, 9 and 170) reviewed for skin conditions and PI.
Additionally, the failed to obtain an order for colostomy care for 1 of 1 Resident (Resident 12) reviewed for colostomy care.
These failures placed the residents at risk for unmet care needs, adverse consequences and/or related complications.
Findings included .
SJIN CONDITIONS, NOT PRESSURE INJURY RELATED
RESIDENT 4
Resident 4 was admitted to the facility on [DATE] for multiple care needs.
Review of February 2022 incident report log showed Resident 4 had a bruise to the right lower arm on 02/14/2022, and to the right calf (back of the right lower leg) on 02/23/2022.
Review of Resident 4's incident investigation report (IIR) for 02/14/2022 at 8:42 AM showed a bruise to right lower arm and IIR for 02/23/2022 at 11:39 AM showed a bruise to the right calf.
Review of Resident 4's clinical records did not show monitoring for bruise to the right lower arm and to the right calf on the February 2022 Treatment Administration Records (TAR). There was no charting that notification was made to the provider and the family regarding the bruises to the right lower arm and right calf.
Further review of the clinical records showed there was no weekly skin tool (form used for weekly skin check or assessment) for the month of January 2022. The January 2022 TAR showed skin check was scheduled every Thursday evenings and to mark - if skin was intact and + if there was a new problem. The nurses had been signing the weekly skin checks on the January 2022 TAR for 01/06/2022, 01/13/2022, 01/20/2022 and 01/27/2022. There was no skin tool form on the electronic health record for 01/06/2022, 01/13/2022, 01/20/2022 and 01/27/2022. The weekly skin check was marked +, meaning new skin problem, on 01/06/2022. There was no documentation by the nurse of the new skin problem that was identified on the TAR for 01/06/2022.
On 04/26/2022 at 2:09 PM, a joint record review of Resident 4's clinical record and shower sheets was conducted with Staff B, Director of Nursing Services (DNS). Staff B stated their process would be for the Nursing Assistanta to check the skin during shower and to mark any skin issue on the shower sheet. Staff B stated the nurses were expected to do skin assessment weekly using the skin tool form. Staff B stated there was no record or documentation about the new skin issue that the nurse had marked on the TAR for 01/06/2022. Staff B added that there was no skin tool form for January 2022 which was the expected documentation for nurses to do when doing weekly skin checks.
On 04/26/2022 at 2:21 PM, a joint record review of Resident 4's care plan for skin was conducted with Staff B. The care plan for skin showed an intervention to monitor surgical incision every shift which was created on 12/04/2020. Staff B stated the monitoring for the surgical site should have been discontinued for it was no longer applicable since the surgical site had been noted a long time ago in 2020.
On 04/26/2022 at 2:23 PM, Staff B was asked about their process if there was a new bruise. Staff B stated the expectation was to do an incident investigation report, to monitor the bruise in either the TAR or Medication Administration Record (MAR) and to notify the family and provider (Medical Doctor). Following a review of the clinical records, Staff B stated there was no record that the provider and family were notified of the bruise noted on 02/23/2022. The February 2022 MAR and TAR showed no monitoring for the bruises noted on 02/23/2022.
RESIDENT 18
Resident was admitted to the facility on [DATE] for multiple care needs.
On 04/19/2022 at 11:18 AM and on 04/21/2022 at 10:54 AM, Resident 18 was observed to have a Mepilex (foam dressing) to the front of his right lower leg, had white bordered dressing to his right forearm (RFA), and steri-strips (type pf dressing for skin tears) to the back of his left hand.
Review of Resident 18's clinical records showed the nurses were signing the April 2022 TAR for weekly skin but no weekly skin tool (the form the nurses were expected to fill out for weekly skin check documentation) for April 2022.
Further review of the April 2022 showed a treatment order to monitor the skin tear on the RFA and to Cleanse with NS [normal saline, type of solution] steristrips applied with telfa [nonstick dressing pad] and rolled bandage. every shift with a start date of 03/26/2022. The white bordered dressing that was observed on the RFA did not match the dressing that was ordered and signed by the nurses every shift on the April 2022. There was no treatment order for the skin tear on the back of the left hand or for the skin issue on the right lower leg.
On 04/21/2022 at 2:09 PM, Staff M, Registered Nurse, was asked if Resident 18 had any skin issue and Staff M stated there was no existing skin issue. Staff M was asked about the dressing noted on Resident 18 and Staff M stated the steri-stips on the back of the left hand was from the hospital and was not a new skin issue, the bordered gauze dressing to the RFA was from the hospital and the foam dressing to the right lower leg that had no date and initial was from the hospital too. Resident 18 had been in the facility for 30 days following admission from the hospital on [DATE]. Staff M stated resident had refused when she tried to do dressing change to the RFA every 3 days. The April 2022 TAR showed the nurses were signing the treatment order for the RFA every shift and had no refusal. Following a review of the April 2022 TAR, Staff M stated there was no treatment order for the skin issues on the back of the left hand and the right lower leg.
On 04/22/2022 at 11:39 AM, Staff B was interviewed regarding the facility's skin care and management process. Staff B stated weekly skin checks were on shower days. Following a review of Resident 18 skin check records, Staff B stated that there were missing weekly skin checks by nurses for April 2022 for the record only had a 03/28/2022 weekly skin tool form.
On 04/22/2022 at 11:47 AM, Staff B stated that if a resident refused care including treatment, there should be a documentation for the refusal such as in the treatment order in the TAR or the progress notes. Following a review of the April 2022 MAR and TAR, Staff B stated that the nurses were signing that they provided treatment to RFA using the Telfa and rolled bandage dressing. Staff B confirmed that there was no treatment order for the right lower leg and the skin tear on the back of the left hand.
SKIN CONDITIONS, PRESSURE INJURY RELATED
RESIDENT 18
Resident was a newly admitted to the facility on [DATE] for multiple care needs.
Review of the facility's matrix for new admission showed Resident 18 had a Stage 1 (non-blanchable [reddened areas of tissue that do not turn white or pale when pressed firmly with a finger or device] erythema [redness] of intact skin) to the left heel. The matrix did not specify if the PI was a facility-acquired (developed in the facility).
On 04/19/2022 at 11:18 AM, Resident 18 was observed with a SAGE boot (foam boot to help relieve pressure on the heel) on his left foot. On 04/21/2022 at 2:07 PM, Resident 18 was observed in bed, was on a specialty mattress and had no SAGE boot to his left foot. The SAGE boot was on the shelf by the wall. The private caregiver offered to apply the SAGE boot but Resident 18 refused to have it on. On 04/22/2022 at 5:28 AM, Resident 18 was observed sleeping and the SAGE boot was on the wall shelf next to the window.
Review of Resident 18's admission skin assessment documentation dated 03/21/2022, showed Resident 18 did not have a Stage I PI to his left heel when he was admitted . The weekly skin check documentation for 03/28/2022 did not include documentation about the left heel Stage I PI. There were no records for April 2022 that weekly skin check for conducted to assess the status of the left heel Stage I PI.
Review of Resident 18's clinical records showed on the 04/20/2022 copy of the [NAME] (an electronic system that gives a brief overview of the resident including care needs and interventions) for Resident 18 to have left heel protector [SAGE boot] when in bed. There was a care plan for skin but did not address the Stage I PI. There was no care plan developed specific for the Stage I PI to the left heel. The April 2022 TAR showed treatment orders to monitor, moisturize and offload the left heel, with a start date of 03/30/2022. There was no specific skin issue documented about the left heel on the order.
On 04/22/2022 at 11:45 AM, Staff B reviewed the clinical records related to the left heel of Resident 18. Following a review of the admission skin assessment and progress notes, Staff B stated the left heel Stage I PI was a facility acquired [for the PI was developed in-house], after the admission date.
On 04/26/2022 at 2:47 PM, Staff B was asked regarding the expectation if a resident had a PI. Staff B stated there should be a treatment, monitoring, and measurement of the PI and documented on the skin tool form. Staff B stated the expectation was to do a weekly measurement to evaluate the wound. Following a review of the list of skin tool form, Staff B stated that no record were found for April 2022 that weekly skin check and weekly measurement for the Stage I PI were done. Staff B stated there should be a care plan to address the Stage I PI or whatever skin issue the resident has. Resident 18's care plan did not show an update to include the Stage I PI on the left heel.
RESIDENT 9
Resident 9 was admitted to the facility on [DATE] and re-admitted on [DATE] for multiple care needs.
Review of Resident 9's skin tool form for 04/13/2022 showed resident had a coccyx [tailbone area] pressure [injury]. The skin tool for the weekly skin check did not indicate the stage, the size and/or the appearance of the PI.
On 04/26/2022 at 10:14 AM, Staff B stated that it was an expectation to have a treatment, monitoring, assessments [such as measurements] and/or documentation on the skin tool form for PI.
On 04/27/2022 at 10:04 AM, Staff B reviewed the 04/13/2022 skin check. Staff B stated the assessment and documentation of the coccyx PI was not thorough for there was no documentation regarding the stage, measurement, and description of the appearance of the PI.
RESIDENT 170
Resident 170 was admitted to the facility on [DATE] for multiple care needs.
On 04/19/2022 at 12:20 PM, Resident 170 was observed sitting on his wheelchair, in his room. At 2:40 PM, more than 2 hours later, Resident 170 was observed in the same position, sitting on his wheelchair.
On 04/22/22 at 8:25 AM, Resident 170 was observed getting incontinence care and the skin on the right buttock/sacral area (area of the skin on the lower back just above and in between the buttocks) had a small open area which was superficial, circular, and about 0.5 centimeter in size and did not have a dressing.
Review of the new admissions matrix report showed the resident had stage II (partial-thickness skin loss with exposed dermis [layer of the skin]) to the coccyx area (skin over the tailbone).
Review of the weekly skin tool form for 04/06/2022 showed redness to the right buttock. The weekly skin tool form for 04/13/2022 showed redness to buttock. A weekly skin tool form for 04/15/2022 showed there was a Stage II PI to the coccyx area. The documentation for the Stage II PI to coccyx did not have measurements/size and/or description of the appearance of the PI.
Review of the April 2022 TAR showed an order for the PI on 04/15/2022, the order did not include a site for the PI. The incomplete order was revised on 04/19/2022 to include the site: Sacral Stage II ., which was different from the coccyx site on the skin tool form for 04/15/2022. The April 2022 TAR showed a treatment order of barrier cream to right buttock with a start date of 04/17/2022, 11 days after the redness was first observed.
Further review of the clinical records showed the care plan for the skin had no information related to the Stage II PI. There was no care plan created to care and manage the Stage II PI to the right buttock/sacral area. The physician order showed an order was obtained for a low-air-loss mattress (specialty mattress) on 04/19/2022, 13 days after the redness was first noted and 4 days after the Stage II PI was discovered.
On 04/26/2022 at 2:40 PM, Staff B stated that it was the expectation for a resident with redness to the buttocks to have a turn schedule, have A&D ointment (skin protectant from moisture such as urine), monitoring in either MAR or TAR and documentation in the progress note. Following a review of Resident 170's April 2022 MAR/TAR, Staff B stated the monitoring and treatment of the redness to the right buttock was started on 04/17/2022, 11 days after it was first noted. Staff B stated the skin assessment and documentation for the Stage II PI on the coccyx was incomplete for it did not include a measurement or description of the injury (or open area).
On 04/26/2022 at 2:49 PM, Staff B stated that it was the expectation to have a care plan in place if resident have PI or skin issues. Resident 170 had no care plan for the redness to the right buttock which now had become a Stage II to right buttock/sacral area.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure preplanned menus were followed. Failure to ensure the menus were followed, could alter the nutritional and caloric valu...
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Based on observation, interview, and record review the facility failed to ensure preplanned menus were followed. Failure to ensure the menus were followed, could alter the nutritional and caloric value of the diet intended, placed residents at risk for sub optimal intake of calorie and nutrients.
Findings included .
On 04/19/2022, between 11:45 AM and 12:40 PM, during observation of the noon meal service the following observation noted Staff D, a cook was observed preparing sandwiches using a piece of bread, spreading tuna salad. Staff D placed one piece of bread, a single slice of tomato and lettuce on one half of the bread, which was then cut in half and folded over, then cut in to two pieces. The half sandwich was then placed on a plate, in some instances a small serving of chips were added to the plates, and served to residents, seated in the dining room.
Resident 16 and the residents in the dining room one received a hot plate, and the other was served a whole sandwich. Although a container of hot soup delivered to the dining room, none of the residents in the dining room were observed to be offered or served any soup.
Staff C, the Food Service Manager (FSM) was observed plating hot foods, which included a shrimp dish identified on the menu as Shrimp Curry which was served with vegetables and rice. Staff C began plating hot food and at time Staff C also prepared plates of entree, using large serving spoon (which appeared to be ½ cup portion), which was served over the rice.
Neither of the staff, had the menu extension, which established the intended portion serving sizes. Staff C and Staff D were not observed to review it during the meal or prior to the meal service.
Review of the menu extension noted a half a cup of shrimp curry, a half a cup of vegetables, and a half a cup of rice should have been served. The portion serving size of the shrimp curry (which included the vegetable and shrimp) appeared to be a half cup serving, should have equaled a cup. The menu extension also documented a whole sandwich should have been served. In addition, residents should have been served a cup of soup, however this item should have been offer and or served but was not. Additional items which could be served as a side dish to accompany the meal were not observed available in the dining room. The only items, observed as a side dish available, was a bowl of fruit (melons, and strawberries), small bags of chips, and a dessert.
On 04/21/2022 during the noon meal service similar observations were made. Although a container of hot soup was delivered to the dining room no residents in the dining room were served the soup during the meal. The hot food option, which included chicken fried steak, mashed potatoes, and green beans. In addition, sandwiches (1/2) were also served with chips were available. The same fruit bowl (melons and strawberries) and potato chips were available in the service area, and it appeared they were served when requested.
Although a pot of tomato soup was delivered to the dining room, no one in the dining room was served the item. In addition, the same bowl of fruit (cut melons and strawberries) was available. The menu posted in the dining room, stated the resident would be served venison and barley soup, however the item as stated on the menu was not available.
Neither of the Staff C or D were observed to have a copy of the menu extension, which identified the portion serving size on 04/19/2022 and on 04/21/2022.
During an interview on 04/25/2022 at 2:15 Staff C, when asked about the menu, Staff C explained they worked with the facility Chef, who wrote the recipes and menu extensions were developed by both. When asked about menu extensions, Staff C stated they had them and agreed to provide them. Staff C was asked how many calories were served during the day, she stated no. Staff C explained the recipes were created by the Chef, but no analysis of the menu was completed. When asked about the change observed with the soup on 04/21/2022, Staff C said she did not know why it was changed.
On 04/26/2022 at 5:00 PM, Staff X, Registered Dietitian was interviewed. When asked how many calories were offered by the menu (or a daily average), the RD stated no. Not ensuring the menu was analyzed to determine what calories and nutrients were offered in the diet, placed residents at risk for sub-optimal nutrient and calorie intake
Reference: (WAC) 388-97-1160 (1)(a)
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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 implement an effective infection control program surv...
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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 an effective infection control program surveillance and/or monitoring to demonstrate ongoing analysis and trending of infectious organisms for 6 of 6 infection line list logs for October 2021, November 2021, December 2021, January 2021, February 2021 and March 2021) and accurately identify healthcare associated infections (HAI or infections that developed in the facility) in 4 of 6 infection line list logs (December 2021, January 2022, February 2022 and March 2022) reviewed for infection prevention.
Additionally, the facility failed to ensure that 3 of 11 staff (Staff R, S and D) used the required eye protection as part of Personal Protective Equipment (PPE) when residents were around and failed to ensure 4 out of 11 staff (Staff C, D, N and O) performed hand hygiene after removing soiled gloves and/or in between tasks.
These failures placed the residents at risk for cross contamination, facility acquired or healthcare-associated infections, and related complications.
Findings included .
INFECTION SURVEILLANCE
Record review of the Surveillance for Infections Policy/Procedure, revised September 2017, showed under policy interpretation and implementation that the purpose of the surveillance of infections was to identify both individual cases and trends of significant organisms and HAI to guide appropriate interventions and to prevent future infections. The policy stated the Infection Preventionist (IP - person who make sure healthcare workers and patients are doing all the things they should to prevent infections) will collect data to help determine the effectiveness of preventative measures and interpret surveillance data. The policy stated, under data collection and recording, to summarize monthly data by site and by pathogen (organism causing the infection) and to compare incidence of current infections to previous data to identify trends and patterns, calculate the average infection rate monthly or quarterly to identify possible increase in infection rate.
Review of infection records showed a summary report of all residents that had orders for antibiotics (medication to treat infection) from October 2021 to April 2022 and the infection line list for the months of October 2021 to March 2022. There was no record of a map showing the location of the resident with infection to identify if there was a trend. There was no monthly or quarterly surveillance summary report to show analysis and/or trending of infections, the site/location/pathogens were not identified, and if antibiotic treatments were needed/effective, and no analysis of infections to see what staff training should be conducted to reduce the spread of infections.
On 04/21/2022 at 2:43 PM, Staff B, Director of Nursing Services, IP, was asked for a copy of the map for infection and summary report of the infection surveillance. Staff B stated she had no record of the map to show location of residents with infection for she was not doing the map for cases of infection on the floor.
On 04/21/2022 at 2:44 PM, Staff B was asked regarding the monthly surveillance summary report or process. Staff B stated she was tracking the residents who were prescribed antibiotic and would bring the report to the Quality Assurance and Performance Improvement meeting monthly. For residents who had infections that did not require antibiotic treatment, they would monitor every shift and do alert charting.
On a follow-up interview on 04/25/2022 at 3:27 PM, Staff B admitted that there was no map of infection cases as part of the surveillance process and was working on how to implement the surveillance plan including data collection, analysis, trending, and tracking.
Further review of the infection line list showed all the infections that were listed for the months of December 2021, January 2022, February 2022, and March 2022 had onset dates (start of infection) which occurred after the admission dates of the listed residents. The infections were all marked as No for HAI or nosocomial infections (infections that developed or occurred on the facility) on the infection line list logs.
On 04/25/2022 at 3:35 PM, Staff B was asked regarding nosocomial infections or HAI. Staff B stated that any infections that had developed or were acquired after the admission date were considered nosocomial infections or HAI. Following record review of the infection line list logs for December 2021, January 2022, February 2022, and March 2022, Staff B stated all the infections listed on the logs should be marked yes for nosocomial infections or HAI.
NOT USING EYE PROTECTION
Review of the universal eye protection policy and procedure, dated 01/04/2021, showed eye protection should be worn throughout the healthcare workers shift when coming into contact with residents. It stated eye protection should be worn for the duration of the shift, if not soiled.
STAFF R
On 04/19/2022 at 8:50 AM, Staff R, Lifestyles Coordinator was observed going into room [ROOM NUMBER] to deliver the activity calendar to Resident 18 who was in the room. Staff R was wearing KN95 mask (a type of mask) and regular eyeglasses. Staff R had no goggles or face shield for eye protection. At 9:05 AM, Staff R was observed arranging flowers in the dining room where Resident 4 and Resident 5 were sitting and was not using eye protection.
On 04/19/2022 at 12:46 PM, Staff R was asked what kind of PPE was required to be used when on the floor. Staff R stated they should be using mask and goggles or face shields. Staff R stated she put on the goggles at about 9:30 AM or 10:00 AM that day. Staff R stated she did not have her goggles when she went in to Resident18's room and just remembered to put on her goggles when she saw the surveyor in the dining room.
STAFF S
On 4/19/2022 at 11:42 AM, Staff S, Nursing Assistant Certified (NAC) was observed in the dining room with a mask on and the goggles placed on top of her head and was asking Resident 14 to fill out the menu. At 11:44 AM, Staff S was observed with the mask on and the goggles on top of her head and was in the dining room asking Resident 15 to fill out the menu.
On 04/19/2022 at 11:48 AM, Staff S was asked regarding the required PPE to be used when interacting with residents. Staff S stated she should be wearing mask. When asked if use of goggles was required, Staff S stated yes and apologized for not having the goggles over her eyes.
STAFF D
On 04/192022 at 11:55 AM, Staff D, Cook, Dietary Aide was observed in the dining room where residents were seated and waiting to be served. Staff D was using mask and no goggles or face shields.
On 04/19/2022 at 12:40 PM, Staff D was asked what PPE was expected for her to use when preparing or serving food. Staff D stated she was expected to wear mask, hairnet, gloves, and goggles. Staff D agreed that she did not have her goggles earlier and had just put them on.
HANDWASHING ISSUES
STAFF C
On 04/19/2022 at 11:57 AM, Staff C, Food Service Manager was in the dining room and was observed removed her gloves she used to prepare the fruits and put on new gloves and did not do handwashing in between glove changes.
On 04/19/2022 at 12:41 PM, Staff C was asked when she would do handwashing or hand hygiene. Staff C stated she would wash or clean her hands after completing a task, after touching something dirty, when working in between residents, going to the ice machine and in between changing gloves. When asked if she should have washed her hands between changing gloves, she stated probably for she had served the fruits, then touched the menu paper that the resident had touched and changed her gloves before serving the entrée.
STAFF D
On 04/19/2022 at 11:17 AM, Staff D was observed bring two carts through the dining room into the kitchen area wearing gloves. One of the carts contained steamtable pans containing hot foods, the other cart contained other food items that were not hot, after removing the items from this cart. Staff D was observed to empty a garbage can, then the staff removed the gloves but did not wash hands. Staff D then pushed the empty cart out of the dining room and exited the area.
On 04/19/2022 at 12:41 PM, Staff C, the Food Service Manager stated the expectation was to wash or clean her hands after completing a task, after touching something dirty.
STAFF N
On 04/19/2022 at 1:40 PM, Staff N, Dietary Aide (DA), entered the dining room pushing a cart (or bin) and was wearing gloves. Staff N pushed the cart throughout the room and emptied 4 different garbage cans, placing the bags in a bin. Staff N then removed the gloves and exited the dining room but did not do hand hygiene. Staff N then went down the hallway and pushed the button for the elevator. While waiting for the elevator, Staff N was asked if hand hygiene was conducted after gloves were removed. Staff N said, you want me to wash my hands, that is it okay. When asked what he was trained to do, Staff N responded, no one trained me.
STAFF O
On 04/20/2022 at 8:40 AM, Staff O, NAC was observed stacking soiled dishes discarding food scraps and staking the dishes on a cart wearing gloves. Staff O then removed her gloves, then went to assist Resident 6. Staff O then entered the kitchen area poured a glass of juice from a dispenser and then pushed Resident 6's wheelchair back to their room carrying the glass of juice. As Staff O exited the dining room, Staff O was asked if she had washed her hands after removing her gloves. Staff O stated she was supposed to wash her hands and explained I am still picking up dishes.
Reference: WAC 388-97-1320 (1) (a) (c)(2)(a)(c)
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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
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 53 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $14,888 in fines. Above average for Washington. Some compliance problems on record.
Bottom line: Mixed indicators with Trust Score of 63/100. Visit in person and ask pointed questions.
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About This Facility
What is Park Shore's CMS Rating?
CMS assigns PARK SHORE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Washington, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Park Shore Staffed?
CMS rates PARK SHORE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes.
What Have Inspectors Found at Park Shore?
State health inspectors documented 53 deficiencies at PARK SHORE during 2022 to 2024. These included: 1 that caused actual resident harm, 51 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Park Shore?
PARK SHORE is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 28 certified beds and approximately 18 residents (about 64% occupancy), it is a smaller facility located in SEATTLE, Washington.
How Does Park Shore Compare to Other Washington Nursing Homes?
Compared to the 100 nursing homes in Washington, PARK SHORE's overall rating (4 stars) is above the state average of 3.2 and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Park Shore?
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 Park Shore Safe?
Based on CMS inspection data, PARK SHORE 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 4-star overall rating and ranks #1 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 Park Shore Stick Around?
PARK SHORE has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Park Shore Ever Fined?
PARK SHORE has been fined $14,888 across 1 penalty action. This is below the Washington average of $33,228. 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 Park Shore on Any Federal Watch List?
PARK SHORE 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.