THE TERRACES AT SKYLINE
Non profit - Corporation
34 Beds
Independent
Data: November 2025
Trust Grade
60/100
#120 of 190 in WA
Photo by Skyline Health Services
Photo by Skyline Health Services
Photo by Skyline Health Services
1 / 5 photos
Last Inspection: August 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
The Terraces at Skyline has a Trust Grade of C+, which means it is slightly above average but not outstanding. It ranks #120 out of 190 facilities in Washington, placing it in the bottom half, and #26 out of 46 in King County, indicating that there are better local options available. The facility's trend is worsening, with issues increasing from 14 in 2024 to 18 in 2025. Staffing is a relative strength with a 4/5 star rating, although turnover is average at 50%. Notably, there have been no fines recorded, which is a positive sign. However, there are specific concerns that families should be aware of. For instance, the facility did not have proper Registered Nurse coverage for one day, which could compromise resident care. Additionally, there were failures in maintaining food safety standards, such as using expired sanitizing solution test strips, which could risk foodborne illnesses. On the positive side, the facility has excellent quality measures, but families should weigh these strengths against the weaknesses highlighted in the report.
- Trust Score
- C+
- In Washington
- #120/190
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 50% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Washington facilities.
- Skilled Nurses ✓ Good
- Each resident gets 53 minutes of Registered Nurse (RN) attention daily — more than average for Washington. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 52 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Bottom 37%
No red flags
14 → 18 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 14 issues
2025: 18 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
3-Star Overall Rating
Near Washington average (3.2)
Meets federal standards, typical of most facilities
Staff Turnover: 50%
Near Washington avg (46%)
Higher turnover may affect care consistency
The Ugly 52 deficiencies on record
Aug 2025
18 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a copy of the advance directive (a written document describi...
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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 copy of the advance directive (a written document describing a resident's wishes for care if they became incapacitated such as a living will or Durable Power of Attorney [DPOA- a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so]) for health care was obtained from the resident/representatives who had an advance directive for 1 of 1 resident (Resident 11), reviewed for advance directive. This failure placed the resident and/or their representative at risk for losing their right to have their preferences honored regarding care Findings included .Review of the facility's policy titled, Advanced Directives, revised on 01/01/2025, showed that the facility will provide residents with information about advanced directives and will take necessary steps to follow resident's directive. The policy further showed that during the initial resident assessment, the Registered Nurse will offer the resident information about the advance directive and a copy of resident valid advance directive, and the most recent advance directive will be kept in the residents' record. Review of a face sheet printed on 08/05/2025 showed that Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's Electronic Health Record (EHR- miscellaneous tab) printed on 08/05/2025 showed there was no copy of an advance directive or documentation that the resident was asked to provide a copy or offered assistance in completing one.In an interview on 08/05/2025 at 11:22 AM, Resident 11 stated that they had a copy of their advance directive at home and that they could not remember if they were asked by the facility to provide a copy. A joint record review and interview on 08/05/2025 at 3:04 PM with Staff C, Social Worker, showed that there was no documentation in the EHR that an advance directive was requested, offered, or obtained. Staff C stated that a copy of an advance directive should have been requested during admission. Staff C further stated that if a resident did not have one then Staff C would help them to formulate or guide them to resources in the community. In an interview and joint record review on 08/07/2025 at 12:02 PM, Staff B, Director of Nursing, stated that social services staff were responsible for requesting a copy of advance directive during admission or offering to formulate one. If one existed, a copy should be in their EHR. A joint record review of Resident 11's EHR showed no copy or documentation of an advance directive. Staff B stated Resident 11 should have had a copy of their advance directive in their EHR. Reference: (WAC) 388-97-0280 (1)(3)(a) .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure non-pharmacological (treating a health problem without using medications) interventions were in place for an antidepressant (medicat...
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Based on interview and record review, the facility failed to ensure non-pharmacological (treating a health problem without using medications) interventions were in place for an antidepressant (medication used to treat depression -feeling loneliness and sadness) for 1 of 5 residents (Resident 3), reviewed for unnecessary medications. This failure placed the resident at risk for unidentified non-pharmacological interventions, unmet care needs, adverse side effects, and a diminished quality of life.Findings included .Review of Resident 3's physician orders showed an order for an antidepressant to treat depression that started on 07/24/2025.Review of Resident 3's health records (physician orders and care plan) printed on 08/05/2025 did not show documentation of non-pharmacological interventions associated with the use of an antidepressant. Review of the August 2025 Medication Administration Record (MAR) did not show Resident 3 had documentation of non-pharmacological interventions associated with the use of an antidepressant.In an interview on 08/07/2025 at 2:36 PM with Staff M, Registered Nurse, stated that Resident 3 was not included in the list of residents that received mental health services (services that include behavioral interventions -individualized, non-pharmacological approaches to treat a health problem).In an interview and a joint record review on 08/07/2025 at 3:01 PM with Staff D, Resident Care Manager, stated that a mental health consultation was not indicated for Resident 3. A joint record review of Resident 3's Electronic Health Records (EHR) including the August 2025 MAR and care plan did not show documentation of non-pharmacological interventions associated with the use of antidepressants. When asked if they expected non-pharmacological interventions associated with antidepressant use would be identified and documented, Staff D stated, I am not sure.In an interview and joint record review on 08/07/2025 at 6:21 PM, Staff B, Director of Nursing, stated that the facility's Interdisciplinary Team (a working group of staff with different kinds of expertise) discussed and identified non-pharmacological interventions for residents receiving medications such as antidepressants. A joint record review of Resident 3's August 2025 MAR did not show documentation of non-pharmacological interventions associated with the use of an antidepressant. Staff B stated that they expected staff would chart non-pharmacological interventions related to antidepressant use in the MAR.Reference: (WAC) 388-97-1060 (3)(k)(i).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Dat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed for 1 of 2 residents (Resident 2), reviewed for significant change of condition. The failure to complete an SCSA within 14 days of a significant change of condition placed the resident at risk for delayed care planning, unmet care needs, and a diminished quality of life.Findings included .Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1 dated October 2024, showed that an SCSA is a comprehensive assessment for a resident that must be completed when the Interdisciplinary Team determined that a resident meets the significant change guidelines for either major improvement or decline. The RAI manual showed, A significant change is a major decline or improvement in a resident's status that:Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; Impacts more than one area of the resident's health status; and Requires interdisciplinary review and/or revision of the care plan.Review of an admission MDS dated [DATE] showed that Resident 2 did not have weight loss. It further showed that Resident 2 did not have functional limitation in range of motion (limitation that interfered with daily functions or placed the resident at risk of injury in the last seven days) to their upper extremity (shoulder, elbow, wrist, hand).Review of a quarterly MDS dated [DATE], showed that Resident 2 had a significant weight loss (5% [five percent] or more in the last month or loss of 10% or more in the last six months) and that Resident 2 was not on a physician-prescribed weight-loss regimen. It further showed that Resident 2 had functional limitation in range of motion to both upper extremities.Review of a document titled, Weights and Vitals Summary, printed on 08/05/2025 showed Resident 2 weighed 160 pounds on 04/14/2025 and 129.4 pounds on 07/14/2024, which indicated a significant weight loss of 19% in three months.In an interview on 08/06/2025 at 8:56 AM, Staff R, Occupational Therapy Assistant, stated that Resident 2 had functional limitation in range of motion to both arms due to their inability to raise or bring up their arms.In a phone interview on 08/07/2025 at 4:36 PM, Staff Q, MDS Coordinator, stated that they followed the RAI Manual for coding accuracy and that they completed MDS assessments for Resident 2. A virtual joint record review of Resident 2's quarterly MDS dated [DATE] showed that Resident 2 was marked to have had a significant weight loss and that Resident 2 was not [NAME] physician-prescribed weight-loss regimen. It further showed that Resident 2 was marked to have had functional limitation in range of motion to both upper extremities. Staff Q stated that the significant weight loss and limited range of motion met two areas of decline and that Resident 2 should have had a SCSA completed.In an interview on 08/07/2025 at 6:21 PM, Staff B, Director of Nursing, stated that they expected MDS assessments would capture the full picture of the resident. Staff B further stated that a SCSA should have been completed for Resident 2 related to their significant weight loss and a decline in range of motion.Reference: (WAC) 388-97-1000 (3)(b).
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 15 residents (Resident 28), reviewed for res...
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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 15 residents (Resident 28), reviewed for resident assessment. The failure to ensure resident assessment was completed accurately on the Minimum Data Set (MDS-an assessment tool) regarding discharge status 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 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.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).Review of the discharge MDS dated [DATE] showed Resident 28 was discharged from the facility on 06/07/2025. Further review of the MDS showed Section A0310G (Type of Discharge) was marked unplanned. Review of Resident's 28 care conference note dated 06/06/2025 showed that the discharge was planned for Resident 28 to discharge to the community (home) on 06/07/2025 and all the transport and care services outside the facility had been coordinated and scheduled.In an interview and joint record review on 08/07/2025 at 9:10 AM, Staff Q, MDS Coordinator, stated that they followed the RAI manual when completing the MDS. A joint record review of the care conference note dated 06/06/2025 showed that Resident 28 had a planned discharge to the community. Further review of the discharge MDS under Section A0310G showed, it was marked as unplanned discharge. Staff Q stated that Resident 28 had a planned discharge to the community and that their MDS was inaccurate. Staff Q further stated that Resident 28's type of discharge should have been marked as a planned discharge.In an interview on 08/07/2025 at 11:34 AM, Staff B, Director of Nursing, stated that they expected the MDS to be completed accurately. Reference: (WAC) 388-97-1000(1)(b).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and/or implement a discharge care plan for 1 of 12 resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and/or implement a discharge care plan for 1 of 12 residents (Resident 15), reviewed for comprehensive care plan. This failure placed the resident at risk for unmet care needs and a diminished quality of life.Findings included .The facility's policy titled, Policy and Procedure - Resident Comprehensive Assessment and Care Plan, dated 10/25/2017, showed the care plan is person centered and involves the interdisciplinary team. The policy further showed that the care plan will identify all the residents' needs according to the comprehensive assessment, care plan decisions will be documented, and it would be completed within seven days of completion of the comprehensive assessment.Review of a face sheet printed on 08/07/2025 showed Resident 15 was admitted to the facility on [DATE].Review of a comprehensive care plan printed on 08/04/2025, showed Resident 15 had no care plan for discharge planning.In an interview on 08/07/2025 at 12:26 PM, Resident 15 stated that they were feeling frustrated and did not understand why no one had discussed their return to assisted living facility. Resident 15 stated they had spoken with several staff, could not recall their names, and they did not appear to know what the plan was regarding their discharge.In an interview and joint record review on 08/05/2025 at 2:58 PM, Staff C, Social Worker, stated that discharge planning was initiated during admission to ensure a smooth and safe transition back to their homes or other care settings after completion of therapy at the facility. A joint record review of Resident's 15's comprehensive care plan did not show a care plan for discharge. Staff C stated that there should have been a discharge plan completed during admission for Resident 15.A joint record review and interview on 08/07/2025 at 11:30 AM with Staff B, Director of Nursing, showed that Resident 15 did not have a discharge care plan. Staff B stated it was their expectation that discharge care planning would be completed during admission.Reference: (WAC) 388-97-1020(1), (2)(a)(b)(c).
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 observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) assistance we...
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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 Activities of Daily Living (ADL) assistance were consistently provided for 1 of 2 residents (Resident 2), reviewed for ADLs. The failure to provide a resident who was dependent on staff for assistance with personal hygiene and nourishment placed the resident at risk for aspiration (food and/or liquid enters the lungs instead of the stomach) and associated complications, poor hygiene, decreased self-esteem, and a diminished quality of life.Findings included .Review of the facility's policy titled, ADLs Policy, revised on 01/01/2025, showed that the purpose of the policy was to assist resident in achieving maximum function and to improve quality of life.PERSONAL HYGIENEReview of a face sheet printed on 08/05/2025, showed Resident 2 readmitted to the facility on [DATE] with diagnosis that included pneumonitis (lung infection) due to inhalation of food and vomit, dysphagia (difficulty swallowing) and rheumatoid arthritis (disease affecting joints).Review of a care plan printed on 08/05/2025, showed that Resident 2 required extensive assistance (hands-on help from others to complete a task) by one to two staff with personal hygiene.An observation on 08/07/2025 at 8:50 AM showed Staff X, Physical Therapist and Staff R, Occupational Therapy Assistant, entered Resident 2's room.An observation on 08/07/2025 at 9:34 AM showed Resident 2 was seated in their wheelchair that was parked in front of their room. Resident 2's hair was worn down and unkempt. Further observation showed Staff U, Certified Nursing Assistant (CNA), assisted Resident 2 into their room and Staff U stated that they should brush [Resident 2's] hair.In an interview on 08/07/2025 at 9:37 AM, Staff U stated Resident 2's hair doesn't [does not] looked brushed to me. Staff U further stated that Resident 2 enjoyed having their hair fixed and that Resident 2 would ask staff to take pics [picture] of it and send it to [Resident 2's representative].In an interview on 08/07/2025 at 9:44 AM, Staff R stated that they provided grooming and personal hygiene assistance for residents. When asked if they assisted Resident 2 with personal hygiene, Staff R stated that they didn't [did not] focus on grooming this morning.In an interview on 08/07/2025 at 9:54 AM with Staff X and Staff R, Staff X stated that they would usually ask residents about their preference for personal hygiene prior to assisting residents outof their rooms. Staff X further stated that they did not offer Resident 2 the opportunity to brush their hair prior to assisting them out of their room and that they should have. Staff R stated that Resident 2's hair looked like it needed brushing while we were at the [parallel] bars (exercise equipment).NOURISHMENTReview of the August 2025 physician orders showed Resident 2 had an order for 1:1 (one on one) feeding related to aspiration precautions dated 07/22/2025.An observation on 08/07/2025 at 12:01 PM showed Resident 2 was seated in the Eight-Floor dining room for lunch. It further showed Staff L, CNA, placed a beverage on the dining table that was within easy reach of Resident 2 before Staff L left the dining table to attend to other residents in the dining room. Resident 2 then brought the beverage up to their mouth and took a sip. It did not show Resident 2 was provided 1:1 assistance with their beverage.In an interview on 08/07/2025 at 12:25 PM, Staff M, Registered Nurse, stated that Resident 2 required 1:1 assistance with meals related to aspiration precautions and poor appetite. Staff M further stated that Resident 2 could drink [fluids] on their own.In an interview and joint record review on 08/06/2025 at 2:49 PM, Staff D, Resident Care Manager, stated that Resident 2 required 1:1 feeding assist as of 07/25/2025. A joint record review of a document titled, Point of Care (POC-care plan for CNA), printed on 08/07/2025, showed Resident 2 had two instructions for level of assistance with meals that included supervision for all meals and provide 1:1 feeding assistance. Staff D stated that the POC needed to be updated and that they expected that staff would sit down with [Resident 2] to provide 1:1 assistance with their meals including drinks.In an interview on 08/07/2025 at 6:21 PM, Staff B, Director of Nursing, stated that ADL assistance was provided by different disciplines including the therapy department. Staff B stated that they expected staff would make sure the resident's dignity is preserved and that Resident 2's hair should have been combed prior to leaving their room. Staff B further stated that they expected Resident 2's POC would be updated to reflect the care needs.Reference: (WAC) 388-97-1060(1)(2)(c)(3)(i).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow a therapeutic diet and to provide education to ...
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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 follow a therapeutic diet and to provide education to the resident's representative regarding the risks of not following the therapeutic diet for 1 of 1 resident (Resident 2), reviewed for nutrition. This failure placed the resident at risk of unmet care needs, medical complications, and a diminished quality of life.Findings included .Review of a face sheet printed on 08/05/2025, showed Resident 2 readmitted to the facility on [DATE] with diagnosis that included pneumonitis (lung infection) due to aspiration (food or liquid enter the lungs instead of the stomach) of food and vomit, and dysphagia (difficulty swallowing).Record review of a physician order dated 07/25/2025 showed Resident 2 was prescribed a diet of minced and moist texture (a diet that consists of foods that are finely chopped and are moist enough to hold together easily) and mildly thick consistency (liquids that are slightly thicker than regular liquids).Review of a document titled, Speech Therapy Treatment Encounter, dated 08/05/2025 showed, It was noted that [Resident 2] had thin [non-thickened] liquids at bedside provided to [Resident 2] by her CNA [Certified Nursing Assistant] staff, the therapist educated nursing and CNA staff of [Resident 2's] thickened liquid precautions.An observation on 08/05/2025 at 3:36 PM showed Resident 2 was lying in bed and had three non-thickened drinks placed on their bedside table within easy reach of Resident 2. Further observation showed Resident 2 had a box of Triscuit (brand name of snack crackers) and a can of Cheetos (brand name of firm and crispy snacks) stored on top of their room furniture.An observation on 08/05/2025 at 12:18 PM showed Resident 2 was assisted by Staff L, CNA, with their snack and drink in the eight-floor dining room. It further showed that Resident 2 was given a small bag of Ritz (brand name) crackers with cheese.In an interview on 08/06/2025 at 11:46 AM, Staff L stated that Resident 2 received soft foods and a lot of thick fluids. When asked if Resident 2 could eat Ritz crackers as part of their ordered diet, Staff L stated, I typically give those as a snack because I noticed [Resident 2] doesn't [does not] have difficulty with it [Ritz crackers]. Staff L further stated that they supplied the Ritz crackers to Resident 2 from the pantry in the dining room.An observation on 08/06/2025 at 2:09 PM, showed Resident 2's representative was standing in Resident 2's room when Resident 22 stopped ambulating in the hallway to greetResident 2's representative. Resident 2's representative stepped out to meet Resident 22 at the doorway and stated, I have homemade cookies, I brought [Resident 2] some, before offering cookies to Resident 22.Additional observation and interview on 08/06/2025 at 2:09 PM showed Resident 2 was accompanied by their representative and that they had a sandwich given to them. Resident 2's representative stated it was a soft sandwich. Resident 2's representative stated that they were aware of Resident 2's prescribed texture diet and that Resident 2 had aspirated twice. Resident 2's representative further stated that Resident 2 could eat the Triscuit and Cheetos stored in their room because they dissolved pretty fast. When asked if the facility had provided education regarding Resident 2's prescribed diet texture, Resident 2's representative stated that they met with the Speech therapist back in June, but that it was prior to Resident 2's change in diet texture.In an interview on 08/06/2025 at 2:17 PM, Staff M, Registered Nurse, stated crackers were not included in Resident 2's prescribed diet texture and that Not dry crackers, it's supposed to be moist, that's [that is] why [Resident 2] is on aspiration precautions.In an interview on 08/06/2025 at 2:49 PM, Staff D, Resident Care Manager, stated that Staff L should not have provided Resident 2 the Ritz crackers and that No, it should be minced and moist. When asked if Resident 2's representative was given education on the risks of not following Resident 2's prescribed diet texture, Staff D stated that they would review Resident 2's health records for documentation.In a follow-up interview and joint record review on 08/06/2025 at 4:09 PM, Staff D stated that it was facility protocol that when staff were aware of risks to a resident that We would provide a risks and benefits education. Staff D further stated that a risks and benefit education had not been provided to Resident 2's representative associated with not following the prescribed diet texture. A joint record review of Resident 2's speech therapy and treatment encounter note dated 08/05/2025 showed Resident 2 was provided with regular liquids by CNA staff. Staff D stated that they expected staff would follow the prescribed diet texture for Resident 2.In an interview and joint record review on 08/07/2025 at 6:21 PM, Staff B, Director of Nursing, stated that a diet prescribed for aspiration precautions was a therapeutic diet. Staff B stated that they expected a discussion with Resident 2's representative would have occurred to explain the risks of not following the prescribed diet texture. A joint record review of Resident 2's Electronic Health Records did not show documentation of risks and benefits education provided to Resident 2's representative. Staff B stated, [Resident 2] doesn't [does not] have one of those.Reference: (WAC) 388-97-1060 (1)(3)(h)(i).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure disinfectants (cleaning products containing ch...
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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 disinfectants (cleaning products containing chemicals that kill germs) were stored properly for 1 of 1 room (room [ROOM NUMBER]), reviewed for accident hazards. This failure placed the residents at risk for potential ingestion and/or exposure to cleaning chemicals and potential negative outcomes.Findings included .Review of the facility's policy titled, Storage of Chemicals, revised on 01/01/2025, showed All chemicals, including cleaning supplies, disinfectants, and hazardous substances, must be stored in a secure, labeled, and well-ventilated area to prevent unauthorized access by residents, staff or visitors.The purpose of this policy is to ensure the safe and compliant storage of chemicals within the nursing facility to prevent accidental poisoning, exposure.Review of a face sheet showed Resident 3 readmitted to the facility to room [ROOM NUMBER] on 04/29/2025.An observation on 08/04/2025 at 10:46 AM showed a metal canister with liquid disinfectant and compressed gas (Lysol - brand name of disinfectant) and a plastic canister with pre-moistened disinfecting wipes (Clorox - brand name of disinfectant) was stored on the bathroom sink counter of room [ROOM NUMBER]. Further observation showed an un-covered used toothbrush, an un-covered water floss pick (dental hygiene device), and un-covered towels were stored on the bathroom sink along with the disinfectants. It did not show disinfectants were stored in a secure manner to prevent unauthorized access by residents, staff or visitors.Another observation on 08/05/2025 at 8:27 AM showed a canister of Lysol spray and a canister of Clorox wipes were stored on the bathroom sink of room [ROOM NUMBER] along with personal hygiene products.In an interview on 08/05/2025 at 11:36 AM, Staff W, Private Caregiver, stated that they used the disinfectant supplies that were stored in the bathroom sink of room [ROOM NUMBER] and that Resident 3 used the personal hygiene supplies stored on the bathroom sink in their room.In an interview on 08/05/2025 at 11:42 AM, Staff M, Registered Nurse, stated that it was the facility's process to store disinfecting supplies with housekeeping staff and that, they keep [disinfectants] in their [cleaning] cart, and they lock when not in use. Staff M further stated that chemicals would not be stored in a resident's room.A joint observation on 08/05/2025 at 11:52 AM with Staff M showed a canister of Lysol spray and a canister of Clorox wipes were stored on the bathroom sink of room [ROOM NUMBER] along with personal hygiene products. Staff M stated that they considered Lysol and Clorox as disinfectants and that they expected disinfectants would not be stored on the bathroom sink of Resident 3's room.In an interview on 08/05/2025 at 3:14 PM, Staff D, Resident Care Manager, stated that housekeeping staff were responsible for daily cleaning of resident rooms to include the bathroom. Staff D further stated that the Lysol spray and Clorox wipes should not be there [room [ROOM NUMBER]]. Staff D further stated that they expected cleaning supplies with chemicals would be safely stored with the housekeeper.In an interview on 08/07/2025 at 6:21 PM, Staff B, Director of Nursing, stated that they expected disinfectants would not be stored in resident rooms because it [disinfectants] can still be accessible by other residents and that chemicals should be stored with housekeeping for safe keeping and for use.Reference: (WAC) 388-97-1060(3)(g).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a Medication Regimen Review (MRR - a comprehensive assessment of resident's medications, performed by a pharmacist [a qualified prof...
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Based on interview and record review, the facility failed to ensure a Medication Regimen Review (MRR - a comprehensive assessment of resident's medications, performed by a pharmacist [a qualified professional to provide expert advice on medication management, safety, and regulatory compliance] to identify and address potential problems) was completed for 1 of 5 residents (Resident 20), reviewed for unnecessary medications. This failure placed the resident at risk of receiving unnecessary medications and a diminished quality of life.Review of the facility's policy titled, Medication Regimen Review, revised on 07/01/2024, showed, Recommendations are acted upon and documented by the facility staff and or the prescriber.Review of the facility provided MRR showed Resident 20 had recommendations dated on 04/11/2025 to change administration times for gabapentin (medication to treat restless leg syndrome [a condition that causes irresistible urge to move the legs]) and magnesium (supplement) to be spaced two hours apart due to the efficacy of gabapentin may be decreased resulting in breakthrough symptoms. Further review showed the pharmacy recommendation was completed on 05/26/2025, 45 days later.In an interview and joint record review on 08/07/2025 at 6:02 PM, Staff B, Director of Nursing, stated that they oversaw the MRR documents. Staff B stated the pharmacist would send/email them the monthly review, the Resident Care Managers (RCMs) would give the recommendations to the provider, after the provider completes them then the RCMs carried out the recommendations. A joint record review of the April 2025 MRR and the April 2025 and May 2025 Medication Administration Records, showed Resident 20 had recommendations that were not implemented until 05/26/2025. Staff B stated that they expected Resident 20's 04/11/2025 MRR recommendations to have been implemented within 24-48 hours of receiving them and not a month [and a half later].Reference: (WAC) 388-97-1300 (4)(c).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure staff was provided education about COVID-19 (a viral illness that causes fever, difficulty breathing or possibly death) vaccination,...
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Based on interview and record review, the facility failed to ensure staff was provided education about COVID-19 (a viral illness that causes fever, difficulty breathing or possibly death) vaccination, including risks, benefits, potential side effects, document if the vaccine was accepted and/or refused in employee record for 1 of 1 staff (Staff O), reviewed for COVID-19 immunizations. This failure placed staff and residents at risk of and exposure to illness from COVID-19.Findings included .Review of the facility's policy titled, COVID-19 Prevention, Response and Reporting, reviewed on 02/07/2025, showed that the facility would offer resources and counseling to healthcare personnel, residents and visitors on the importance of receiving the COVID-19 vaccine and staying up to date with all recommended COVID-19 vaccine doses.Review of the staff list showed Staff O, Certified Nursing Assistant, was hired on 06/11/2010.In an interview on 08/06/2025 at 2:43 PM, Staff O stated they refused the COVID-19 vaccine booster and was informed of the risks and benefits last year and signed a paper.In an interview on 08/07/2025 at 6:24 PM, Staff E, Staffing Coordinator, stated that staff were provided information regarding COVID-19 vaccine risk and benefits. When asked for a copy of the risk and benefits, Staff E did not provide documentation regarding COVID-19 vaccination education and/or risk and benefits for Staff O.In an interview on 08/07/2025 at 7:32 PM, Staff B, Director of Nursing, stated they were going to look for documentation for Staff O's COVID-19 vaccine education and/or risks and benefits.On 08/07/2025 at 8:30 PM Staff A, Administrator, stated that they were not able to find documentation to show that Staff O was provided risks and benefits related to COVID-19 vaccination.Reference: (WAC) 388-97-1320(1)(a).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
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 bed rails (bed enablers) were properly secured...
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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 bed rails (bed enablers) were properly secured and maintained for safety for 2 of 2 residents (Residents 9 & 29), reviewed for accident hazards. This failure placed the residents at risk for injury and/or entrapment.Findings included .Review of the facility's policy titled, Bed Rail, revised on 01/01/2025, showed that the facility would ensure the safe and appropriate use of bed rails in compliance with federal and state regulations, minimize risk of injury, and protect resident rights. It further showed that nursing staff would inspect rails each shift for secure attachment and defects, check resident's positioning and skin integrity, and monitor for signs of distress, agitation, or injury.RESIDENT 9Review of the activities of daily living care plan initiated on 11/30/2020, showed Resident 9 used bilateral (both) grab bars/enablers to maximize independence with turning and repositioning in bed dated 07/23/2024.Observations on 08/04/2025 at 9:47 AM and on 08/07/2025 at 11:47 AM, showed Resident 9's right bed rail was not tightly secured and was easily moved from side to side when manually checked.In an interview and joint observation on 08/07/2025 at 1:17 PM, Staff S, Licensed Practical Nurse, stated they did not expect residents' bed rails to be loose. A joint observation with Staff S showed Resident 9's right bed rail was not tightly secured to their bed. Staff S stated that Resident 9's right bed rail was more loose than the left bed rail, and that they should not have been loose.In an interview and joint observation on 08/07/2025 at 1:56 PM, Staff P, Director of Facilities, stated that maintenance staff would check residents' rooms including beds and bed rails monthly. Staff P stated that if there were issues with bed rails, maintenance staff would fix them. A joint observation of Resident 9's right bed rail showed it was not tightly secured and was easily moved from side to side. Staff P stated that they were going to replace Resident 9's bed rails.RESIDENT 29Review of a face sheet printed on 08/04/2025 showed Resident 29 was admitted to the facility on [DATE].An observation and interview on 08/04/2025 at 11:01 AM, showed that Resident 29's right bed rail was not tightly secured, it was loose. Resident 29 stated that their right bed rail was wobbly. Another observation and interview on 08/07/2025 at 12:47 PM, showed Resident 29's right bed side rail was not tightly secured. Resident 29 stated, it worries me that it [bed rail] is wobbly because I am a strong and I use it all the time.A joint observation and interview on 08/07/2025 at 1:19 PM with Staff S, showed Resident 29's right bed rail was not tightly secured. Staff S stated, the bed rail is loose and it should not have been.A joint observation and interview on 08/07/2025 at 1:59 PM with Staff P, showed Resident 29's right bed rail was not tightly secured and was easily moved from side to side. Resident 29 stated, it worries me that it is wobbly, I use it all the time. Staff P stated that they would replace Resident 29's right bed rail.In an interview on 08/07/2025 at 5:32 PM, Staff A, Administrator, stated that they expected residents' bed rails to be secured.Reference: (WAC) 388-97-2100.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper storage, dating and labeling of respira...
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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 proper storage, dating and labeling of respiratory equipment for 3 of 4 residents (Residents 1, 2 & 3), reviewed for respiratory care. These failures placed the residents at risk for respiratory infection, related complications, and a diminished quality of life.Findings Included .
Review of the facility's policy titled, Oxygen Administration,” revised on 02/07/2024 showed, it is the policy of the facility to administer oxygen to the residents when insufficient oxygen is being carried by the blood to the tissues. Place nasal cannula (a flexible tubing that delivers oxygen through the nose) or mask in place with date written on label attached to tubing. The oxygen tubing should be changed every week with a new cannula or mask.
RESIDENT 1Review of a face sheet printed on 08/07/2025 showed Resident 1 was admitted to the facility on [DATE] with diagnosis that included parainfluenza (a group of viruses that cause different types of lung infections) and acute and chronic respiratory failure with hypoxia (a condition characterized by low levels of oxygen in the blood).
Review of Resident 1's April 2025 physician's orders showed an order for one to four liters (unit of measurement) per minute of oxygen as needed and a use of Continuous Positive Airway Pressure (CPAP- a device that helps people with breathing difficulties) at night. Further review of the orders showed instruction for staff to change oxygen tubing weekly in the evening every Tuesday for oxygen use.
Observation of Resident 1's oxygen equipment on the following dates showed:-On 08/04/2025 at 2:42 PM, the oxygen nasal cannula was not labelled/dated, laying on the resident's recliner, and not properly stored. The CPAP tubing nose piece (inserted through the nose for delivery of air) was observed laying on the nightstand table and was not properly stored.
-On 08/05/2025 at 11:52 AM, the oxygen nasal cannula was not labelled/dated. The CPAP tubing nose piece was observed laying on the nightstand table and was not properly stored.
A joint observation and interview on 08/05/2025 at 12:19 PM with Staff M, Registered Nurse, showed Resident 1's nasal cannula tubing was not labelled or dated. The CPAP tubing nose piece was observed laying on the nightstand table and was not properly stored. Staff M stated that the nasal cannula tubing should be dated and initialed when it was changed, and the CPAP nose piece should be properly stored when not in use.
In an interview on 08/07/2025 at 11:12 AM, Staff B, Director of Nursing, stated that it was their expectation that oxygen nasal cannula tubing be changed once a week with date and staff initial. Staff B further stated that oxygen nasal cannula tubing and CPAP nose piece should be properly stored in a clear plastic bag when not in use.
RESIDENT 2Review of a face sheet printed on 08/04/2025 showed Resident 2 readmitted to the facility on [DATE] with diagnosis that included pneumonia (lung infection that makes it hard to breathe).
Review of Resident 2's physician orders printed on 08/05/2025 did not show an order for nebulizer (a small machine that turns liquid medicine into a mist for inhaling) treatment.
An observation on 08/07/2025 at 12:35 PM showed Resident 2 had a nebulizer machine attached with respiratory equipment and was placed on the bedside drawer. Further observation showed the respiratory equipment was unlabeled/undated.
In an interview on 08/07/2025 at 3:19 PM Staff D, Resident Care Manager, stated that it was the facility's process to label respiratory equipment with the date of first use and to be “bagged” for clean storage.
A joint observation of Resident 2's room on 08/07/2025 at 3:48 PM showed a nebulizer machine attached with respiratory equipment placed on the bedside drawer that was unlabeled. Staff D stated they would remove the nebulizer machine from Resident 2's room because Resident 2 did not have an “order for it.”
RESIDENT 3Review of a face sheet printed on 08/04/2025 showed Resident 3 admitted to the facility on [DATE] with diagnosis that included obstructive sleep apnea (a condition where breathing repeatedly stops and starts during sleep) and human parainfluenza virus pneumonia (a lung infection caused by a virus) with an onset date of 07/30/2025.
Review of the physician orders printed on 08/05/2025, showed Resident 3 had an order for CPAP at bedtime. It further showed that Resident 3 had an order for nebulizer treatment three times a day for dyspnea (shortness of breath).
An observation on 08/07/2025 at 12:22 PM in Resident 3's room showed nebulizer parts to include a mouthpiece were uncovered and placed on a paper towel on top of a stack of cardboard boxes near the bedside. Further observation showed the nebulizer parts were unlabeled.
In an interview on 08/07/2025 at 3:19 PM, Staff D stated that respiratory equipment included nebulizer equipment as well as CPAP equipment.
A joint observation and interview on 08/07/2025 at 3:58 PM with Staff D, showed Resident 3's room nebulizer parts were unlabeled/uncovered and were placed on a paper towel on top of a stack of cardboard boxes near the bedside. Further observation showed Resident 3's CPAP equipment including a nose piece was uncovered and placed on top of Resident 3's bedside drawer. Staff D stated that they expected Resident 3's respiratory equipment would be labeled and/or stored in a “clean bag.”
In an interview on 08/07/2025 at 6:21 PM, Staff B stated that it was the facility's policy to label respiratory equipment and to properly store them.
Reference: (WAC) 388-97-1060(3)(j)(vi)
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to dispose expired medication in accordance with current...
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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 dispose expired medication in accordance with current accepted professional standards for 1 of 1 medication refrigerator (8th Floor Medication Room Refrigerator), reviewed for medication storage and labeling. This failure placed the residents at risk for receiving compromised or ineffective medications, potential unsafe medication administration, and potential adverse side effects. Findings included .Review of the facility's policy titled, Medication Label, revised on [DATE], showed that nursing staff would ensure resident's medication was appropriately labeled according to pharmacy recommendation. Multi-dose vials that have been opened or accessed (e.g., needle punctured) were dated and discarded within 30 days unless the manufacturer specified a shorter or longer date for the open vial.A joint observation and interview on [DATE] at 2:08 PM with Staff M, Registered Nurse, showed the Eighth Floor Medication Room Refrigerator had one multi-dose vial of tuberculin (purified protein derivative, is a combination of proteins that are used in the diagnosis of tuberculosis [a serious illness caused by a type of bacteria that mainly affects the lungs]) with an open date of [DATE]. Staff M stated that tuberculin was good for 30 days from the date it was opened. Staff M stated that the tuberculin vial was two days past the expiration date and should have been discarded.In an interview on [DATE] at 11:40 AM, Staff B, Director of Nursing, stated that they referred to a pharmacy sheet with names of medication and when medication would expire. Staff B further stated that it was their expectation that staff would identify and properly dispose of expired medication.Reference: (WAC) 388-97-1300 (2).
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 a detailed written description of the facility's water system was included in their water management program and/or ap...
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Based on observation, interview, and record review, the facility failed to ensure a detailed written description of the facility's water system was included in their water management program and/or appropriate personnel were included in the water management team that assessed the potential growth of Legionella (a family of micro-organisms which are naturally found in water bodies), failed to ensure an outbreak (a sudden rise in the incidence of a disease or infection) was reported for 4 of 4 residents (Residents 6, 3, 1 & 22), and failed to ensure appropriate Personal Protective Equipment (PPE- equipment wore to minimize exposure to hazards that can cause serious illnesses) was used for 2 of 7 residents (Residents 7 & 3), reviewed for infection control. 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, “Legionella Water Management Program,” reviewed on 04/11/2024, showed that “as part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team.” The document further showed that the water management team consisted of at least the following personnel: the infection preventionist, administrator, medical director (or designee), director of maintenance and the director of environmental services. The policy further showed that the facility's water management program included a detailed description and diagram of the water system in the facility.
Review of the facility's policy titled, “Enhanced Barrier Precautions [EBP- precautions to protect the spread of infectious organisms],” revised on 01/01/2025, showed that the facility would implement EBP for the prevention of transmission of multidrug-resistant organisms (bacteria that is resistant to one or more classes of antibiotics (medicine that prevents or treats infections) using gown and gloves during high-contact resident care activities that included dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, and urinary catheter (or foley urinary catheter - a semi-flexible tube inserted into the bladder [a hollow muscular sac that stores urine] to drain urine) care.
WATER MANAGEMENTReview of the “Water Management and Legionella Prevention Plan,” revised on 07/20/2025, did not show that infection preventionist and/or medical director were part of the water management team members. Further review of the document did not show a detailed description of the facility's water system.
A joint record review and interview on 08/07/2025 at 2:13 PM with Staff P, Director of Facilities, showed the facility's water management program had a schematic diagram of the facility's water system and did not show a detailed written description of the facility's water system. Staff P stated that the water management schematic diagram was the facility's water system.
In an interview on 08/07/2025 at 4:48 PM, Staff D, Infection Preventionist (IP), stated they were not part of the water management program/plan team.
A joint record review and interview on 08/07/2025 at 5:29 PM with Staff A, Administrator, did not show the facility's water management plan included a detailed description of the facility's water system. Staff A stated that the water management plan should have included a detailed description of the facility's water system. A joint record review of the water management program did not show that the IP and/or the medical director were included in the water management team. A joint record review showed the facility's water management policy indicated that the IP and medical director were part of the water management team. Staff A stated that the IP and medical director should have been part of the water management team.
OUTBREAK REPORTINGReview of the facility's policy titled, “Infection Outbreak Response and Investigation,” revised on 01/01/2025, showed that two or more residents or staff with similar symptoms were considered an outbreak. Further review of the policy showed that the outbreak would be notified to the “Local/State Health Department.”
Observations on 08/04/2025 at 2:55 PM showed Residents 6, 3, 1 & 22 were placed on droplet precautions (steps used to stop the spread of germs that travel through the air in tiny droplets when someone talks, coughs, or sneezes) and/or contact precautions (measures to prevent the spread of germs from one person to another by touching the infected person or their environment).
Review of a nursing progress note dated 07/28/2025 showed Resident 6 had possible Human Parainfluenza (HPIVs-commonly cause upper and lower respiratory infections) and was placed on droplet precautions.
Review of a nursing progress notes dated 07/31/2025 showed Resident 3 had a diagnosis of parainfluenza and was placed on droplet precautions.
Review of a nursing progress notes dated 07/29/2025 showed Resident 1 had a diagnosis of parainfluenza and was placed on droplet precautions.
Review of nursing progress notes dated 07/25/2025 showed Resident 22 had respiratory symptoms and was placed on droplet precautions.
In an interview on 08/07/2025 at 4:37 PM, Staff D stated they did not know if the respiratory symptoms for Residents 6, 3, 1 and 22 were an outbreak and/or should have been reported to the state and/or local health department.
In an interview on 08/07/2025 at 4:58 PM, Staff B, Director of Nursing, stated they did not know if the respiratory symptoms for Residents 6, 3, 1 and 22 were considered an outbreak and that their respiratory symptoms were not reported to the State and/or local health department.
USE OF PPE-EBP PRECAUTIONSRESIDENT 7Review of Resident 7's physician orders printed on 08/04/2025 showed an order dated 06/03/2024 for “Enhanced Barrier for device care: PEG tube (Percutaneous Endoscopic Gastrostomy or feeding tube - a special type of flexible tubing that allows a person to receive nutrition, hydration, and medication through the tube instead of by mouth) and Foley Catheter Placement.”
Observation on 08/04/2025 at 4:12 PM showed Staff I, Certified Nursing Assistant (CNA) and Staff J, CNA, were entering Resident 7's room with a Hoyer (mechanical lifting device) lift without wearing their gown. Further observation showed Resident 7 had an EBP signage outside their room that instructed staff to wear gowns and gloves for high-contact resident care activities that included transferring and urinary catheter care.
In an interview and joint record review on 08/04/2025 at 4:21 PM, Staff I and Staff J, stated that they transferred Resident 7 from bed to wheelchair using the Hoyer lift, and emptied Resident 7's urinary catheter bag. A joint record review with Staff I and Staff J showed an EBP signage outside Resident 7's room that instructed staff to wear gowns and gloves for high-contact resident care activities that included transferring and assisting with catheter care. Staff I and Staff J stated that they should have worn a gown when assisting Resident 7 with catheter care and transfers.
In an interview on 08/06/2025 at 4:15 PM, Staff K, Registered Nurse (RN), stated staff [Staff I and Staff J] should have worn their gown when assisting Resident 7 with high-contact care activities.
In an interview on 08/07/2025 at 4:23 PM, Staff D stated that staff [Staff I and Staff J] should have worn a gown when assisting Resident 7 with catheter care and transfers.
In an interview on 08/07/2025 at 5:10 PM, Staff B stated they expected staff to wear a gown when providing high-contact care activities to residents on EBP precautions. Staff B further stated that Staff I and Staff J should have worn their gown when assisting Resident 7 with catheter care and transfers.
USE OF PPE-DROPLET PRECAUTIONSRESIDENT 3Review of the facility's policy titled “Infection Control Prevention and Control Program,” revised on 04/01/2025, showed that the facility established and maintained an infection prevention and control program that prevented, identified and controlled the spread of infections and communicable disease in the facility. It further showed that the facility provided PPE to support compliance with transmission-based precautions (steps used to stop the spread of germs) and ensured that it was readily available for staff use.
Review of a face sheet printed on 08/05/2025, showed Resident 3 had a diagnosis of Human Parainfluenza Virus (HPIV) pneumonia (a lung infection caused by a virus called HPIV) with an onset date of 07/30/2025.
Review of Resident 3's physician orders showed an order for droplet precautions for HPIV dated 08/04/2025.
An observation and record review on 08/04/2025 at 9:21 AM showed that signage indicated droplet precautions and a PPE isolation cart were placed at the entrance of Resident 3's room. Review of the droplet precautions sign showed that everyone must “make sure their eyes, nose and mouth are fully covered before room entry.”
An observation on 08/06/2025 at 9:03 AM showed Staff L, CNA, wore a gown, gloves, face mask and eye protection that was secured across Staff L's forehead via a strip of adhesive. Staff L wore their personal eyeglasses in addition to eye protection. Further observation did not show Staff L's eyes were fully covered on the sides prior to entering Resident 3's room.
In an interview and joint observation on 08/07/2025 at 9:23 AM, Staff M, RN, stated that to properly wear the eye protection with the adhesive strip, personal eyeglasses had to be removed to allow for the adhesive strip to “stick” and protection to the sides of the eyes was provided. Staff M stated that they used a face shield as eye protection because it allowed them to wear their personal eyeglasses with eye protection. A joint observation of Resident 3's PPE isolation cart did not show alternative forms of eye protection were available for staff use. Staff M stated that face shields were “gone,” but that they expected face shields would be stocked in the PPE cart.
An observation on 08/07/2025 at 8:41 AM showed Staff N, Lifestyles Assistant, wearing a gown, gloves and a face mask prior to entering Resident 3's room. Further observation did not show Staff N's eyes were fully covered prior to room entry.
In an interview and joint record review on 08/07/2025 at 8:44 AM, Staff N stated that they wore a gown, gloves, and a face mask prior to entry of rooms indicated for droplet precautions. Joint record review of Resident 3's droplet precautions sign showed an indication to wear eye protection prior to room entry. Staff N stated that they should have worn the “shield” and that they should have worn eye protection prior to room entry.
In an interview on 08/07/2025 at 3:19 PM, Staff D stated that they expected staff would follow isolation precautions indicated by “signs” posted prior to room entry. Staff D stated that they expected staff with personal eyeglasses to wear eye protection that fully covered their eyes. Staff D further stated that they expected PPE isolation carts would be stocked with PPE for staff use.
In an interview on 08/07/2025 at 6:21 PM, Staff B stated that the facility followed the Centers for Disease Control and Prevention guidelines for infection prevention and control. Staff B further stated that they expected staff would follow isolation precautions when indicated and that PPE for staff use would be “always available and replenished.”
Reference: (WAC) 388-97-1320 (1)(a)(5)
.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to establish a grievance policy that designated a Grievance Official (an individual responsible for overseeing the grievance process) for 2 of...
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Based on interview and record review, the facility failed to establish a grievance policy that designated a Grievance Official (an individual responsible for overseeing the grievance process) for 2 of 2 floors (Seventh & Eighth Floor), reviewed for grievances. This failure placed residents and their representatives at risk of not having access to the required information regarding the Grievance Official, potentially hindering the facility's ability to investigate and resolve concerns effectively.Findings included .Review of the facility's policy titled, Grievances, revised on 01/01/2025, showed that Residents are welcome to approach staff members to express their complaints or recommendations.The social worker will meet residents as needed, and as requested by the nursing department, to discuss and address any complaints or recommendations residents may have.When a problem(s) occurs or becomes known, the person responsible for responding and correcting it should be notified.When grievances cannot be resolved or the person making a complaint does not feel comfortable speaking with the person(s) responsible for its resolution, it can be referred to the facility Administrator for necessary action and response. Further review did not show that a Grievance Official was designated to oversee the grievance process.Review of an undated grievance forms posted next to elevators on the seventh and eighth floors did not show documentation of information regarding the Grievance Official, including contact information.In a group interview on 08/06/2025 at 10:30 AM, Residents 31, 16, and 23 were asked if the facility Grievance Official responded to the resident or family group concerns, Residents 31, 16, and 23 stated that the [previous Administrator] did. Residents 31, 16, and 23 could not identify who the grievance official was currently.In an interview and joint record review on 08/07/2025 at 4:01 PM, Staff A, Administrator, stated that the Social Services Director was the facility's Grievance Official. A joint record review of the facility's grievance policy did not show documentation that a Grievance Official and their contact information was designated. Staff A stated that, The previous Administrator changed it to be him, but it should be the Social Services Director and that the facility's policy did not reflect that.Reference: (WAC) 388-97-0460.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide the required Registered Nurse (RN) coverage for 1 out of 30 days (08/03/2025), reviewed for staffing. This failure placed the resid...
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Based on interview and record review, the facility failed to provide the required Registered Nurse (RN) coverage for 1 out of 30 days (08/03/2025), reviewed for staffing. This failure placed the residents at risk for inadequate assessments, delay in care services by an RN, unmet care needs, and a diminished quality of life.Findings included .Review of the facility's document titled, Daily Clinical Staff Posting, dated 08/03/2025 did not show documentation of RN coverage on 08/03/2025 for at least eight consecutive hours a day.In an interview and joint record review on 08/07/2025 at 11:43 AM, Staff E, Staffing Coordinator, stated they were responsible for the daily clinical staff posting. Staff E further stated they would schedule 16 hours of RN coverage a day. A joint record review of the clinical staff posting dated 08/03/2025 showed no RN coverage for 08/03/2025. Staff E further stated there was no RN coverage on 08/03/2025 and that there should have been.In an interview on 08/07/2025 at 12:30 PM, Staff A, Administrator, stated there should be at least eight consecutive hours a day of RN coverage. Staff A further stated that they expected there to be at least eight consecutive hours a day of RN coverage on 08/03/2025.Reference: (WAC) 388-97-1080 (8).
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 sanitizing solution test strips were not used after expiration date and failed to keep records of the sanitizing solut...
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Based on observation, interview, and record review, the facility failed to ensure sanitizing solution test strips were not used after expiration date and failed to keep records of the sanitizing solution test log forms for 1 of 1 kitchen (Fourth Floor Main Kitchen), and failed to ensure food items were discarded after the use-by-date in accordance with professional standards for food safety for 1 of 3 storage rooms (Seventh Floor Storage Area), reviewed for food services. These failures 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, Test Strips for Sanitizing Solution, revised on 01/01/2025, showed that sanitizing solutions used in the facility would be tested daily and would use approved testing strips to verify correct concentration levels. The results would be documented and maintained for compliance with federal, state, and local regulations. The policy further showed that salinizing solution test logs would be retained for a minimum of three months or per facility policy.Review of the facility's policy titled, Food Storage, revised on 04/11/2025, showed that the facility would ensure all food was stored appropriately according to state and federal food code to prevent foodborne illness in the community.SANITIZING TEST STRIPS/TEST LOG RECORDS-FOURTH FLOOR MAIN KITCHENA joint observation and interview on 08/04/2025 at 10:59 AM with Staff F, Sous Chef, showed they were using the sanitizing test strip to check the level of Parts Per Million (PPM - unit of measure for concentration) of the sanitizing solution. Further joint observation of the sanitizing solution test strips with Staff F showed that the test strips read Hydrion QT-40 (brand name - used to check the level of sanitizing solution) had an expiration date of 08/15/2024. Staff F stated that the sanitizing solution test strip was expired. Staff F found an unopened Hydrion QT-40 sanitizing solution test strip with an expiration date of 08/15/2024. Staff F stated that the additional sanitizing solution test strip was also expired. Staff F stated that the kitchen staff had been using the expired test strips and that the sanitizing test strips should have been discarded.In an interview on 08/07/2025 at 9:02 AM, Staff G, Sous Chef, stated that they expected staff to use sanitizing test strips that were not expired. Staff G further stated that they did not know the sanitizing solution test strips had expired. When asked Staff G for the sanitizing solution test log for the last six months, Staff G stated that the facility did not keep records of previous months' sanitizing solution test logs and that they were discarded at the end of the month. Staff G further stated that they did not know that sanitizing solution test logs records needed to be maintained.FOOD ITEMS BEYOND USE BY DATE-SEVENTH FLOOR STORAGE AREAA joint observation and interview on 08/06/2025 at 12:28 PM with Staff T, Cook, showed the Seventh-Floor Kitchen storage area had a bottle of tabasco [brand of hot spicy] sauce had a use-by-date of 08/03/2025 and a bottle of chocolate sauce that had a use-by-date of 07/25/2025. Staff T stated that the bottles of chocolate sauce and tabasco sauce should have been discarded by their use-by-date.In an interview on 08/06/2025 at 4:02 PM, Staff H, Executive Chef, stated they expected food items to be discarded by their use-by-date. Staff H further stated that the food items from the Seventh-Floor Kitchen storage should have been discarded.In an interview on 08/07/2025 at 5:29 PM, Staff A, Administrator, stated they expected staff to discard expired sanitizing solution test strips and that records for the logs should have been kept. Staff A further stated that they expected foods items to be discarded by their use-by-date.Reference: (WAC) 388-97-1100 (3).
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure infections related to initiation of antibiotic (medicine that prevents or treats infections) practices were based on the Center for ...
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Based on interview and record review, the facility failed to ensure infections related to initiation of antibiotic (medicine that prevents or treats infections) practices were based on the Center for Disease Control and Prevention (CDC) approved criteria for 6 of 6 months (February 2025, March 2025, April 2025, May 2025, June 2025 & July 2025), reviewed for antibiotic stewardship program. This failure placed the residents at risk of receiving or not receiving necessary antibiotics, and a diminished quality of care.Findings included .Review of the facility's policy titled, Antibiotic Stewardship Program, revised on 01/22/2024, showed that the antibiotic stewardship program was to optimize the treatment of infections while reducing adverse events associated with antibiotic use. It showed that the facility used Loeb Minimum Criteria [a set of clinical guidelines designed to help determine if a resident in long term care likely has an infection, even if the infection has not been confirmed by diagnostic testing - these criteria include specific signs and symptoms that, when present, suggest the need for antibiotic therapy] to determine whether to treat an infection with antibiotics. The policy further showed that nursing would monitor the initiation of antibiotics on residents and conduct an antibiotic timeout within 48-72 hours of antibiotic therapy to monitor response to the antibiotic and review laboratory results and consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings. Review of the Infection Control Log, from February 2025 to July 2025 did not show documentation that the Loeb's criteria was used to indicate if residents' signs and symptoms met the minimum criteria prior to their prescribed antibiotics. A joint record review and interview on 08/07/2025 at 4:52 PM with Staff B, Director of Nursing, showed the infection control log from February 2025 to July 2025 did not have documentation that the signs and symptoms of residents met the minimum criteria for antibiotic use. Staff B stated that they believe the facility had not been using the Loeb Minimum Criteria to check if the residents' signs and symptoms met the criteria prior to antibiotic use. No Associated WAC.
Aug 2024
14 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure informed consent for an antidepressant (medication used to t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure informed consent for an antidepressant (medication used to treat depression) was completed before administration for 1 of 5 residents (Resident 4), reviewed for unnecessary medications. This failure placed the resident and/or their representative at risk of not being fully informed of the risks and benefits before making decisions about medications before administration.
Findings included .
A review of the facility's policy titled, Psychotropic Drug Use, revised on 04/01/2024, showed that residents and/or their responsible parties will be asked to make an informed choice concerning the use of a psychoactive (mind altering) drug and for an informed choice to be made, potential negative outcomes (risks) and benefits for the drug use would be explained.
A review of Resident 4's face sheet printed on 08/20/2024 showed that Resident 4 was readmitted to the facility on [DATE].
A review of a physician's order dated 03/19/2024 showed Resident 4 had an order for antidepressant medication.
A review of the Medication Administration Records from March 2024 to August 2024 showed Resident 4 had been taking antidepressant medication since 03/20/2024.
A joint record review and interview on 08/22/2024 at 11:03 AM with Staff C, Resident Care Manager, showed Resident 4 signed a consent for antidepressant medication on 05/28/2024. Staff C stated that Resident 4's consent should have been obtained before starting the medication.
On 08/22/2024 at 11:33 AM, Staff B, Corporate Director of Health Services, stated that they expected residents to have consent before taking psychotropic medications to explain the risks and benefits. Staff B further stated that the consent should have been completed before Resident 4 started taking antidepressant medication.
Reference: (WAC) 388-97-0260 (2) (a-d)
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 20
A review of Resident 20's face sheet showed they were admitted to the facility on [DATE].
A review of the medication...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 20
A review of Resident 20's face sheet showed they were admitted to the facility on [DATE].
A review of the medication administration record for August 2024 showed Resident 20 was taking the following medications:
-Fluticasone Propionate Nasal Suspension (nasal spray to treat seasonal allergies) Two sprays in both nostrils one time a day for allergy. Unsupervised self-administration.
-Calcium-Cholecalciferol oral tablet (a dietary supplement to maintain bone strength). Give one table by mouth two times a day for Supplement. Please give for self-med [self-medication administration]/may leave at the bedside table.
-Ocean Nasal Spray Nasal Solution (used to prevent dry nasal passages). Two sprays in both nostrils twice a day to prevent the nose from drying due to nasal cannula. Leave at the bedside for self-administration.
-Refresh Tears Ophthalmic Solution (used to treat dry eyes). Instill one drop in both eyes two times a day for dryness unsupervised self-administration. May keep resident at bedside per resident request.
- Ponaris Nasal Solution (to help moisturize the nasal passages) in both nostrils as needed for nasal irritation four times a day as needed. (There is no self-administration order for this medication).
A review of the Medication Self-Administration Safety Screen assessment, dated 10/20/2023, did not include the Fluticasone Nasal spray and Ponaris Nasal solution.
A review of Resident 20's comprehensive care plan, printed on 08/20/2024, did not show a care plan for self-medication administration.
An observation and interview on 08/19/2024 at 9:40 AM showed a medication cup containing a green tablet on the bedside table in Resident 20's room. Further observation showed the Refresh tears, Fluticasone, Ponaris nasal solution, and nasal normal saline spray were on the resident's bedside table. Resident 20 stated that the medication in the medication cup was their calcium pill.
In a joint record review and interview on 08/22/2024 at 3:32 PM with Staff C, the physician orders showed no medication self-administration order for Resident 20's Ponaris Nasal solution and Fluticasone Nasal Spray. Staff C stated that they did not find a self-administration order and would have to request it.
In a joint record review and interview on 08/22/2024 at 4:07 PM, Staff B, Corporate Director of Health Services, stated that the facility would make sure the residents were competent to take their medications and were able to vocalize the side effects. Staff B stated that they did not see that medication self-administration was included in Resident 20's comprehensive care plan.
Reference: (WAC) 388-97-0440, 1060 (3)(j)(i)
Based on observation, interview, and record review, the facility failed to ensure the residents were evaluated and assessed, and/or a physician order was obtained for safe administration of medication for 2 of 2 residents (Residents 235 & 20), reviewed for self-medication administration. This failure placed the residents at risk for inaccurate and unsafe medication administration, adverse side effects, medical complications, and a diminished quality of life.
Findings included .
A review of the facility's policy titled, Self-Administration of Medications, revised on 07/01/2024, showed that the facility would provide each resident with the opportunity to self-administer medications if the resident chooses. Self-administration of medications is listed as one of the rights, the resident is given the opportunity and may choose to do so if the interdisciplinary team determines the resident is safe to self-administer. An assessment of the resident's capabilities to self-administer is performed by the IDT [Interdisciplinary Team]. Assessments will be updated quarterly. A physician order is obtained. The care plan is updated. The medication sheet states the medication and that the resident is self-administering.
RESIDENT 235
A review of the face sheet printed on 08/21/2024, showed Resident 235 was admitted to the facility on [DATE].
A review of the August 2024 Medication Administration Record (MAR) showed that Resident 235 was getting enoxaparin (an anticoagulant medication used to prevent and treat harmful blood clots) injection once daily. Further review of the MAR did not show an order for self-medication administration.
During Resident 235's medication administration on 08/21/2024 at 9:07 AM, Staff E, Licensed Practical Nurse (LPN), stated, I have your injection. Resident 235 cleaned their abdominal skin area with an alcohol wipe, pinched their skin, and then self-administered the enoxaparin injection, then Resident 235 handed the empty syringe with the exposed needle to Staff E. Staff E pushed the syringe plunger, and the needle retracted. Resident 235 stated that they preferred to give their enoxaparin injection themselves.
On 08/22/2024 at 9:23 AM, Resident 235 stated that they had been administering enoxaparin injections themselves since June 2020, before admitting to the facility. Resident 235 stated that the facility staff had not assessed them for self-medication administration of the injection. Resident 235 stated, I won't let them give me the enoxaparin injections, I have been doing it myself for so long.
On 08/22/2024 at 9:38 AM Staff E stated that Resident 235 had let them inject their enoxaparin injection one time since they were admitted to the facility and that Resident 235 had been doing it. A joint record review of Resident 235's electronic clinical records did not show an assessment, an order, and/or a care plan for self-medication administration for their enoxaparin injection. Staff E stated they did not assess the resident for self-medication administration, and that there was no order, and/or care plan for self-medication of enoxaparin injection for Resident 235.
On 08/22/2024 at 10:01 AM, Staff C, Resident Care Manager (RCM), stated that when a resident wants to self-administer medications, the facility completes an assessment, obtains an order from the doctor, and then care plans the self-medication administration. A joint record review of Resident 235's clinical records did not show an assessment, an order, and/or a care plan for self-administration of their enoxaparin injection. In a follow-up interview at 10:36 AM, Staff C stated that Resident 235 should have had an assessment done, an order, and a care plan for self-medication administration for enoxaparin injection.
On 08/22/2024 at 11:42 AM, Staff B, Corporate Director of Health Services, stated that if a resident wanted to do self-medication, the facility assessed the residents for self-medication administration, obtained an order for self-medication of the specific medication, and then care planned the self-medication administration. Staff B stated that Resident 235 should have had an assessment, an order, and a care plan for self-medication administration.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written transfer/discharge notice to the resident and/or ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written transfer/discharge notice to the resident and/or their representative for 1 of 1 resident (Resident 12), reviewed for hospitalization. This failure placed the resident and/or their representative at risk for not having an opportunity to make informed decisions about transfers/discharges.
Findings included .
A review of the facility's policy titled, Transfer/Return, revised on 04/14/2024, showed that before facility-initiated transfer, the resident would be notified in writing the reasons for transfer in a language and manner they can understand. The policy also showed that the notice would contain the reasons for transfers and be documented in the resident's record by the facility and the physician.
A review of the discharge Minimum Data Set (MDS-an assessment tool) dated 05/28/2024 showed that Resident 12 was discharged to the hospital. A review of the admission MDS dated [DATE] showed that Resident 12 was readmitted back to the facility on [DATE].
A review of the nursing progress note dated 05/28/2024 showed Resident 12 was transferred to the hospital for further evaluation.
A review of the clinical health record (electronic and paper chart) did not show documentation that a written notice of transfer/discharge was provided to Resident 12 and/or their representative.
In an interview on 08/20/2024 at 1:56 PM, Staff E, Licensed Practical Nurse, stated that when residents transfer to the hospital, they notify family/representatives by phone. Staff E stated that they did not notify Resident 12 and/or their representatives in writing.
In an interview on 08/20/2024 at 3:22 PM, Staff C, Resident Care Manager, stated that the facility notified family/representatives about hospital transfer by phone. Staff C stated that they did not provide a written notice to Resident 12 and/or their representative.
In an interview on 08/22/2024 at 11:33 AM, Staff B, Corporate Director of Health Services, stated that it was their expectation for the facility to notify resident and/or their representative in writing.
Reference: (WAC) 388-97-0120 (2)(a)(b)(c)
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
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 bed hold (the opportunity to reserve a resident's current oc...
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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 bed hold (the opportunity to reserve a resident's current occupied bed while out of the facility to ensure their room was available when ready to return) notice was offered for 1 of 1 resident (Resident 12), reviewed for hospitalization. This failure placed the resident or their representative at risk for lack of knowledge regarding the right to hold their bed while in the hospital.
Findings included .
A review of the facility's policy titled, Bed Hold, revised on 01/22/2024, showed that It is the policy of this community to provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident to the hospital or the resident goes on therapeutic leave.
A review of the discharge Minimum Data Set (MDS-an assessment tool) dated 05/28/2024 showed Resident 12 discharged to the hospital. A review of the admission MDS dated [DATE] showed Resident 12 was readmitted to the facility on [DATE].
A review of the nursing progress note dated 05/28/2024 showed Resident 12 was transferred to the hospital for further evaluation.
A review of the clinical health record (electronic and paper chart) did not show documentation that Resident 12 was offered a bed hold notice for their transfer to the hospital.
In an interview and joint record review on 08/20/2024 at 1:56 PM, Staff E, Licensed Practical Nurse, stated that when the residents transferred to the hospital, they provided a bed hold notice to residents and /or their representatives. A joint review of the clinical health record with Staff E did not show that Resident 12 and/or their representative were provided with a bed hold notice. Staff E stated that the bed hold notice should have been provided.
In a joint record review of clinical health records and an interview on 08/20/2024 at 3:22 PM with Staff C, Resident Care Manager, did not show that Resident 12 and/or their representative were provided a bed hold notice. Staff C stated that the bed hold notice should have been provided to Resident 12 and/or their representative.
In an interview on 08/22/2024 at 11:33 AM, Staff B, Corporate Director of Health Services, stated that it was their expectation for the facility to provide bed hold notice to Resident 12 and/or their representative.
Reference: (WAC) 388-97-0120 (4)(a)
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Dat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS- an assessment tool) was completed timely for 1 of 1 resident (Resident 9), reviewed for significant change in condition. The failure to complete a SCSA 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) 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 that a significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered 'self-limiting,' 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary [involving two or more different subjects or areas of knowledge] review and/or revision of the care plan. The RAI showed that an SCSA is required to be performed when a terminally ill resident enrolls in a hospice program or changes hospice providers and remains a resident at the nursing home. The RAI manual further showed that the assessment should be completed no later than 14 days after the determination was made (determination date plus 14 calendar days).
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).
A review of the face sheet printed on 08/27/2024 showed Resident 9 admitted to the facility on [DATE].
A review of the clinical health record (Electronic Health Record [EHR] and paper chart) showed Resident 9 was admitted to hospice care on 09/22/2023.
A review of the SCSA MDS with an ARD of 09/27/2023 showed it was completed on 10/10/2024, which was four days late.
In an interview and joint record review on 08/22/2024 at 11:55 AM, Staff K, MDS Coordinator, stated that the SCSA MDS should be completed within 14 days of the significant change in status. A joint record review of the EHR showed Resident 9 was admitted to hospice care on 09/22/2024. In a follow-up email dated 08/22/2024 at 12:21 PM, Staff K stated that the SCSA MDS was completed late per the RAI manual.
In a phone interview on 08/23/2024 at 8:45 AM, Staff B, Corporate Director of Health Services, stated they expected an SCSA MDS to be completed timely.
Reference: (WAC) 388-97-1000 (3)(b)
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident-centered care and treatment were prov...
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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-centered care and treatment were provided in accordance with professional standards of practice when the facility failed to ensure consistent communication and collaboration of care occurred between the facility and hospice care for 1 of 1 resident (Resident 9), reviewed for hospice services. This failure placed the resident at risk of not receiving necessary comfort care services, unmet care needs, and a diminished quality of life.
Findings included .
A review of the facility's policy titled, Nursing Services-Hospice, revised on 02/13/2024, showed that the facility will ensure all documentation of hospice visit[s] are complete according to the state and federal regulations.
A review of the face sheet printed on 08/27/2024 showed Resident 9 admitted to the facility on [DATE].
A review of the Electronic Health Record (EHR) showed Resident 9 was admitted to hospice care on 09/22/2023.
A review of Resident 9's clinical health records (EHR and paper chart) showed the most recent hospice notes were from December 2023.
A review of the August 2024 Treatment Administration Record showed an order for a left heel wound treatment and dressing change that started on 07/11/2024.
In an interview and joint record review on 08/21/2024 at 12:50 PM, Staff F, Licensed Practical Nurse, stated that they would look for hospice notes about Resident 9's left heel wound but they could not find any hospice visit notes in Resident 9's EHR. A joint record review of Resident 9's paper chart showed the last hospice notes were from December 2023. Staff F stated the Resident Care Manager (RCM) would call hospice and request recent hospice notes.
In an interview on 08/22/2024 at 8:47 AM, Staff D, RCM, stated they did not expect the hospice notes to be readily available in the facility, but they could request the notes if needed. Staff D further stated that they had to request the documents for Resident 9 because there were no recent hospice notes readily available to show if hospice had been following the left heel wound.
In an interview on 08/22/2024 at 10:32 AM, Staff B, Corporate Director of Health Services, stated that there should be verbal and written communication to coordinate care between the facility and hospice. Staff B stated they expected that after hospice visited a resident, their notes would be readily available and on hand in the facility. Staff B further stated they would not expect the last hospice notes in the resident's chart to be from December 2023.
Reference: (WAC) 388-97-1060 (1)
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 thoroughly assess and stage a pressure ulcer (localiz...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to thoroughly assess and stage a pressure ulcer (localized damage to the skin and underlying tissue from prolonged pressure, friction, or shear, causing pain) at onset and weekly and maintain clear and accurate wound documentation for a pressure ulcer for 1 of 1 resident (Resident 9), reviewed for pressure ulcer. This failure placed the resident at risk for deterioration of their pressure ulcer and a diminished quality of life.
Findings included .
A review of the facility's policy titled, Pressure Ulcers and Skin Breakdown, revised on 04/11/2024, showed, The nurse shall describe and document/report the following: Full assessment of pressure sore [ulcer] including location, stage.
A review of the face sheet printed on 08/27/2024 showed Resident 9 admitted to the facility on [DATE].
A review of the skin integrity care plan revised on 07/10/2024, showed Resident 9 had a left heel wound. A review of the mobility care plan revised on 08/20/2024, showed Resident 9 had a left heel pressure ulcer.
A review of the facility's document titled, Skin Only Evaluation, dated 07/03/2024, showed Resident 9 had discoloration on their left heel that was not opened.
A review of the facility's document titled, Skin Only Evaluation, dated 07/10/2024, showed Resident 9 had discoloration on their left heel that was not opened and was not described as a pressure ulcer.
In an interview and joint record review on 08/21/2024 at 12:50 PM, Staff F, Licensed Practical Nurse, stated that they did not know if Resident 9's left heel wound was a pressure ulcer. A joint review of the Skin Only Evaluation, dated 07/10/2024, showed discoloration and did not describe the wound as a pressure ulcer or document the staging. A joint review of Resident 9's mobility care plan showed Resident 9 had a left heel pressure ulcer. Staff F stated they expected there to be documentation of the staging for Resident 9's pressure ulcer.
In an interview and joint record review on 08/22/2024 at 8:47 AM, Staff D, Resident Care Manager, stated that Resident 9's left heel wound started as a blister, and opened on 07/05/2024, was called a pressure injury and treatment was started. A joint review of the Skin Only Evaluations dated 07/03/2024, 07/10/2024, and 07/21/2024, showed no documentation of staging the wound. Staff D stated, Once it [the blister] pops that should have been the start of staging.
In an interview and joint record review on 08/22/2024 at 10:32 AM, Staff B, Corporate Director of Health Services, stated that it was very important to stage [or staging of pressure ulcer - is a classification system used to describe the severity of the injury to the skin and underlying tissue caused by prolonged pressure]. pressure ulcers and they expected this to be done and should be documented. A joint record review of the Skin Only Evaluation from 07/03/2024 and 07/10/2024, showed no change and continued to describe the left heel as having discoloration. Staff B stated it doesn't look like a new assessment was done. A joint record review of the physician's order for the wound treatment that started on 07/10/2024 showed no staging. Staff B stated, I would expect the order to state the stage of the pressure ulcer.
In a joint observation and interview on 08/22/2024, Staff V, Hospice Registered Nurse Case Manager, showed Staff V was cleaning dry skin from Resident 9's wound. Once the skin was removed, Staff V described the pressure ulcer on the bottom of the heel as unstageable [a type of pressure ulcer, which the depth is unknown due to a wound base that is covered by slough [moist, loose, stringy dead tissue that covers the wound, often appearing as a yellow, tan, or white fibrous material] and the open parts on both sides of the heel as Stage 2 (shallow open wound and may also present as an intact or open/ruptured blister) pressure ulcers. Staff V stated that they recommend starting a new treatment based on the observation of Resident 9's heel.
On 08/22/2024 at 5:25 PM, Staff D stated, Even if a resident is on hospice there should be staging of their pressure ulcer. Staff D further stated that staging was not done for Resident 9's pressure ulcer.
Reference: (WAC) 388-97-1060 (3)(b)
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 20
A review of Resident 20's face sheet showed they were admitted to the facility on [DATE] with a diagnosis that inclu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 20
A review of Resident 20's face sheet showed they were admitted to the facility on [DATE] with a diagnosis that included chronic respiratory failure (a long-term condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body).
A review of Resident 20's comprehensive care plan revised on 06/26/2024, showed an oxygen therapy care plan that directed staff to .provide extension tubing or portable oxygen apparatus.
Observation on 08/19/2024 at 9:36 AM showed Resident 20 was sitting in their room wearing a nasal cannula that was connected to the oxygen concentrator. The oxygen concentrator had a humidifier bottle of water. This bottle of water did not have a date written on it to indicate when the bottle was opened, and the oxygen tubing/nasal cannula was not labeled or dated. Further observation showed Resident 20 had a portable oxygen tank with a nasal cannula that was draped over Resident 20's walker that was not labeled or dated.
In an interview on 08/19/2024 at 9:36 AM, Resident 20 stated that the oxygen tubing gets changed when they ask the nurse to change it.
In an interview on 08/21/2024 at 1:50 PM, Staff E, LPN, stated that Resident 20's tubing gets changed weekly. Staff E stated that Resident 20 would ask for the tubing to be changed and manage their oxygen on their own.
In a joint record review and interview on 08/21/2024 at 2:20 PM with Staff E, showed a physician's order for oxygen that was ordered on 08/20/2024. Staff E stated they could not find an order before 08/20/2024.
In an interview and joint record review on 08/22/2024 at 4:16 PM, Staff B, Corporate Director of Health Services, stated that their expectation regarding oxygen therapy included having physician orders for oxygen and the water (for the concentrator) and oxygen tubing labeled with a date. A joint record review of the physician's order with Staff B showed no oxygen orders before 08/20/2024. Staff B stated that they were unable to find an oxygen order before 08/20/2024.
Reference: (WAC) 388-97-1060 (3)(j)(vi)
Based on observation, interview, and record review, the facility failed to maintain, label/date, and properly store oxygen tubing/supplies and nasal cannula (flexible tubing that sits inside the nose and delivers oxygen) for 2 of 2 residents (Residents 23 & 20), reviewed for respiratory care. This failure placed the residents at risk for unmet care needs, respiratory infections, and related complications.
Findings included .
A review of the facility's policy titled, Oxygen Administration, revised on 02/07/2024, showed that the facility administers oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues. The policy showed that the facility would assess the need for oxygen, obtain an order from a physician if needed longer than 24 hours, write the date on prepackaged humidifier bottles and discard the bottle after 7 days or when sterile water was gone, place nasal cannula(prongs) or mask in place with a date written on a label attached to tubing, and that oxygen tubing should be changed every week with new nasal cannula or mask.
RESIDENT 23
A review of the face sheet showed Resident 23 was admitted to the facility on [DATE] with a diagnosis that included pulmonary fibrosis (scarring and thickening of the tissue around and between the air sacs called alveoli in the lungs making it harder for oxygen to pass into the bloodstream).
A review of Resident 23's physician orders printed on 08/20/2024 showed no orders for oxygen.
On 08/19/2024 at 11:46 AM, Resident 23 was observed to have an oxygen concentrator and a portable oxygen device in their room. The oxygen concentrator had a humidifier bottle of water that was undated (or unlabeled), and the nasal cannula was lying uncovered on top of the concentrator. The nasal cannula tubing from the portable oxygen device was on the floor, uncovered, and undated. Resident 23 stated they did not remember the last time the oxygen tubing and humidifier bottle were changed. Resident 23 stated they used their portable oxygen as needed throughout the day, and that they used the oxygen concentrator nightly all night every night.
Observation on 08/20/2024 at 3:18 PM showed Resident 23's oxygen tubing from the oxygen portable oxygen device was undated, uncovered, and on the floor. Resident 23's oxygen concentrator tubing, nasal cannula, and humidifier bottle were undated. Both oxygen nasal cannulas from Resident 23's oxygen concentrator and portable oxygen were not being used and were uncovered.
A joint observation and interview on 08/20/2024 at 3:27 PM with Staff G, Licensed Practical Nurse (LPN), showed Resident 23's portable oxygen nasal cannula was on the floor uncovered and undated; and the oxygen concentrator nasal cannula was uncovered and undated. Staff G stated that Resident 23's nasal cannulas should have been dated, labeled, initialed, and covered with a bag when not in use. Staff G further stated that the portable oxygen nasal cannula should have not been on the floor.
On 08/20/2024 at 3:36 PM, Staff D, Resident Care Manager (RCM), stated that the oxygen tubing and nasal cannula should not have been on the floor, should be in a plastic bag when not in use, and be dated. A joint record review and interview with Staff D showed Resident 23's physician orders did not have orders for oxygen and/or orders for changing the oxygen tubing and the humidifier bottle. Staff D stated that Resident 23 used a portable oxygen device during the day and that they did not see oxygen protocol orders and/or oxygen orders. Staff D stated that there should have been oxygen orders in place for Resident 23. Staff D stated Resident 23's oxygen tubing and humidifier bottle should have been labeled, and dated, not on the floor, and nasal cannulas covered with a plastic bag when not in use. Another joint record review and interview with Staff D showed Resident 23's medical provider progress note and a portable oxygen concentrator order form dated 05/10/2024 documented that Resident 23 needed oxygen and the amount they needed per minute. Staff D stated that Resident 23's protocol for oxygen orders should have been started on 05/10/2024.
In another interview on 08/21/2024 at 10:05 AM, Staff D stated that Resident 23's nasal cannulas from the oxygen concentrator and portable oxygen device and the humidifier bottle should have been dated, initialed, and labeled.
On 08/22/2024 at 11:53 AM, Staff B, Corporate Director of Health Services, stated they expected an order for oxygen, oxygen protocol to monitor oxygen, oxygen tubing, and humidifier water bottle should be changed, dated, and initialed, and that nasal cannula needs to be appropriately stored when not in use. Staff B stated Resident 23's oxygen nasal cannula tubing should not have been on the floor and that they should have been covered in a breathable bag when not in use. A joint record review of the clinical records showed Resident 23 oxygen orders were entered on 08/20/2024, Staff B stated that there were no orders for oxygen in place before that date. A joint record review of the portable oxygen order form and medical provider's note dated 05/10/2024 showed orders for oxygen for portable concentrator device and oxygen concentrator, Staff B stated that Resident 23's oxygen orders should have been in place since around that time.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
SEVENTH FLOOR DINING ROOM
RESIDENT 235
Observation on 08/19/2024 at 8:56 AM, showed Staff E, LPN, checked Resident 235's blood pressure and oxygen saturation levels and then gave Resident 235 their me...
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SEVENTH FLOOR DINING ROOM
RESIDENT 235
Observation on 08/19/2024 at 8:56 AM, showed Staff E, LPN, checked Resident 235's blood pressure and oxygen saturation levels and then gave Resident 235 their medication in the dining room during the breakfast meal.
Observation on 08/19/2024 at 12:28 PM showed Staff E, administered medication to Resident 235 in the dining room during lunch meal.
RESIDENT 19
Observation on 08/19/2024 at 12:34 PM, showed Staff E administered medications to Resident 19 in the dining room.
RESIDENT 14
Observation on 08/19/2024 at 12:39 PM, showed Staff E administered medications to Resident 14 in the dining room.
RESIDENT 13
Observation on 08/19/2024 at 12:42 PM, showed Staff E checked Resident 13's blood pressure before administering a medication in the dining room.
In an interview on 08/19/2024 at 1:21 PM, Staff E stated that they try to administer medications before residents get to the dining room and did not always get to them on time. Staff C further stated that some of the medications have parameters and needed to get the vital signs before giving the medications. Staff E stated that when the facility was short-staffed, they ended up administering medications in the dining room.
In an interview and joint record review on 08/22/2024 at 4:22 PM, Staff B, Corporate Director of Health Services, stated that if the resident requested to have their medication administered in the dining room, then it could be administered if it was included in the care plan. A joint record review of the comprehensive care plans for Resident 235, Resident 19, Resident 14 & Resident 13 did not show that medication administration in the dining room was included in their care plan.
Reference: (WAC) 399-97-0880 (1)
Based on observation, interview, and record review, the facility failed to ensure a homelike dining environment was provided during 2 of 3 dining observations to 6 of 8 residents (Residents 3, 8, 235, 19, 14 & 13). The failure to ensure licensed nurses refrained from administration of medications during resident meals placed the residents at risk for diminished quality of life.
Findings included .
A review of the facility's policy titled, Medication Administration, revised on 04/11/2024, showed that medications were administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.
EIGHTH FLOOR DINING ROOM
RESIDENT 3
Observation on 08/19/2024 at 8:35 AM, Staff F, Licensed Practical Nurse (LPN), was observed assisting Resident 3 with their oral medications in the dining room during the breakfast meal.
RESIDENT 8
Observation on 08/19/2024 at 8:42 AM, Staff F was observed giving Resident 8 their oral medications in the dining room.
On 08/21/2024 at 11:26 AM, Staff F stated that medications were not supposed to be given in the dining room. Staff F stated they should not have given Resident 3 and Resident 8's morning medications in the dining room.
On 08/22/2024 at 10:16 AM, Staff D, Resident Care Manager (RCM), stated they expected staff to provide medications to the residents in their room. Staff D stated Resident 3 and Resident 8 should not have been given their medications in the dining room.
On 08/22/2024 at 11:40 AM, Staff B, Corporate Health Services Director, stated that Resident 3 and Resident 8 should not have been given their medications in the dining room.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to provide the required Registered Nurse (RN) coverage for 6 of 92 days (10/07/2023, 10/08/2023, 10/15/2023, 10/21/2023, 10/22/2023 & 11/04/20...
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Based on interview and record review, the facility failed to provide the required Registered Nurse (RN) coverage for 6 of 92 days (10/07/2023, 10/08/2023, 10/15/2023, 10/21/2023, 10/22/2023 & 11/04/2023), reviewed for sufficient and competent nurse staffing. This failure placed the residents at risk for inadequate assessments, delay in care services by an RN, unmet care needs, and a diminished quality of life.
Findings included .
A review of the facility's policy titled, Staffing Requirement, revised on 04/01/2024, showed that the facility will ensure the staffing sufficient of accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable data in a uniform format according to specifications. The policy also showed that the standard minimum staffing will significantly reduce the risk of unsafe and low-quality care for residents. Total direct nursing care to residents of at least 0.55 hours per resident per day of care must be provided by RNs.
A review of the facility's form titled, Daily Nursing Staff Posting, from 10/01/2023 to 12/31/2023, showed the following dates without (or did not have) eight-hour RN coverage:
10/07/2023
10/08/2023
10/15/2023
10/21/2023
10/22/2023
11/04/2023
A joint record review and interview on 08/23/2024 at 12:35 PM with Staff I, Staffing Coordinator, showed the Daily Nursing Staff Posting, did not have RN coverage for eight hours on 10/07/2024, 10/08/2023, 10/15/2023, 10/21/2023, 10/22/2023 and 11/04/2023. Staff I stated that they were not short of staff but I don't know what happened.
On 08/23/2024 at 1:01 PM Staff A, Administrator, stated that the regulation requires the facility to have RN coverage and we should meet the requirement. Staff A stated that it was their expectation for the facility to have RN coverage.
Reference: (WAC) 388-97-1080 (3)
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CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to appropriately label/store medications/biologicals (diverse group of medicines made from natural sources) and/or medical suppl...
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Based on observation, interview, and record review, the facility failed to appropriately label/store medications/biologicals (diverse group of medicines made from natural sources) and/or medical supplies for 2 of 2 medication rooms (Seventh Floor and Eighth Floor Medication Rooms), reviewed for medication storage. This failure placed the residents at risk for receiving compromised and ineffective medications and medical supplies.
Findings included .
Review of the facility's policy titled, Medication Label, revised on 04/11/2024, showed that nursing would ensure resident's medication was appropriately labeled according to pharmacy recommendation. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 30 days unless the manufacturer specifies a shorter or longer date for the open vial.
SEVENTH FLOOR MEDICATION ROOM
A joint observation and interview on 08/20/2024 at 1:13 PM with Staff C, Resident Care Manager (RCM), showed the Seventh Floor Medication Room's refrigerator had one multidose vial of tuberculin (purified protein derivative, is a combination of proteins that are used in the diagnosis of tuberculosis [a serious illness caused by a type of bacteria that mainly affects the lungs]) with an open date of 07/18/2024. Staff C stated that tuberculin was good for 30 days from the date it was first opened. Staff C stated that the tuberculin date was a few days past the 30 days, and it was expired by three days. Staff C further stated that the tuberculin should have been discarded.
EIGHTH FLOOR MEDICATION ROOM
A joint observation on 08/20/2024 at 1:24 PM with Staff N, Registered Nurse, showed the Eighth Floor Medication Room's refrigerator had one bottle of amoxicillin (an antibiotic - medication that fights infections) 400-57 10.9 milliliters (a unit of measurement) with an expiration date on 08/06/2024 for Resident 22.
The Eighth Floor Medication Room also showed the following expired supplies:
- One intermittent catheter (a hollow, partially flexible tube that collects urine - inserted and removed several times a day to empty the bladder) with an expiration date of 05/31/2024.
- One intermittent catheter with an expiration date of 09/30/2022.
- One latex Foley catheter (flexible tube used to drain urine from the bladder) with an expiration date of 07/28/2023.
In an interview on 08/20/2024 at 1:48 PM, Staff N stated that Resident 23 used intermittent catheters. Staff N stated that the amoxicillin, two intermittent catheters and Foley catheter tube were expired, and that they should have been discarded.
In an interview on 08/22/2024 at 10:21 AM, Staff D, RCM, stated that they expected medications and supplies to be labeled, checked for expiration dates, and to be discarded when expired. Staff D stated that the amoxicillin, the two intermittent catheters, and one foley catheter tube found in the Eighth Floor Medication Room should have been disposed.
In an interview on 08/22/2024 at 11:48 AM, Staff B, Corporate Director of Health Services, stated that the expired medications and medical supplies should be removed from the medication rooms. Staff B further stated that the expired tuberculin, amoxicillin, and the three urinary catheter tubes should have been discarded.
Reference: (WAC) 388-97-1300 (2)
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CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure expired food items were discarded after the expiration date or use by date and failed to have a working thermometer in...
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Based on observation, interview, and record review, the facility failed to ensure expired food items were discarded after the expiration date or use by date and failed to have a working thermometer in accordance with professional standards for food safety for 1 of 5 refrigerators (Kitchen Walk-In Refrigerator). These failures placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages).
Findings included .
A review of the facility's policy titled, Food Safety Requirement, revised on 12/01/2023, showed that Food service safety refers to handling, preparing, and storing food in ways that prevent foodborne illness. The policy showed that expired food would be removed immediately. The policy further showed practices to maintain safe refrigerated storage included monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation and labeling, dating, and monitoring food, including, but not limited to leftovers, so it is used by its use-by date.
A review of the facility's policy titled, Food Storage, revised 04/11/2024, showed the temperatures shall be monitored in all refrigeration and freezer units, checked daily (or more often if there is a problem), and recorded. Even if there is an outside thermometer, one thermometer shall be placed in the warmest part of the unit, preferably near the door, to ensure that the proper minimum temperature is maintained.
A joint observation and interview on 08/19/2024 at 8:28 AM with Staff U, Sous Chef, showed a tray of four Impossible Burger [brand] patties with a used-by date of 08/16/2024 was found in the Kitchen Walk-In Refrigerator. A tray of raw pork chops was also observed with a label that read, prep date 08/12 [08/12/2024], use by 8/18 [08/18/2024]. Staff U stated they would remove these items.
In another joint observation and interview on 08/19/2024 at 8:34 AM, with Staff U, a thermometer was observed attached to the shelf in the Kitchen Walk-In Refrigerator. Staff U was unable to read the temperature on this thermometer and stated, This is a broken one. Another thermometer was found on the same shelf but tucked on the side. When Staff U was asked to read the thermometer, they stated that it was also broken.
In an interview on 08/22/2024 at 3:53 PM, Staff A, Administrator, stated that the expectation was to have a thermometer inside the refrigerator. Staff A stated that they had expired foods that they did not discard immediately.
Reference: (WAC)388-97-1100(3)
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CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** INFECTION CONTROL DURING MEDICATION PASS
A review of the facility's policy titled, Medication Administration, revised on 04/11/2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** INFECTION CONTROL DURING MEDICATION PASS
A review of the facility's policy titled, Medication Administration, revised on 04/11/2024, showed that medications were administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.
RESIDENT 6
On 08/21/2024 at 8:39 AM, Staff E, Licensed Practical Nurse, was observed preparing medications. Staff E donned gloves and poured Resident 6's seven medications on their hand, then placed them in a medication cup after opening the medication cart, medication bottles, and medication bubble cards (medications placed in bingo cards) with the same gloved hands. Staff E brought the medication cup and the bubble card containing metoprolol tablets (medication that lowers the blood pressure) on a medication tray to Resident 6's room. Joint observation with Staff E showed there was an EBP signage outside Resident 6's room. Staff E stated that they had to put on Personal Protective Equipment [PPE-gown, gloves and mask] prior to entering Resident 6's room. Staff E brought the vital sign machine in Resident 6's room to take their blood pressure (BP) and pulse. After obtaining Resident 6's BP and pulse, Staff E popped a tablet of metoprolol in a medication cup and gave it to Resident 6. Staff E removed their gown, gloves and mask, and took the metoprolol bubble card back to the medication cart.
RESIDENT 235
On 08/21/2024 at 8:57 AM, Staff E was preparing the medications for Resident 235. Staff E put their gloves on, poured Resident 235's five oral medications into their hand, then placed them in a medication cup after opening the medication cart, medication bottles, and medication bubble cards with the same gloved hands. Staff E brought the medication cup and the lisinopril (medication that lowers the blood pressure) bubble pack in Resident 235's room. Staff E took the vital signs machine and obtained Resident 235's blood pressure and heart rate, then popped one tablet of lisinopril in the medication cup and gave it to Resident 235. Staff E took the lisinopril bubble card back to the medication cart.
RESIDENT 18
On 08/21/2024 at 9:26 AM, Staff E was preparing Resident 18's oral medications. Staff E put gloves on, poured Resident 18's six medications in their hand, placed them in a plastic medication cup, and gave it to Resident 18.
On 08/21/2024 at 9:35 AM, Staff E stated they took the blood pressure medications in the rooms to give to the residents after they obtained their blood pressure and heart rate while they were in the residents' rooms. Staff E stated that they wore gloves to pour residents' medications because they did not like to touch the medications. Staff E stated it was not clean and should have not placed Residents 6, 235 & 18's medications on their gloved hands after touching the medication cart, medication bottles, and medication bubble cards with the same gloved hands.
On 08/22/2024 at 9:46 AM, Staff C, Resident Care Manager, stated they expected nurses to provide medications to the residents as ordered, timely, and free from contamination. Staff C stated that the nurse [Staff E] should have placed the oral medications for Residents 6, 235 and 18 in medication cups and not in their gloved hand. Staff C stated that the medications bubble/bingo cards for Residents 6 and 235 should have not been taken to their room.
On 08/22/2024 at 11:26 AM, Staff B, Corporate Director of Health Services, stated that the nurse (Staff E) should not have poured the medications for the residents [Resident 6, 235 & 18] on their gloved hands and should have put them directly into the residents' medication cup. Staff B stated that the medications should be prepared on the medication cart and that medication bubble cards should have not been taken to Residents 6 and 235's rooms.
Reference: (WAC) 388-97-1320(1)(a)(c)
Based on observation, interview, and record review, the facility failed to ensure hand hygiene practices were followed during meal tray pass for 1 of 4 staff (Staff L), reviewed for infection control. In addition, the facility failed to follow infection control practices for 3 of 10 residents (Residents 6, 235 & 18), reviewed for medication administration. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.
Findings included .
A review of the facility's policy titled, Handwashing Policy, revised on 04/11/2024, showed hand hygiene was indicated, immediately before touching a resident .after touching a resident .after touching the resident's environment.
HAND HYGIENE DURING MEAL TRAY PASS
Observation on 08/19/2024 at 8:53 AM, showed Staff L, Certified Nursing Assistant, set up the meal tray for the resident in room [ROOM NUMBER] and left the room without performing hand hygiene. Staff L then touched the meal cart, removed a meal tray, entered room [ROOM NUMBER], set the tray on the bedside table and exited the room and touched the meal cart. No hand hygiene was performed before or after entering room [ROOM NUMBER]. Staff L then brought a meal tray to room [ROOM NUMBER], raised the resident's bed, touched the bedside table and then exited the room. No hand hygiene was performed before or after entering room [ROOM NUMBER]. Staff L removed the next tray from the cart and brought it to room [ROOM NUMBER] (an Enhanced Barrier Precautions [EBP] room-requiring extra precautions including washing hands before and after entering the room), touched the bed controls, the bedside table, and set up the tray for the resident. No hand hygiene was performed before or after entering room [ROOM NUMBER].
In an interview and joint observation on 08/19/2024 at 9:02 AM, Staff L stated they washed their hands prior to passing meal trays but did not wash their hands when going between resident's rooms and delivering trays. Joint observation of the EBP sign outside room [ROOM NUMBER] showed that everyone should wash hands before entering the room and when exiting the room. Staff L stated I should have washed my hands when entering and exiting room [ROOM NUMBER].
In an interview on 08/22/2024 at 1:30 PM, Staff D, Resident Care Manager/Infection Preventionist, stated they expected staff to perform hand hygiene between passing meals to residents and before and after going into resident rooms.
In an interview on 08/22/2024 at 5:18 PM, Staff B, Corporate Director of Health Services, stated they expected staff to perform hand hygiene during meal tray pass. Staff B further stated they expected staff to wash hands before and after going into resident rooms.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Staffing Data
(Tag F0851)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure that direct care staffing information was submitted timely to the Centers for Medicare and Medicaid Services (CMS), for 1 of 1 quart...
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Based on interview and record review, the facility failed to ensure that direct care staffing information was submitted timely to the Centers for Medicare and Medicaid Services (CMS), for 1 of 1 quarter (Quarter 4) for the fiscal year 2023 (which included October 2023 through December 2023), reviewed for Payroll Based Journal (PBJ- mandatory reporting of staffing information based on payroll data) submission. This failure caused the CMS to have inaccurate data related to nursing home staffing levels and had the potential to impact resident care and services.
Findings included .
A review of the facility's policy titled, PBJ, revised on 07/01/2024, showed it is the policy of this facility to electronically submit timely to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.
In an interview on 08/21/2024 at 1:32 PM, Staff J, Staffing/Central Supply Coordinator stated that they prepared the PBJ report for the 4th quarter of 2023 and provided it to the staff that submitted it to CMS. Staff J stated that they were not certain if the 4th quarter PBJ data was submitted.
On 08/23/2024 at 1:01 PM, Staff A, Administrator, stated that the PBJ data for the 4th quarter of 2023 was not submitted promptly.
Reference: (WAC) 388-97-1090(3)
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May 2023
20 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD) was obtained from the r...
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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 copy of the Advance Directive (AD) was obtained from the residents/representatives who have an AD in place and ensure a copy was readily available in the medical records for 2 of 6 residents (Residents 22 and 6) 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 directive is a written instruction, such as a living will (LW) or durable power of attorney (DPOA), relating to the provision of health care when an individual is incapacitated.
Review of the facility's policy titled, Policy and Procedure Advanced Directives, dated 10/25/2017, showed that a resident's AD will be documented in the clinical record and the care plan.
RESIDENT 22
Resident 22 admitted to the facility on [DATE]. Resident 22's clinical records did not show a copy of AD document in their physical or electronic chart.
On 04/25/2023 at 3:10 PM, Staff G, Medical Records, stated that Resident 22 did not have an AD document in their medical file.
On 04/26/2023 at 11:45 AM, Resident 22 stated they had an AD document, but they were unsure if the facility requested their AD.
On 04/26/2023 at 2:07 PM, Staff E, Social Services Coordinator, acknowledged that Resident 22 had no AD in their clinical record.
RESIDENT 6
Resident 6 admitted to the facility on [DATE].
Review of Resident 6's quarterly Minimum Data Set (an assessment tool) dated 03/02/2023, showed the resident was cognitively intact.
Review of Resident 6's Electronic Health Records and physical chart showed no AD documents.
On 04/25/2023 at 3:15 PM, Staff G stated that they were unable to find the AD documents in Resident 6's medical records.
On 04/27/2023 at 12:15 PM, Staff E acknowledged that Resident 6 had no AD documents in the medical records, was not offered to formulate AD, and no documentation of Resident 6's goals and wishes reflecting their current preferences.
Reference: (WAC) 388-97-0280 (3)(a)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Notice of Medicare (national health program) Non-Coverage ...
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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 Notice of Medicare (national health program) Non-Coverage (NOMNC) was issued at least two calendar days before Medicare services ended and/or inform residents of their potential liability for payment for 1 of 6 sampled residents (Resident 178) reviewed for liability notice and coverage. This failure placed the resident and/or their representative at risk for not having adequate information to make financial decisions related to continued stay in the facility.
Findings included .
NOMNC, Form CMS-10123, is given by the facility to Medicare beneficiaries (residents) before the end of a Medicare covered Part A stay or when all of Part B therapies are ending to inform the beneficiary, they may have to pay for any services the Medicare provider (facility) as determined that Medicare probably will not pay for.
Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN), Form CMS-10055, is issued by the facility if the beneficiary intends to continue services and the facility believes the services may not be covered under Medicare. It is the facility's responsibility to inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services.
Resident 178 admitted to the facility on [DATE]. Review of the medical record showed Resident 178 received Medicare Part A skilled services from 12/28/2022 to 01/20/2023 and remained in the facility after skilled services ended. A NOMNC issued to Resident 178 showed a last day of Medicare A coverage of 01/20/2023, signed on 01/19/2023, one day before the end of Medicare services.
Resident 178's medical records did not show documentation that the NOMNC and SNF ABN were provided two days prior to the last covered day of Medicare A benefits, as required.
On 04/28/2023 at 8:15 AM, Staff E, Social Services Coordinator, acknowledged that the NOMNC and the SNF ABN were signed on 01/19/2023 and there was no documentation to support the NOMNC and SNF ABN were provided two days before Resident 178's last covered day.
Reference: (WAC) 388-97-0300 (1)(e)
.
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 ensure allegations of abuse were reported to the State Agency (SA) ...
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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 allegations of abuse were reported to the State Agency (SA) within the required timeframe for 2 of 3 residents (Residents 11 & 78) reviewed for abuse. This failure placed the residents at risk for further abuse and lack of protection due to unrecognized abuse/neglect.
Findings included .
According to the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), For the purposes of reporting abuse .neglect .a nursing home employee (or other mandated reporter) is required to make a report if he or she had reasonable cause to believe the incident occurred. Examples of reasonable cause may include the individual observed the incident or heard the victim state it happened; or the individual heard about an incident from a permissive reporter who had direct knowledge of the incident; and Immediate telephone reporting was required when there was reasonable cause to believe abuse, neglect . had occurred . Federal law requires the facility to report all allegations of abuse or neglect. This would include taking seriously any allegation from residents or others with a history of making allegations.
The facility's policy titled, Policy and Procedure Abuse/neglect, dated 10/25/2017, showed, It is the policy of the facility that all suspected, alleged, or actual cases of resident abuse, including injuries of unknown origin, shall be thoroughly and completely investigated, and reported according to State and Federal regulations.
RESIDENT 11
Resident 11 admitted to the facility on [DATE].
Review of the quarterly Minimum Data Set (MDS - an assessment tool) dated 03/17/2023, showed Resident 11 had impaired cognition and required extensive assistance with activities of daily living.
On 04/27/2023 at 3:32 PM, Resident 11's Representative (RR1) stated that they were informed by the resident that during day shift on 04/24/2023, Resident 11 dropped their glasses and called for help, an unnamed staff member came to Resident 11's room, picked up their glasses, and then punched Resident 11 in the stomach. RR1 reported that Resident 11 feared the unnamed staff member. RR1 stated that they had reported the allegation to Staff D, Resident Care Coordinator (RCC), and Staff E, Social Services Coordinator.
On 04/28/2023 at 8:58 AM, Resident 11 stated that they recalled that when they dropped their glasses and turned on their call light, an unnamed staff member came to their room, picked up their glasses and punched them in the stomach.
On 04/28/2023 at 9:50 AM, Staff D stated that they were aware of Resident 11's allegation and stated that an investigation was pending.
On 05/01/2023 at 10:25 AM, Staff B, Director of Nursing, was asked if Resident 11's allegation was reported to the SA. Staff B stated that during the facility's Interdisciplinary Team discussion, it was determined that Resident 11's allegation was not reportable, and it was not reported to the SA.
RESIDENT 78
Resident 78 admitted to the facility on [DATE].
Review of the admission MDS assessment dated [DATE] showed that Resident 78 had impaired cognition and required extensive assistance with transfers and bathing.
On 04/25/2023 at 1:12 PM, Resident 78's Representative (RR2), stated that two weeks ago, Staff M, Certified Nursing Assistant (CNA), scanned Resident 78's forehead to take their temperature. Staff M stated, It is a gun. RR2 stated that it was very upsetting, and that this kind of inappropriate joke might cause fear for Resident 72. They stated that they had to reassure the resident that they were safe and that it was a joke. RR2 also stated that on that same day, they observed Staff M rough handling the resident during transfers by holding the neck of Resident 78. RR2 stated that they had reported both incidents to the facility's RCC.
On 04/26/2023 at 11:34 AM, Staff D stated they were aware of the incident about Staff M's joke, and it was investigated as a grievance, education was provided to Staff M, and Staff M was removed from Resident 78's care. When asked if it was reported to the SA as an allegation of abuse, Staff D stated that it was not reported to the SA.
On 04/26/2023 at 2:51 PM, RR2 reported to the surveyor that on 04/25/2023 around 7:30 PM, when Resident 72 was assisted to shower in their bathroom, RR2 overheard Resident 72 saying to Staff P, CNA, You are harassing me. Then when Staff P was assisting Resident 72 to bed, Staff P stated, Do not scratch your b**t. RR2 stated that they felt Staff P was shaming the resident. RR2 stated they did not report the allegation to the facility.
On 04/26/2023 at 3:30 PM, this surveyor informed Staff A, Health Services Director, of the incident on 04/25/2023 that RR2 had reported. Staff A stated they would investigate the allegations.
On 05/01/2023, the facility provided the updated April 2023 incident investigation log. Review of the log showed the facility did not log the allegations of abuse and they were not reported to the SA.
On 05/01/2023 at 10:21 AM, Staff B stated that the allegations were investigated as grievance and that it was not reported to the SA.
On 05/01/2023 at 10:45 AM, Staff A stated the facility interviewed Resident 1, Resident 78, and their representatives, and stated that they felt safe with the facility staff. When asked if the allegations of abuse were reported, Staff A stated the allegations were not reported to the SA.
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 identify allegations of abuse and ensure investigations were initia...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify allegations of abuse and ensure investigations were initiated and/or thoroughly investigated for 2 of 3 residents (Residents 11 and 78) reviewed for abuse investigation. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.
Finding included .
The facility's policy titled, Policy and Procedure Abuse/neglect, dated 10/25/2017, showed, It is the policy of the facility that all suspected, alleged, or actual cases of resident abuse, including injuries of unknown origin, shall be thoroughly and completely investigated, and reported according to State and Federal regulations.
RESIDENT 11
Resident 11 admitted to the facility on [DATE].
Review of the quarterly Minimum Data Set (MDS - an assessment tool) dated 03/17/2023, showed Resident 11 had impaired cognition and required extensive assistance with activities of daily living.
On 04/27/2023 at 3:32 PM, Resident 11's Representative (RR1) stated that they were informed by the resident that during day shift on 04/24/2023, Resident 11 dropped their glasses and called for help, an unnamed staff member came to Resident 11's room, picked up their glasses, and then punched Resident 11 in the stomach. RR1 reported that Resident 11 feared the unnamed staff member. RR1 stated that they had reported the allegation to Staff D, Resident Care Coordinator (RCC), and Staff E, Social Services Coordinator.
On 04/28/2023 at 8:58 AM, Resident 11 stated they recalled that when they dropped their glasses and turned on their call light, a staff member came to their room, picked up their glasses, and punched them in the stomach.
On 04/28/2023 at 9:50 AM, Staff D stated they were aware of Resident 11's allegation and stated that the investigation was pending.
Review of the completed investigation document provided by the facility, showed interviews were conducted with Resident 11, RR1, and six other residents. The investigation document showed, interviews were not conducted with the facility staff who cared for Resident 11. In addition, there was no documentation to show the facility completed a root cause analysis and/or whether they substantiated the abuse allegation or not.
RESIDENT 78
Resident 78 admitted to the facility on [DATE].
Review of the admission MDS assessment dated [DATE] showed that Resident 78 had impaired cognition and required extensive assistance with transfers and bathing.
On 04/25/2023 at 1:12 PM, Resident 78's Representative (RR2), stated that two weeks ago, Staff M, Certified Nursing Assistant (CNA), scanned Resident 78's forehead to take their temperature. Staff M stated, It is a gun. RR2 stated that it was very upsetting, and that this kind of inappropriate joke might cause fear for Resident 72. They stated that they had to reassure the resident that they were safe and that it was a joke. RR2 also stated that on that same day, they observed Staff M rough handling the resident during transfers by holding the neck of Resident 78. RR2 stated that they had reported both incidents to the facility's RCC.
On 04/26/2023 at 11:34 AM, Staff D stated they were aware of the incident about Staff M's joke, and it was investigated as a grievance, education was provided to Staff M, and Staff M was removed from Resident 78's care. When asked if it was reported to the SA as allegations of abuse, Staff D stated that it was not reported to the SA.
On 04/26/2023 at 2:51 PM, RR2 reported to the surveyor that on 04/25/2023 around 7:30 PM, when Resident 72 was assisted to shower in their bathroom, RR2 overheard Resident 72 saying to Staff P, CNA, You are harassing me. Then when Staff P was assisting Resident 72 to bed, Staff P stated, Do not scratch your b**t. RR2 stated that they felt Staff P was shaming the resident. RR2 stated they did not report these allegations to the facility.
On 04/26/2023 at 3:30 PM, this surveyor informed Staff A, Health Services Director, of the incident on 04/25/2023 that RR2 had reported. Staff A stated they would investigate the allegations.
Review of the investigation document provided by the facility titled, Compliments, Concerns & Resolution Report dated 04/18/2023 under the heading, Plan of Action/Comments, showed R/O [Rule Out] Abuse and neglect. Further review of the document showed no interviews were completed with other residents or staff, and no documentation to provide the facility completed a root cause analysis and/or whether the allegation was substantiated or not.
Review of the facility provided investigation report dated 04/25/2023, showed the interviews were conducted with Resident 76, RR2, Staff P, Staff I (CNA), and six other residents. The investigation document did not show the facility completed a root cause analysis and/or whether the facility substantiated the allegation or not.
On 05/01/2023 at 10:21 AM, Staff B stated that the allegations were investigated as a grievance and no abuse investigations were completed for Resident 11 or Resident 72.
On 05/01/2023 at 10:45 AM, Staff A stated that the facility interviewed Residents 11 and 78 and their representatives and both said they felt safe with the facility staff. Staff A stated the allegations were not investigated as a potential abuse.
Reference: (WAC) 388-97-0640 (6)(a)(b)(c)
.
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 Minimum Data Set (MDS...
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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 Minimum Data Set (MDS) assessment for 1 out of 2 residents (Resident 18) 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 Assessment Reference Date or ARD (A2300) and 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.
Resident 18 admitted to the facility on [DATE].
Review of the clinical record showed Resident 18 admitted to hospice care on 11/20/2022. Further review of Resident 18's clinical record showed the significant change in status MDS assessment dated [DATE] was signed and completed on 12/15/2022, 25 days after Resident 18 was admitted to hospice care. The significant change in status MDS assessment should have been completed on 12/04/2022.
On 04/28/2023 at 2:35 PM, Staff B, Director of Nursing, stated that they used the RAI criteria for completing MDS assessments. After a joint review of the RAI criteria for a significant change in status MDS, Staff B acknowledged that the MDS for Resident 18 should have been completed on 12/04/2022.
Reference: (WAC) 388-97-1000 (3)(b)
.
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** Based on interview and record review, the facility failed to complete and transmit resident assessment data to the Centers for M...
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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 and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframes for 1 of 3 residents (Resident 4) reviewed for timeliness in completing and transmitting discharge tracking records. This failure placed the resident at risk of unmet care needs and a diminished quality of life.
Findings included .
According to the Resident Assessment Instrument (RAI)/Minimum Data Set (MDS) Manual, Discharge MDS assessments must be completed no later than 14 days after the Assessment Reference Date (ARD) (A2300), and it must be submitted/transmitted within 14 days of the MDS completion date (Z0500B + 14 days) to the database as required.
RESIDENT 45
Resident 45 admitted to the facility on [DATE].
Review of a progress note dated 01/17/2023 showed Resident 45 was discharged to home.
Review of Resident 45's MDS assessments showed no discharge MDS was done.
On 04/27/2023 at 10:53 AM, Staff B, Director of Nursing, stated that the facility follows the RAI Manual as their policy for completion of MDS assessments. Staff B acknowledged that no discharge MDS was completed for Resident 45 and stated that it should have been completed.
Reference: (WAC) 388-97-1000 (5)(a)(e)(iii)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents with limited range of motion (ROM) re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for 2 of 3 residents (Residents 6 and 11) reviewed for ROM services. The failure to consistently assess, develop, implement, and/or revise individualized care plan interventions related to ROM placed the residents at risk for decline in functional ability and a diminished quality of life.
Findings included .
The facility's policy titled, Policy and Procedure - Restorative Nursing Program dated 2017, showed the purpose of Restorative Nursing Program (RNP) was to assess resident's needs for restorative care in mobility, Activities of Daily Living (ADL) and toileting. To create an environment which allows the residents to actively maintain or increase independence in mobility, ADLs, and toileting.
RESIDENT 6
Resident 6 admitted to the facility on [DATE] with diagnoses that included Hemiplegia/Hemiparesis (one-sided muscle paralysis or weakness) following a Cerebral Infarction (stroke) affecting the right dominant side. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a one-sided (right) impairment on their upper and lower extremities.
Review of the task list in the electronic medical record showed, Resident 6 had a Nursing Rehab Program (NRP) dated 04/15/2022, for the use of an Omni cycle (arm and leg pedal exerciser) to be used 10-15 minutes, five times/week.
Review of the ADL care plan revised on 01/09/2023 showed, Resident 6's goal was to remain free of complications related to immobility, including contractures (permanent tightening of the muscles, tendons, joints, and skin), blood clot formation, and to increase the level of mobility.
On 04/25/2023 at 1:30 PM, Resident 6 stated they were no longer walking due to their stroke and had not been on the Omni cycle for a while.
On 04/27/2023 at 12:23 PM, Staff J, Certified Nursing Assistant (CNA)/Restorative Aide (RA), stated there was no active NRP since last year and that the RAs were pulled to work on the floor.
On 04/28/2023 at 11:43 AM, Staff B, Director of Nursing, stated the NRP had stopped last year due to staffing. Staff B stated there were no programs to address Resident 6's restorative goals.
RESIDENT 11
Resident 11 admitted to the facility on [DATE] with diagnoses that included Cerebral Vascular Accident (a stroke) and Hemiplegia (one-sided paralysis or weakness) affecting the left side.
Review of the quarterly MDS assessment dated [DATE], showed Resident 11 had one sided limitation in ROM on their upper and lower extremities.
On 04/25/2023 at 11:27 AM, observation showed Resident 11 was lying in bed, and was unable to move their left upper and lower extremities.
Review of the electronic health record titled, Documentation Survey Report for March 2023 and April 2023, showed Resident 11 had a functional maintenance NRP to be provided five times a week. Further review of the record showed no documentation that the program was provided to Resident 11.
On 04/27/2023 at 8:37 AM, Staff J stated that the restorative program had been discontinued and they were no longer working as a RA.
On 04/28/2023 at 2:13 PM, during a joint record review and interview with Staff C, Resident Care Coordinator, and Staff D, RCC, they both stated that the facility did not have an NRP due to staffing issues and that Resident 11 was not restorative program for the past 3 months.
On 04/28/2023 at 2:57 PM, Staff B stated that the facility suspended their NRP due to staffing challenges.
Reference: (WAC) 388-97-1060 (3)(d)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary respiratory care and services were p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary respiratory care and services were provided in accordance with professional standards of practice about the use and proper care of Continuous Positive Airway Pressure (CPAP - a therapy that pumps air into the lungs through the nose and mouth that keeps the airway open) for 1 of 1 resident (Resident 329) reviewed for respiratory care. In addition, the facility failed to ensure a physician's order for use of O2 was accurate and/or followed according to resident's needs. These failures placed the resident at risk for respiratory infections and related complications.
Findings included .
Review of the facility document titled, CPAP Procedure revised in November 2022, showed that each part of the CPAP including any tubing will be labeled with the date it was opened, and changed per manufacturer's instruction.
Resident 329 admitted to the facility on [DATE] with diagnosis to include dependence on supplemental oxygen.
On 04/25/2023 at 9:29 AM, Resident 329 had a CPAP machine on their bedside table. Resident 329 stated the CPAP was their own machine.
Review of the physician's order summary in the electronic health record (EHR), showed no order for the use of CPAP. Further review of the EHR, showed the resident had an order for O2 at 2 Liters (L)/minute signed by the nurses every shift.
On 04/26/2023 at 11:07 AM, Resident 329 stated they wore the CPAP last night. Observation of the CPAP machine showed it was placed on the bedside table with the facemask stored in the drawer. The facemask was without a bag, and the CPAP tubing was unlabeled. Resident 329 was observed without using their supplemental O2.
On 04/27/2023 at 8:50 AM, Staff H, Licensed Practical Nurse, stated they follow the provider's order for CPAP and O2, including the settings and maintenance. Staff H stated that Resident 329 did not have an order for the CPAP machine. Staff H stated Resident 329 had an active order for O2 at 2L, but the resident had been on room air.
On 04/27/2023 at 10:01 AM, Staff C, Resident Care Coordinator, stated that Resident 329's CPAP should have an order that included the settings and maintenance.
On 04/28/2023 at 8:12 AM, Staff B, Director of Nursing, stated their expectation was that there would be an order obtained for CPAP and O2 use. Joint record review showed Resident 329 did not have an order for CPAP including the settings and maintenance. Staff B also stated the O2 order should be accurate to reflect the resident's needs.
Reference: (WAC) 388-97-1060 (3)(j)(vi)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 3
Resident 3 admitted to the facility on [DATE] with a broken right arm.
Review of the comprehensive MDS assessment dat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 3
Resident 3 admitted to the facility on [DATE] with a broken right arm.
Review of the comprehensive MDS assessment dated [DATE], showed Resident 3 required extensive assistance with bed mobility and transfers.
Observations on 04/25/2023 at 1:14 PM and 04/27/2023 at 9:13 AM, showed Resident 3 had quarter side rails on both sides of their bed in the raised position.
On 04/27/2023 at 9:13 AM, Resident 3 stated they had started to use the quarter siderail.
Review of the Electronic Health Record (EHR) showed that a device assessment was not completed, no consent for use, and no documentation that risk and benefits were reviewed with the resident or their representative for the siderail use.
Review of the comprehensive care plan showed Resident 3 was not care planned for the use of quarter siderails.
On 04/27/2023 at 12:04 PM, Staff C, RCC, stated that staff would complete a device assessment and care plan for the use of siderails.
On 04/28/2023 at 11:55 AM, a joint interview and record review with Staff B, showed the device assessment and care plan was not completed for Resident 3's quarter siderails. Staff B stated that their process was to do a device assessment, get an order from the doctor and care plan the use of siderails. Staff B stated that Resident 3 should have had a device assessment and care plan completed for the siderails use.
Reference: (WAC) 388-97-1060 (3)(g)
Based on observation, interview, and record review the facility failed to assess, obtain physician orders, provide risks/benefits of use, and develop care plans to meet the needs of 2 of 3 residents (Residents 18 and 3) for whom siderails devices were reviewed. This failed practice placed the residents at risk for injury.
Findings included .
A review of the facility provided policy titled, Policy and Procedure-Restraint and Device, dated 10/25/2017, showed the facility considered quarter siderails to be restraints/devices. It also showed, all residents have a Restraint/Device Assessment .completed prior to initiating any restraint/device .A physician's order is obtained for the use of any device that meets the definition of a restraint .The care plan identifies the type of restraint/device, when to be used .risks/benefits to use and interventions to decrease these specific risks.
RESIDENT 18
Resident 18 admitted to the facility on [DATE] with diagnoses that included dementia (memory loss) and Parkinson's (a disorder of the central nervous system that affects movement) disease.
Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident 18 had severe cognitive impairment and required extensive assistance for bed mobility and transfers.
Review of Resident 18's clinical record showed no assessment for the use of a siderail, no physician orders, and no consent from the resident's representative for the risks and benefits to using bed/mobility devices.
Additional review of Resident 18's clinical record did not include a care plan for siderail/devices.
Observations on 04/25/2023 at 12:11 PM, 04/26/2023 at 10:25 AM, 04/27/2023 at 8:42 AM and 04/28/23 at 8:41 AM, showed quarter siderails in the raised position on both sides of Resident 18's bed.
On 04/28/2023 at 8:51 AM, Staff T, Certified Nursing Assistant, stated that Resident 18 did not use the siderails for bed mobility as Resident 18 was totally dependent.
On 04/28/2023 at 8:59 AM, Staff K, Registered Nurse, stated they were not sure why Resident 18 had siderails.
On 04/28/2023 at 9:25 AM, Staff C, Resident Care Coordinator (RCC), stated that their expectation for the use of siderails would be that resident's would have an assessment done by therapy and then an order would be obtained. Staff B stated that they would expect the siderails to be in the lowered position until an assessment was done. Staff C stated they would not expect the side rails to be in the raised position for Resident 18.
On 04/28/2023 at 10:03 AM, Staff B, Director of Nursing, stated that their expectation for the use of siderails included a completed device assessment, physician orders and it needed to be care planned. Staff B stated that Resident 18 needed to be assessed for use of siderails.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0729
(Tag F0729)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to obtain registry verification to ensure staff met competency evaluation requirements before allowing to serve as a nurse aide for 1 of 3 sta...
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Based on interview and record review, the facility failed to obtain registry verification to ensure staff met competency evaluation requirements before allowing to serve as a nurse aide for 1 of 3 staff (Staff M) reviewed for nursing aide registry. The facility's failure to receive registry verification that the individual had met competency evaluation requirements placed the residents at risk for abuse and unmet care needs.
Findings included .
Staff M was hired on 02/14/2022 as a Certified Nursing Assistant.
Review of Staff M's employee record did not include documentation from the nurse aide registry.
On 05/01/2023 at 2:15 PM, Staff A, Health Services Director (HR), stated that new staff completed on-boarding with Human Resources, which included background checks and the nurse aide registry. Staff A stated that Staff M did not have a nurse aid registry and that HR had been looking for it.
Reference: (WAC) 388-97-1660(3)(c)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure medications were labeled and dated for 1 of 2 medication storage rooms (7th floor medication room) reviewed for medica...
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Based on observation, interview, and record review, the facility failed to ensure medications were labeled and dated for 1 of 2 medication storage rooms (7th floor medication room) reviewed for medication storage. This failure placed the residents at risk for receiving compromised and/or ineffective medications.
Findings included .
Review of the facility policy titled, Medication Storage, dated 04/12/2023, showed that the facility will follow the manufacturer's recommendations for proper medication storage.
Review of the manufacturer package instructions for Lorazepam (an antianxiety medication) Oral Concentrate showed that an opened bottle should be discarded after 90 days.
7th FLOOR MEDICATION STORAGE ROOM
On 04/26/2023 at 1:53 PM, during a joint observation and interview with Staff C, Resident Care Coordinator, showed two bottles of Lorazepam 2 milligrams/milliliters/30 ml bottle concentrate. Both bottles of the Lorazepam did not have an open date and/or no information on the bottle when they were first use or opened. Staff C stated the bottles of Lorazepam were opened and used but not dated.
On 4/28/2023 at 11:51 AM, Staff B, Director of Nursing, stated that the nurses were trained and expected to write the date when the medication was first opened or used. Staff B stated that the Lorazepam bottles should have been dated when they were first opened.
Reference: (WAC) 388-97-1300 (2)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents and resident representatives were provided educati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents and resident representatives were provided education about COVID-19 vaccination, including risks, benefits, potential side effects, document if the vaccine was accepted and/or refused in the medical record, and document as to why the vaccine was refused for 1 of 5 residents (Resident 330) reviewed for COVID-19 immunizations. This failure denied the resident and/or their representative of the right to make informed decisions.
Findings included .
COVID-19 is an infectious disease by a virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death.
Resident 330 admitted to the facility on [DATE]. Review of Resident 330's medical record showed no documentation to support that risks and benefits and/or education were provided to the resident and/or the resident's representative, and no information was found as to why the resident and/or the resident's representative declined the COVID-19 vaccine.
On 04/28/23 at 1:59 PM, Resident 330 stated they declined the COVID-19 vaccines when it was offered. When Resident 330 was asked if they were provided educational information or notified of risks and benefits about COVID-19, the resident stated, No.
On 04/28/2023 at 11:49 AM, Staff B, Director of Nursing Services, stated residents were screened for COVID-19 vaccine on admission and it was offered to them if they need it. Residents who agreed to receive the COVID-19 vaccines, education was provided, but no education was provided to the residents that opted not to receive the COVID-19 vaccine.
Reference: (WAC) 388-97-1780(1)(2)(d)
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) had the required abuse and neglect and/or dementia management training annually for 1 of 3 staff...
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Based on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) had the required abuse and neglect and/or dementia management training annually for 1 of 3 staff (Staff W). This failure placed residents at risk for potential negative outcomes and unmet care needs.
Findings included .
Staff W was hired on 12/29/2017 as a CNA.
Review of the facility's employee record showed Staff W received abuse and neglect training dated 02/27/2018. Further review of the employee record showed Staff W did not have documentation to support Staff received the dementia management training.
On 05/01/2023 at 11:43 AM, Staff B, Director of Nursing, stated staff had missing training documentation, and if the training record was not provided, then the education was not completed. Staff B also stated that staff attended Skills Day training at hire and annually, and that the dementia management training was not part of their Skills Day training, but it would be included moving forward.
Reference: (WAC) 388-97-1680 (2)(b)
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 12
Resident 12 admitted to the facility on [DATE] with wounds to their coccyx (tailbone)/sacral (bottom of spine) and l...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 12
Resident 12 admitted to the facility on [DATE] with wounds to their coccyx (tailbone)/sacral (bottom of spine) and left heel.
Joint wound care observation with Staff H, Licensed Practical Nurse, on 04/27/2023 at 9:35 AM, showed Resident 12 had multiple small open wounds on their sacrum and both buttocks. Staff H stated that Resident 12 admitted with the wounds and that the wounds had improved.
Review of the facility document titled, Admit/Readmit Screener dated 04/14/2023, showed Resident 12 had multiple skin issues on their right buttock specified as mixed etiology (cause or origin). Additionally, it showed that Resident 12 had very small open areas to left buttock, unable to measure.
Review of the March 2023 Treatment Administration Record showed orders for the coccyx/sacral wound dated 04/15/2023 and left heel wound dated 04/17/2023.
Review of the comprehensive MDS assessment dated [DATE], showed Section M (skin conditions) were not coded for pressure ulcers/pressure injury (bed sore).
On 04/28/2023 at 10:36 AM, during a joint record review and interview, Staff C, Resident Care Coordinator, acknowledged that section M was not coded for pressure ulcers. Staff C stated that the wounds on Resident 12's coccyx and buttocks were due to moisture and pressure and that the left heel was caused by pressure. Additionally, Staff C stated the wounds were present on admission. Staff C stated that section M should have been coded for pressure ulcers on the MDS assessment.
On 04/28/2023 at 12:14 PM, Staff B stated that they follow the RAI manual for MDS completion. Staff B reported that Resident 12 admitted with pressure ulcers on their coccyx/sacrum and left heel. Staff B acknowledged that Resident 12's MDS assessment was coded inaccurately. RESIDENT 22
Resident 22 admitted to the facility on [DATE].
DENTAL
On 04/25/2023 at 9:46 AM, Resident 22 stated their two front teeth were broken.
Review of Resident 22's admission MDS assessment dated [DATE], showed no broken natural teeth was marked in Section L (oral/dental status).
On 04/27/2023 at 1:29 PM, Staff B stated that Section L for Resident 22's was coded inaccurately.
INJECTIONS
Review of the admission MDS assessment dated [DATE], showed Section N (medications, under injections) was coded 0, indicating Resident 22 did not receive injections.
Review of Resident 22's February 2023 MAR, showed the resident received Enoxaparin (a medication used to prevent the formation of blood clots) 40 milligrams/0.4 milliliters solution subcutaneous (under the skin) injection twice a day from 02/22/2023 to 02/28/2023.
On 04/27/2023 at 1:29 PM, Staff B stated that Resident 22's MDS assessment was inaccurate and that the Enoxaparin injections should have been coded on the MDS.
Reference: (WAC) 388-97-1000 (1)(b)(2)(n)
Based on interview and record review, the facility failed to accurately assess 4 of 6 residents (Residents 18, 11, 12 and 22) reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding hospice, antipsychotic medication, pressure ulcers, dental and injections 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, dated 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.
RESIDENT 18
Resident 18 admitted to the facility on [DATE]. Review of the clinical record showed Resident 18 admitted to hospice care services on 11/20/2022.
Review of the quarterly MDS assessment dated [DATE], showed Resident 18's hospice status was not coded in Section O (Special Treatments).
On 04/28/2023 at 2:35 PM, a joint record review and interview with Staff B, Director of Nursing, showed Resident 18 was receiving hospice care and Staff B acknowledged that Resident 18's quarterly MDS assessment should have been coded in Section O for hospice care.
RESIDENT 11
Resident 11 admitted to the facility on [DATE].
Review of the quarterly MDS assessment dated [DATE], showed Section N (days of Antipsychotic [a type of drug used to treat mental disorder]) medication received was coded 0, indicating no antipsychotic medication received during the assessment period.
Review of Resident 11's March 2023 Medication Administration Record (MAR), showed Resident 11 received Aripiprazole (an antipsychotic medication) daily.
On 04/27/2023 at 10:55 AM, Staff B acknowledged that Resident 11 received the Aripiprazole during the assessment period. Staff B stated that used of antipsychotic medication should have been coded on Section N of the MDS assessment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 329
Resident 329 admitted to the facility on [DATE].
Review of Resident 329's EHR showed no documentation that a summar...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RESIDENT 329
Resident 329 admitted to the facility on [DATE].
Review of Resident 329's EHR showed no documentation that a summary of the baseline care plan was given to the resident and/or the resident's representative within 48 hours of admission.
RESIDENT 330
Resident 330 admitted to the facility on [DATE].
Review of Resident 330's EHR showed no documentation that a summary of the baseline care plan was given to the resident and/or the resident's representative within 48 hours of admission.
On 04/27/23 at 10:00 AM, in a joint interview and record review, Staff C, stated that the baseline care plan should be formulated in the first 48 hours of admission by the admission nurse, and a copy should be offered to the resident and/or the resident representative. Staff C was unable to provide documentation that a baseline care plan summary was offered or provided to the resident and/or their representative.
On 04/28/23 at 8:12 AM, Staff B stated that the expectation was that a baseline care plan was completed in the first 48 hours of admission and a copy was provided or offered to the resident and/or their representative. Staff B acknowledged that the baseline care plan summary was not provided to Resident 329 and Resident 330 and/or their representatives.
Reference (WAC) 388-97-1020 (3)
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 7 of 9 residents (Residents 12, 79, 378, 379, 128, 329 & 330) 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 .
Review of the facility's policy titled, Baseline Care Plan dated 10/25/2017, showed A baseline care plan will be developed for all newly admitted residents within 48 hours of admission. The policy also showed the facility will provide the resident and their representative a summary of the baseline care plan.
RESIDENT 12
Resident 12 admitted to the facility on [DATE].
Review of the Electronic Health Record (EHR) showed no documentation that a summary of the baseline care plan was given to the resident and/or the resident's representative within 48 hours of admission.
On 04/27/2023 at 11:51 AM, Staff H, Licensed Practical Nurse (LPN), stated that they were involved in developing the baseline care plan on admission. Staff H stated they do not provide a copy of the baseline care plan to the resident or have them sign that they received the baseline care plan summary. Staff H stated that the signature portion of Resident 12's baseline care plan was not signed.
On 04/27/2023 at 11:55 AM, Staff C, LPN, stated the baseline care plan was initiated by the admission nurse and was to be completed within two days. Staff C stated they were inconsistent with printing the baseline care plan.
On 04/28/2023 at 10:45 AM, during a joint record review and interview with Staff B, Director of Nursing, stated that the baseline care plan was not reviewed with Resident 12 and/or their representative and that a summary of the baseline care plan was not provided.
RESIDENT 128
Resident 128 admitted to the facility on [DATE].
Review of Resident 128's clinical record showed no documentation that a summary of the baseline care plan was reviewed and/or provided to the resident and/or their representative within 48 hours of admission.
On 04/25/2023 at 9:23 AM, Resident 128 stated no care plan summary was provided to them.
On 04/27/2023 at 9:55 AM, Staff D stated that Resident 128's clinical record did not show that a summary of the baseline care plan was reviewed and/or provided to the resident and/or their representative within 48 hours of admission.
On 4/28/2023 at 11:41 AM, Staff B acknowledged that a summary of the baseline care plan should have been given to Resident 128 within 48 hours of admission.
RESIDENT 378
Resident 378 admitted to the facility on [DATE].
Review of Resident 378's clinical record showed a document titled, Baseline Care Plan, dated 04/24/2023, did not show whether a written summary of the baseline care plan was provided to Resident 378 and/or their representative.
RESIDENT 379
Resident 379 admitted to the facility on [DATE].
Review of Resident 379's clinical record showed a document titled, Baseline Care Plan, dated 04/14/2023, did not show whether a written summary of the baseline care plan was provided to Resident 379 and/or their representative.
During a joint record review and interview on 04/27/2023 at 12:18 PM, Staff C stated that Resident 378 and Resident 379's clinical record did not show that a written baseline care plan summary had been provided to Resident 378 or Resident 379 and/or their representatives.
RESIDENT 79
Resident 79 admitted to the facility on [DATE].
On 05/01/2023 at 10:02 AM, Resident 79 stated they did not remember if the facility offered or gave them a summary of the baseline care plan.
Review of Resident 79's baseline care plan dated 04/21/2023, showed no record that a summary of the baseline care plan was offered or given to Resident 79.
On 05/01/2023 at 10:05 AM, Staff D, Resident Care Coordinator (RCC), stated they were not sure if the summary of the baseline care plan was given to Resident 79.
On 05/01/2023 at 10:17 AM, Staff B stated the summary of baseline care plan should have been provided to Resident 79.
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** Review of the facility policy titled, Restraint and Device dated 10/25/2017, showed that The care plan identifies the type of re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the facility policy titled, Restraint and Device dated 10/25/2017, showed that The care plan identifies the type of restraint/device, when to be used, the medical symptom being treated, risks/benefits to use and interventions to decrease these specific risk.
RESIDENT 3
Resident 3 admitted to the facility on [DATE].
Observations on 04/25/2023 at 1:14 PM and 04/27/2023 at 9:13 AM, showed Resident 3 had quarter side rails on both sides of their bed in the raised position.
On 04/27/2023 at 9:13 AM, Resident 3 stated that they used the side rails.
Review of the comprehensive CP printed on 04/26/2023, showed Resident 3 was not care planned for the use quarter side rails.
On 04/27/2023 at 12:04 PM, Staff C stated that a CP would be developed for residents who used quarter side rails.
On 04/28/2023 at 11:55 AM, during a joint interview and record review with Staff B, showed that Resident 3 did not have a CP for quarter side rails. Staff B stated that Resident 3 did not have a CP for the quarter side rails. and should have had a CP.
RESIDENT 12
Resident 12 admitted to the facility on [DATE] with multiple wounds on their coccyx (tailbone), sacrum (end of spine) and left heel.
Observations on 04/25/2023 at 11:11 AM and 04/27/2023 at 8:55 AM, showed Resident 12 used an air mattress.
Review of the comprehensive CP printed on 04/25/2023, showed Resident 12 was not care planned for the use of an air mattress.
On 04/27/2023 at 2:50 PM, Staff V, Registered Nurse (RN), stated that they develop a CP for air mattress use and checked for their proper functioning every shift.
On 04/27/2023 at 3:02 PM, during a joint interview and record review with Staff C, showed that Resident 12 did not have a CP for air mattress use. Staff C stated that Resident 12 did not have a care plan and that the air mattress was not checked for proper functioning.
On 04/28/2023 at 12:06 PM, Staff B stated that Resident 12 did not have a CP for the use of an air mattress and that it should have had a CP.
Review of the facility's policy titled, Resident Comprehensive Assessment and Care Plan, dated 10/25/2017, showed care planning is person centered and that the care plan will be completed within 7 days of completion of the comprehensive assessment.
RESIDENT 22
Resident 22 admitted to the facility on [DATE]. Review of Resident 22's admission MDS assessment dated [DATE], showed the ADL and pain care areas were triggered and marked for completion and/or to be developed into a CP.
Review of Resident 22's CP, initiated on 02/21/2023, showed the ADL CP did not state what type of assistance the resident required with their ADLs (toileting, dressing, bathing, and personal hygiene). Further review of the CP showed, transfers, bed mobility, eating, and pain were not included/developed in Resident 22's CP.
On 04/27/2023 at 1:29 PM, Staff B stated that their expectation was for CPs to be completed within 21 days of the resident's admission. Staff B stated that Resident 22's ADL CP was incomplete and not person-centered and that the pain CP was not developed.
Reference: (WAC) 388-97-1020 (1)(2)(a)
RESIDENT 18
Resident 18 admitted to the facility on [DATE].
Review of Resident 18's quarterly MDS assessment dated [DATE], showed Resident 18 required two person extensive assistance with bed mobility. The MDS also showed Resident 18 had severely impaired cognition.
SIDE RAILS
Observations on 04/25/2023 at 12:11 PM, 04/26/2023 at 10:25 AM, 04/27/2023 at 8:42 AM and 04/28/2023 at 8:41 AM, showed Resident 18's bed with left and right quarter siderails were in the raised position.
Review of Resident 18's comprehensive CP printed on 04/26/2023, showed there was no CP initiated for the use of siderails.
On 04/28/2023 at 8:51 AM, Staff T, Certified Nursing Assistant (CNA), stated that Resident 18 did not use the siderails for bed mobility.
On 04/28/2023 at 9:25 AM, Staff C stated that Resident 18 did not have the ability to use the siderails for bed mobility and that they would not expect the siderails to be in the raised position.
On 04/28/2023 at 10:03 AM, Staff B stated that the expectation for the use of siderails would be to have an assessment, get a physician order, and then initiate a CP.
AIR MATTRESS
Observations done on 04/26/2023 at 10:25AM, 04/27/2023 at 8:42AM and 04/28/2023 at 8:41AM, showed Resident 18 was using an air mattress.
Review of Resident 18's comprehensive CP printed on 04/26/2023, showed there was no CP initiated for use of an air mattress.
On 04/28/2023 at 9:25 AM, Staff C stated that the use of an air mattress was something that they expected to be care planned.
On 04/28/2023 at 10:03 AM, Staff B stated that there should have been a CP for use of an air mattress for Resident 18.
Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan (CP) for 5 of 8 residents (Residents 11, 18, 3,12 and 22) reviewed for comprehensive CPs. The failure to develop CPs for residents' limited range of motion, medication, siderails, air mattresses, activities of daily Living (ADL) and pain, placed the residents at risk for unmet care needs and a diminished quality of life.
Findings included .
The facility's policy titled, Policy and Procedure - Resident Comprehensive Assessment and Care Plan, dated 10/25/2017, showed the CP is person centered and involves the interdisciplinary team. The policy also showed that the CPs will identify all the residents' needs according to the comprehensive assessment, and it would be completed within 7 days of completion of the comprehensive assessment.
RESIDENT 11
Resident 11 admitted to the facility on [DATE] with diagnoses that included Cerebral Vascular Accident (a stroke) and Hemiplegia (one-sided muscle paralysis or weakness, affecting the left upper and lower extremities), and heart failure.
Review of the quarterly Minimum Data Set (MDS - an assessment tool) dated 03/17/2023, showed Resident 11 had functional limitation in Range of Motion (ROM) of the upper and lower extremities (left side). The assessment also showed Resident 11 received a diuretic (water pill - a drug used to manage excess fluid in a body) during the assessment period.
On 04/25/2023 at 11:27 AM, observation showed Resident 11 was lying in bed, and was unable to move their left upper and lower extremities.
Review of the February 2023, March 2023, and April 2023 Medication Administration Record (MAR) showed, Resident 11 was on three different diuretic medications.
Review of Resident 11's CP initiated on 06/07/2022 showed no comprehensive CP was initiated for Resident 11's left sided weakness and/or their diuretic medication use.
On 04/28/2023 at 9:51 AM, Staff D, Resident Care Coordinator (RCC), acknowledged that Resident 11 was on three diuretic medications and no CP was in place.
On 04/28/2023 at 2:15 PM, during joint record review and interview with Staff C, RCC, and Staff D, both stated there was no CP in place for Resident 11's limited ROM.
On 04/28/2023 at 2:57 PM, Staff B, Director of Nursing, stated there should be a CP for Resident 11's limited ROM and diuretic medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
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 foods stored in the refrigerator and kitchen s...
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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 foods stored in the refrigerator and kitchen storage were labeled/dated when opened, and discard food products on or before the use by date in 1 of 3 refrigerators (main kitchen walk-in refrigerator) and 1 of 1 kitchen dry storage. These failures placed the residents at risk for developing food borne illness (caused by ingestion of contaminated food or beverages).
Findings included .
Review of the facility's policy and procedure titled, Food Storage, revised on 03/09/2020, showed all food products should be inspected for safety and quality, dated upon receipt, and when opened and/or prepared. The policy directs staff to discard any expired or outdated food products.
MAIN KITCHEN WALK-IN REFRIGERATOR
On 04/25/2023 at 8:48 AM, joint observation of the main kitchen walk-in refrigerator with Staff N, Dining Services Manager, showed the following:
- A container of full paneer cheese, labeled with use by date of 04/01/2023.
- A half full container of tartar sauce, labeled/prepared on 04/21/2023, but no use by date label.
- A container of apple sauce, labeled with use by date of 04/23/2023.
- A container of orange marmalade, labeled/prepared on 04/18/2023, but no use by date label.
MAIN KITCHEN DRY STORAGE
- One opened low sodium matzo container, labeled with use by date of 04/13/2023.
- One baking soda powder repackaged in a small Ziploc bag dated 04/19/2023, but no use by date label.
- One opened [NAME] corn starch box wrapped with a plastic wrap, had no use-by date label. Further observation of the box showed the best used by date was November 18, and it did not indicate the year.
On 04/25/2023 at 9:07 AM, Staff N stated that all food items in the walk-in refrigerator and the dry kitchen storage should have been labeled properly, and food discarded when past their use-by date.
Reference: (WAC) 388-97-1100 (3)
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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** INFECTION CONTROL SURVEILLANCE
Review of the facility's Infection Control Prevention and Control Program dated 04/03/2023, show...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** INFECTION CONTROL SURVEILLANCE
Review of the facility's Infection Control Prevention and Control Program dated 04/03/2023, showed The facility is to maintain a surveillance system with the capacity to identify possible communicable diseases and infections before they can spread to other persons in the facility. To identify infections the following information regarding residents is reviewed on an ongoing basis and information is to be communicated by staff in meetings to the responsible for infection control.
Review of the facility's policy, Surveillance of Nosocomial Infection (facility acquired infection) dated 10/02/2022, showed that the Infection Control Nurse is responsible for collecting infection data on an ongoing basis and providing quarterly reports to the infection Control Committee. The policy further documented 6. Monthly infection rates are reported quarterly to Quality Assurance Committee with recommendations by the Infection Control Nurse.
A joint record review and interview on 04/28/2023 at 8:16 AM, Staff B stated that the infection control line list, analysis, and mapping (a diagram to track infection) was completed from January 2023 to March 2023 and kept it in a binder. Staff B stated they did not recall if an ongoing analysis of surveillance data and follow up activity in response to the infection surveillance data was shared with the medical director, QAPI or Infection Control Committee. Staff B stated it was shared occasionally with the Resident Care Managers (RCM) [and/or RCC] but mostly it stayed in the binder for record keeping. Staff B stated that the infection surveillance data should be analyzed and shared with the team to better manage and prevent infection in the facility.
STAFF EDUCATION
Review of facility's Infection Control staff education dated 01/26/2022 and 03/10/2022 included the following topics:
1. Completion on Paper Health Screening Tool or Computer Health Screening Tool.
2. Review of precautions and how to put on and off protective equipment.
3. Video of customer service.
4. Where to locate infection control protocol book.
5. What to do if you notice a pattern of symptoms.
6. Handwashing [Hand Hygiene].
On 05/01/2023 at 8:40 AM, Staff B was asked about COVID-19 staff education, Staff B was unable to provide documentation to support that COVID-19 staff education was provided. Staff B stated they put out memos at times and discussed vaccines in stand-up meetings, but they have no other records of staff education about COVID-19 infection control and prevention.
Based on observation, interview and record review, the facility failed to ensure hand hygiene was performed between glove change for 1 of 1 resident (Resident 12) reviewed for wound care, and 1 of 6 residents (Resident 328) reviewed for medication pass. In addition, the facility failed to ensure components of an effective infection control program to include: Provide an on-going analysis of the infection surveillance data and review the surveillance data in their Quality Assurance Performance Improvement (QAPI), provide documentation to support that education was provided to staff about 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), and ensure the soiled linen room, the sink in the soiled linen room to perform hand hygiene, and the red biohazard bin to place biohazard materials, were accessible to staff were implemented to provide a safe and sanitary environment to help prevent the development and spread of communicable disease and infections. These failures placed the residents at risk for cross contamination, health care associated infection, and related complications.
Findings included .
HAND HYGIENE - WOUND CARE
Review of the facility policy titled, Infection control prevention and Control Program, revised on 04/03/2023, showed that the facility required staff to perform hand hygiene as indicated by national guidelines and would provide infection prevention and control training upon hire and ongoing, to which include hand hygiene.
RESIDENT 12
Resident 12 admitted to the facility on [DATE] with open wounds on their coccyx (tailbone) and sacral (bottom of spine) area.
Review of the April 2023 Treatment Administration Record, showed a treatment for coccyx/sacral wound care: Clean with saline, pat dry, apply skin prep (forms a protective film or barrier on the skin) around the wound, cover open areas with Xeroform (a sterile, non-adhering dressing with fine-mesh gauze impregnated with a water-in-oil emulsion blend), and cover with Allevyn (foam dressing) every other day and as needed until resolved one time a day every other day for wound care.
During a wound dressing observation on 04/27/2023 at 9:33 AM, Staff H, License Practical Nurse, performed hand hygiene, applied gloves, then wiped off a thick paste from the resident's coccyx/sacral area with a moistened washcloth. Staff H then removed the contaminated gloves, did not do hand hygiene, applied new gloves, cleaned the resident's wounds with gauze and sprayed the area with skin prep. Staff H then removed their contaminated gloves, did not do hand hygiene before applying a new pair of gloves, and assisted in applying a new brief under the resident. Staff H did not change their gloves and did not perform hand hygiene, before applying the new Xeroform mesh gauze and Allevyn dressing to the coccyx/sacral wound.
On 04/27/2023 at 9:48 AM, Staff H stated they had not performed hand hygiene between glove change. Staff H stated that they did not know that they had to perform hand hygiene each time they changed their gloves.
On 04/28/2023 at 12:10 PM, Staff B, Director of Nursing Services/Infection Preventionist, stated they expected their staff to follow proper hand hygiene guidelines and that staff should perform hand hygiene between glove change.
8TH FLOOR SOILED LINEN ROOM
Review of the facility's policy titled, Infection Control Prevention and Control Program, revised on 04/03/2023, showed that the facility was to provide a safe, sanitary, and comfortable environment; and to help prevent the development and transmission of disease and infection.
On 04/26/2023 at 8:15 AM, observation of the 8th floor soiled linen room showed the following:
1. Two bedside commodes, one of the bedside commodes had a brown dry material on the left side middle handle.
2. A garbage/soiled linen container, a shower chair, and a bedside commode were in front of the sink, blocking staff access to wash their hands.
3. Four shower chairs, two small bedside commodes, and one bariatric (big) shower chair were in front of the red biohazard (may contain chemicals or infectious materials like blood) bin preventing staff to access to it.
Further observations of the 8th floor soiled linen room on 04/27/2023 at 8:44 AM, 04/27/2023 at 2:59 PM, 04/28/2023 at 9:00 AM and 05/01/2023 at 9:13 AM, showed one of the bedside commodes had a brown dry material on the left side middle handle. The sink and the red biohazard bin were inaccessible to staff.
On 04/28/2023 at 3:10 PM, Staff L, Nursing Assistant Registered, was observed placing a clear tied plastic bag containing soiled materials into the garbage bin in the 8th floor soiled linen room. Staff L did not perform hand hygiene when leaving the soiled linen room, walked all the way to the sink by the 8th floor nurse's station and washed their hands.
On 04/28/2023 at 3:14 PM, Staff L acknowledged that they washed their hand in the sink next to the nurse's station after placing a soiled item in the soiled linen room. Staff L stated that they prefer to use the sink next to the nurse station to wash their hands.
A joint observation of the 8th floor soiled linen room on 05/01/2023 at 9:59 AM with Staff D, RCC, showed the sink and the red biohazard bin were not accessible to staff, there were two garbage containers, two soiled linen containers, five shower chairs and three bedside commodes, blocking the sink and the red biohazard bin access.
On 05/01/2023 at 10:34 AM, Staff B stated that the Certified Nursing Assistants were responsible to clean the assistive devices in the soiled linen room. Staff B added that housekeeping was responsible to clean the soiled linen room. Additionally, Staff B stated that their expectation was for staff to follow their infection control policy for hand hygiene and disposing the biohazard materials when they used the soiled linen room.
On 05/01/2023 at 10:39 AM, during a joint observation and interview with Staff B in the 8th floor soiled linen room, Staff B acknowledged that the soiled linen room was full of devices and that staff had no access to the sink to perform hand hygiene or to the biohazard bin to dispose hazardous materials.
Reference: (WAC) 388-97-1320 (1)(a)(c)(2)(a)(b)(c)(4)(5)(a)
HAND HYGIENE - MEDICATION PASS
On 04/28/2023 at 7:48 AM, Staff K, Registered Nurse, with gloves on, was observed taking Resident 328's blood pressure (BP), then touched the resident's right toes. Staff K removed their gloves, gave Resident 328's medications but did not do hand hygiene after removing their contaminated gloves.
On 04/28/2023 at 8:20 AM, Staff K stated that they did not know hand hygiene had to be performed after taking off their gloves.
On 04/28/2023 at 10:28 AM, Staff C, Resident Care Coordinator (RCC), stated that nurses were trained to perform hand hygiene during medication pass. Staff C confirmed that Staff K should have performed hand hygiene after removing their gloves and before giving the medications to Resident 328.
On 04/28/2023 at 11:41 AM, Staff B stated that licensed nurses received hand hygiene training and were expected to perform hand hygiene before giving the medications and after removing their soiled gloves for any reason. Staff B acknowledged that Staff K should have performed hand hygiene.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to develop and implement an antibiotic stewardship program (ASP) to promote appropriate use of antibiotics, failed to obtain/analyze and make a...
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Based on interview and record review the facility failed to develop and implement an antibiotic stewardship program (ASP) to promote appropriate use of antibiotics, failed to obtain/analyze and make antibiotic resistance patterns based on laboratory data and/or use of an antibiogram (antibiogram-a set of information usually in the form of a table reviewing the proportion of individual bacterial pathogens sensitive to different antimicrobial agents or medicine), failed to provide feedback to prescribing providers on their antibiotic use and compliance with the ASP, and failed to share ongoing analysis of surveillance data with the infection control committee. These failures placed the residents at risk for potential adverse outcomes associated with the inappropriate/unnecessary use of antibiotics, and an increased risk for multi-drug resistant organisms (MDRO-germs that are resistant to antibiotics).
Findings included .
The facility policy titled, Antibiotic Stewardship Program, dated 10/25/2017, showed that the facility was to maintain an ASP that promotes the appropriate use of antibiotics to treat infections and reduce adverse events related to antibiotic use .Records are reviewed monthly as part of the overall infection control program to ensure appropriate documentation for use of the antibiotic .Antibiotics ordered outside the guidelines set by this policy will result in review by the Medical Director and further action taken as needed .All infections and treatments are monitored, and a report is provided monthly to the Quality Assessment and Performance Improvement (QAPI) Committee .An analysis of all infections will be provided to the QAPI Committee .Recommendations by the QAPI will be implemented.
On 04/27/2023 at 11:36 AM, Staff B, Director of Nursing/Infection Preventionist, stated that the facility had not developed or implemented any antibiotic protocols that would look at clinical signs and symptoms as well as laboratory reports to determine if an antibiotic was indicated or need adjustment. Staff B also stated that the facility had no antibiogram available to be shared to the providers or staff to review antibiotic use.
On 04/28/2023 at 8:16 AM, in a joint interview and review of the facility's infection log binder, Staff B acknowledged that the completed monthly infection logs had not been discussed in QAPI or with the medical director. Additionally, Staff B stated that there was no ongoing analysis of surveillance data, and that the data should have been shared with the infection control committee.
No associated WAC
.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately posted and updated with actual hours worked for each shift for 30 out of ...
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Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately posted and updated with actual hours worked for each shift for 30 out of 30 days reviewed for sufficient and competent staffing. This failure placed the residents, the residents' representatives, and visitors at risk of not being fully informed of the current staffing levels and census information.
Findings included .
Observations on 04/25/2023 at 2:22 PM, 04/26/2023 at 8:14 AM and 2:44 PM, 04/27/2023 at 2:21 PM and 4:30 PM, and 04/28/2023 at 2:36 PM, showed the facility's daily nursing staffing form located on the wall on the 7th floor by the nurse's station did not display the total actual nursing staff hours worked for previous shifts.
Observations on 04/25/2023 at 2:30 PM, 04/26/2023 at 2:46 PM, 04/27/2023 at 2:26 PM, and 04/28/2023 at 9:29 AM, showed the facility's daily nursing staffing form located on the wall on the 8th floor by the nurse's station did not display the total actual nursing staff hours worked for previous shifts.
Review of the daily nursing staffing information form from 04/01/2023 to 04/30/2023 had no total actual hours worked per shift/day.
On 05/01/2023 at 11:45 AM, during a joint record review and interview with Staff R, Staff Coordinator, showed that the nurse staff posting dated 04/28/2023 for total actual hours worked was blank. Staff R stated that they were not trained to complete the total actual hours worked and had not completed the total actual hours worked since they started working as a Staff Coordinator.
On 05/01/2023 at 11:29 AM, Staff A, Health Services Director, stated that Staff R did not complete the total actual hours worked. Staff A stated they expected their staff to complete the total actual hours worked as required.
No Associated WAC
.
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
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Washington facilities.
Concerns
- • 52 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
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About This Facility
What is The Terraces At Skyline's CMS Rating?
CMS assigns THE TERRACES AT SKYLINE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Washington, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is The Terraces At Skyline Staffed?
CMS rates THE TERRACES AT SKYLINE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 50%, compared to the Washington average of 46%. RN turnover specifically is 60%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at The Terraces At Skyline?
State health inspectors documented 52 deficiencies at THE TERRACES AT SKYLINE during 2023 to 2025. These included: 52 with potential for harm. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates The Terraces At Skyline?
THE TERRACES AT SKYLINE 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 34 certified beds and approximately 28 residents (about 82% occupancy), it is a smaller facility located in SEATTLE, Washington.
How Does The Terraces At Skyline Compare to Other Washington Nursing Homes?
Compared to the 100 nursing homes in Washington, THE TERRACES AT SKYLINE's overall rating (3 stars) is below the state average of 3.2, staff turnover (50%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting The Terraces At Skyline?
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 The Terraces At Skyline Safe?
Based on CMS inspection data, THE TERRACES AT SKYLINE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Washington. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at The Terraces At Skyline Stick Around?
THE TERRACES AT SKYLINE has a staff turnover rate of 50%, which is about average for Washington nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was The Terraces At Skyline Ever Fined?
THE TERRACES AT SKYLINE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is The Terraces At Skyline on Any Federal Watch List?
THE TERRACES AT SKYLINE 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.