Peninsula Health Center By Harborview

Based on observation, interview, and record review, the facility failed to ensure two (#52 and #8) of eleven sampled residents , who dined in the main dining room, were provided and assisted with their meal until 30 and 40 minutes after all the others were served and ate their meal. Findings included: 1. On 9/16/2024 at 11:59 a.m., the main dining room was observed for lunch service. The room was observed with over twelve tables and many chairs. Prior to the meal observation, the room was used as a group activity, and there were many residents who were in attendance of that activity. After the activity was completed, there were nine residents who remained in the room to wait and be served their lunch. There were three staff members who were either talking/interacting with the residents in the room, or were providing them hydration. It was observed at this time, Residents #52 and #8 had been seated in the main dining room since the group activity ended. On 9/16/2024 at 12:08 p.m., a meal tray cart came out from the kitchen and the three staff members immediately began to serve and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure an assessment and physician orders were obtained for medication self-administration for one (#36) of eight residents sampled. Findings include: On 9/17/2024 at 9:41 a.m., an observation was made of Resident #36 in her room. A tracheostomy with a respiratory cap was visualized along with supplies for tracheostomy care. The resident stated she did most of her own tracheostomy care including her nebulizer treatments. Resident #36 stated her nebulizer medication was in her top left hand dresser drawer. Resident #36 gave permission to open drawer. An observation was made of two packets of Albuterol Sulfate Nebulization solution 0.63 mg/3 ml (milligram/milliliter) with one packet opened. Resident #36 stated she gave herself her own nebulizer treatment but the facility supplied her with the items and medication. A review of Resident #36's admission Record showed she was admitted to the facility with diagnoses which included but not limited…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure one (#67) out of eight residents sampled had the proper paperwork for the resident's code status. Findings include: A record review of Resident #67's physician orders show an order dated [DATE] for Do Not Resuscitate (DNR). Resident #67's medical record did not have the [Do Not Resuscitate order form] signed by the physician in the electronic medical record. On [DATE] at 9:55 a.m., an interview was conducted with Staff F, Licensed Practical Nurse (LPN). Staff F was assigned to the North wing of the facility and stated there was a DNR binder in the nurses' station in which all the residents in the entire facility with a DNR order were in the binder. Staff F, LPN stated there was another binder in the East wing nurses' station. Staff F, LPN stated the North wing DNR binder rational for all the residents was to account for the residents from the other wing (east) who might be transporting either walking or self-propelling via wheelchair…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a base line care plan was developed for the use of continuous oxygen therapy for two (#206 and #360) of twenty sampled residents who received oxygen therapy. Findings included: 1. On 9/16/2024 at 10:00 a.m., an observation and interview was conducted with Resident #206. She was lying in bed, under the covers and with the head of her bed at approximately 45 degrees. An oxygen concentrator was on the left side of the bed. The concentrator was on and the flow rate read 4.5 (lpm) liters a minute. The resident said she needed oxygen all the time and did not know what the flow rate should be. She confirmed it felt a little rushed in through her nose. When she found out the oxygen flow rate on the concentrator was at 4.5 lpm, she said that was too high. She revealed she had just been readmitted from the hospital and had been utilizing the oxygen since her readmission. Resident #206 revealed she had a diagnosis of Chronic Obstructive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility did not ensure services provided/arranged by an individual had the skills, experience, knowledge and licensure to perform tasks for one (#57) out of eight residents observed. Findings include: On 9/17/2024 at 8:15 a.m., an observation was made of an individual feeding Resident #57 in his high back wheelchair. An observation was made of the resident assisted by this individual to drink from a small plastic commercial bottle of apple juice without a straw. On 9/17/2024 at 10:14 a.m., an observation and interview were conducted in Resident#57's room with the individual sitting next to him. The individual sitting next to Resident #57 denied she was the resident's Certified Nursing Assistant (CNA) but a companion hired by the family. Resident #57's hired companion stated she would feed the resident in which the staff would provide the meal tray. The hired companion stated she would do incontinence care for the resident as well and stated the staff would bring her the supplies such as briefs and linen. The hired companion…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure enteral feedings were provided according to physician orders for one (#67) of two residents observed. Findings include: On 9/16/2024 at 11:10 a.m., an observation was made of Resident #67's enteral feeding pump of the total volume infused at 22,525 milliliters (ml). Photographic evidence obtained. On 9/17/2024 at 9:30 a.m., an observation was made of Resident #67 out of her room with the enteral feeding hanging, bottle half empty and pumped turned off. Staff H, Licensed Practical Nurse (LPN) assigned to Resident #67 stated resident was out to dialysis. Staff H stated the resident was scheduled early for dialysis and left the facility between 5:00 a.m. to 6:00 a.m. On 9/17/2024 at 11:37 a.m., an observation was made of Resident #67 returning from dialysis and wheeled into her room by a staff member. On 9/17/2024 at 12:35 p.m., an observation was made in Resident #67's room. The enteral tube feedings had not been connected to the resident for enteral nourishment. Photographic evidence obtained. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility did not ensure the timeliness of reporting critical lab values for one (#67) out of eight residents sampled. Findings include: On 9/16/2024 at 11:10 a.m., an observation was made of Resident #67 in her room. Resident #67 was in bed, eyes closed with heavy breathing. Resident #67 did not wake up while interviewing her roommate. An unknown nursing staff member stated Resident #67 sleeps like that all the time. A review of Resident #67's medial record showed a critically low lab value dated 9/14/2024 for serum sodium of 127 millimoles per liter (mmol/L). A previous sodium level was from a lab drawn on 9/12/2024 with a sodium result of 132 mmol/L (normal 133-143 mmol/L). Photographic evidence obtained. On 9/17/2024 at 9:05 a.m., an interview was conducted with the Assistant Director of Nursing (ADON) regarding the low critical serum sodium level dated 9/14/2024. The ADON stated she would call the dialysis center to have them collect a specimen for a repeat lab for the resident's chemistry but stated the results might take…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide two (#206 and #54) of forty-four sampled residents with food items per their preference during one of three breakfast meal services observed. Findings included: 1. On 9/16/2024 at 10:00 a.m., Resident #206 was observed lying in bed, under the covers and with the head of the bed at approximately 45 degrees. She had an over the bed table placed in front of her with many personal items on it. During the visit, Resident #206 complained she was not receiving the correct diet and the food came to her cold, as well as she received things she did not like. On 9/17/2024 at 8:00 a.m., Resident #206 was observed in her room and seated upright in bed at 90 degrees. She was observed with her over the bed table placed in front of her with her breakfast tray on it, along with various other personal items. Her breakfast consisted of scrambled eggs, sausage, mashed potatoes, coffee, milk and water. The resident's meal ticket read she was to receive a Mechanical Soft CCHO [Controlled Carbohydrate] diet. Observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a care plan was developed for the use of continuous oxygen therapy for one (#27) of twenty sampled residents who received oxygen therapy. Findings Included Review of the record for Resident # 27 revealed she was readmitted to the facility on [DATE] with diagnoses which included Acute and Chronic Respiratory Failure with Hypoxia. Review of a quarterly Minimum Data Set ( MDS ) assessment, dated July 7, 2024, revealed under Section J Health Conditions Shortness of Breath shortness of breath or trouble breathing with exertion and shortness of breath or trouble breathing when lying flat were both checked. An observation of Resident # 27 was conducted on 9/16/24 at 10: 28 a.m. She was observed seated in her wheelchair in her room wearing a nasal cannula in her nares. The nasal cannula and tubing was attached to an 02 concentrator set at 2 liters. Resident # 27 stated that she utilized her oxygen continuously and could not leave her room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility did not ensure a Preadmission Screening and Resident Review (PASRR) Level II was completed for one (Resident #97) of 32 sampled residents. Findings Included: A review of Resident #97's medical records revealed a Level I screen for Serious Mental Illness and/or Intellectual Disability or Related Conditions for Medicaid Certified Nursing Facility only. The Level I screen indicated Resident #97 had anxiety disorder, depressive disorder, and schizoaffective disorder. It also indicated the resident had recent treatment for mental illness including psychiatric treatment more intensive than outpatient care. With these indications a Level II PASRR evaluation must be completed prior to admission, unless the individual meets the definition of hospital discharge exemption. Resident #97 was admitted to the facility under the 30-day hospital discharge exemption. The exemption stated, if the individual's stay is anticipated to exceed 30 days, the NF (Nursing Facility) must…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility did not ensure one (Resident #99) of 32 residents reviewed, received treatment and care in accordance with professional standards of practice related to a change in condition, assessment, and following physician orders. Findings included: An observation of Resident #99 was made on 7/6/22 at 2:44 p.m. The resident was lying in bed with her eyes closed. She had steri-strips on her left hand and a scabbed over wound on the right side of her nose. A review of admission records indicated Resident #99 was admitted on [DATE] with diagnoses including type II DM, unspecified dementia with behavioral disturbance, psychotic disorder with hallucinations due to known physiological condition, and anxiety. A review of Resident #99's orders indicated an order dated 3/5/22 for head-to-toe skin checks weekly with special instructions to complete non-pressure observations or wound management form if appropriate. A review of Resident #99's Minimum Data Set (MDS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure one (Resident #97) of four residents reviewed for nutrition services was monitored for weight change and intake at meals. Resident #97 was noted to have lost 37 lbs., a 14% weight loss, over a two-month period, even though he was not on a physician ordered weight loss program. Findings included: A review of Resident #97's electronic medical record revealed the resident weighed 256 pounds (lbs.) on 4/4/2022 and 219 lbs. on 6/9/22. This was a weight loss of 37 lbs., calculated to be a 14.45% weight loss in 2 months, which the facility's policy identified as severe. According to the facility's policy titled Weighting and Measuring Height Policy Resident, dated 3/22/22, a loss of 7.5% or greater is described as a severe weight loss. A review of admission records indicated Resident #97 was admitted on [DATE] with diagnoses including adult failure to thrive, acute kidney failure, hyperosmolality and hypernatremia, dysphagia,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility did not ensure post dialysis care was provided for two (Resident #30 and #7) of two residents reviewed for dialysis Findings included: During a facility tour on 07/06/22 10:14 AM, Resident #30 was observed in his room being assisted by a staff member. Resident #30 was preparing to leave for dialysis. An attempt to interview the resident was not successful. Resident #30 was not easily understood but responded to yes and no questions. When asked if he had a snack or lunch packed for later, Resident #30 stated he did. Review of Resident #30's electronic medical record (EMR) showed the resident is [AGE] years old and was admitted to the facility on an 04/14/22 with diagnosis to include chronic kidney disease, unspecified. Review of physician orders for Resident #30 dated 04/14/22 - 07/07/22 showed: Medications administered prior to dialysis as ordered by physician. Receives dialysis at [name of facility] on Monday, Wednesday, and Friday at 11:15 a.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, and facility record review, the facility failed to ensure resident medications were stored and supervised in a manner that was free from access to other residents during one (3/11/2021) of four days observed, and on one (East wing) of two units. It was observed that loose pills and capsules were placed visibly in the space between the wall and the back of the handrail on a main hallway. Findings included: On 3/11/2021 at 1:00 p.m., the 200 East hallway was observed during the lunch meal service. While standing in the main hallway, between resident rooms [ROOM NUMBERS], the space between the wall and the back of the handrail was observed with loose pills and capsules. Further observations revealed one orange round tablet, one white round tablet, and one large white capsule. The medications were easily visible from the hallway and could easily be accessed by anyone who walked by. This area was observed with high traffic of both residents and staff members. There were three…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.