Bellevue Post Acute

Based on interview and record review, the facility failed to conduct a thorough investigation for 1 of 1 resident (Resident 45), reviewed for abuse investigations. This failure placed the resident at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.Findings included .Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised in September 2024, showed all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are thoroughly investigated. The policy showed any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. The policy further showed the individual conducting the investigation at a minimum would interview the resident (as medically appropriate) or the resident's representative, staff members who had contact with the resident during the period of the alleged incident, and other residents to whom the accused employee provided care or services for.Review of Resident…

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 interview and record review, the facility failed to provide a written transfer/discharge notice as required for 2 of 3 residents (Residents 6 & 64), reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their protection of resident rights during transfers, and a diminished quality of life.Findings included. Review of the facility's policy titled, Transfer or Discharge Notice, revised in March 2021, showed residents and/or representatives are notified in writing and in a language and format they understand, at least thirty days prior to a transfer or discharge. The policy showed under certain circumstances, the notice would be given as soon as practicable but before the transfer or discharge. The policy further showed the resident and representative would be notified in writing the specific reason, date, location for the transfer/discharge, an explanation of the resident's rights to appeal, and contact information for the Office of the State Long-term…

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 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 timely placed the resident at risk for unmet care needs and a diminished quality of life.Findings included .Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated October 2025, showed that a SCSA is required to be performed when a terminally ill resident enrolls in a hospice (compassionate care provided to individuals who are in the final stages of a terminal illness) program or changes hospice providers and remains a resident at the nursing home. The Assessment Reference Date (ARD - observation period over which the resident's condition or status is captured by the MDS and ends at 11:59…

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 interview and record review, the facility failed to accurately assess 2 of 16 residents (Residents 9 & 19), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments were coded on the MDS regarding injections and prognosis (an estimate about whether a patient [resident] will recover from an illness) placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.Findings included .According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated October 2025, 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…

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 interview and record review, the facility failed to ensure Level II (or Level 2) Preadmission Screening and Resident Review (PASARR or PASRR - an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or Related Conditions are not inappropriately placed in nursing homes for long-term care) referral was made for 1 of 5 residents (Resident 19), reviewed for PASRR screening. This failure placed the resident at risk for unmet care needs and a diminished quality of life.Findings included.Review of the facility's policy titled, admission Criteria, revised in March 2019, showed, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level I [or Level 1] PASARR screen for all potential admissions, regardless of payer source, to determine if the individual…

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 interview and record review, the facility failed to notify the State Pre-admission Screening and Resident Review (PASARR or PASRR-an assessment used to identify people [residents] referred to nursing facilities with Serious Mental Illness [SMI], intellectual disabilities, or related conditions are not inappropriately placed in nursing facilities for long term care) Coordinator after a significant change in status occurred for 1 of 1 resident (Resident 9), reviewed for PASRR screening. This failure placed the resident at risk for unmet care needs and a diminished quality of life.Findings included.Review of the facility's policy titled, admission Criteria, revised in March 2019, showed, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level I [or Level 1] PASARR screen for all potential admissions, regardless of payer…

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 interview and record review, the facility failed to monitor a resident taking a diuretic (medication used to help remove extra fluid from the body) medication and failed to notify the provider of weight gain for 1 of 5 residents (Resident 5), reviewed for unnecessary medications. This failure placed the resident at risk for unrecognized weight gain, medical complications, and a diminished quality of life.Findings included.Review of a physician note dated 09/30/2025 showed that Resident 5 had diagnoses that included Chronic Heart Failure (CHF-a condition where the heart muscle cannot pump blood efficiently, causing fluid back up in the lungs).Review of Resident 5's physician orders printed on 01/06/2026, showed an order for furosemide (a diuretic medication) for fluid retention. It further showed an order to weigh the resident daily and to call the cardiologist [a doctor specializing in treating heart conditions] if the resident gained three pounds (lbs. -a unit of measurement) in 24 hours or five lbs. in a week.Review of Resident 5's CHF care plan, initiated on 05/08/2024,…

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 pharmacy services were provided to meet the needs of 1 of 6 residents (Resident 15), reviewed for unnecessary medications. The failure to administer medication in accordance with professional standards of practice placed the resident at risk for negative outcomes and a diminished quality of life.Findings included .Review of the facility's policy titled, Medication Labeling and Storage, revised in February 2023, showed, multi-dose vials that have been opened or accessed (e.g. [example], needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. The policy further showed, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.Review of the facility's policy titled, Administering Medications, revised in [DATE], showed, The…

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 interview and record review, the facility failed to ensure 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]) recommendations were completed accurately and in a timely manner for 2 of 6 residents (Residents 15 & 5), reviewed for unnecessary medications. These failures placed the residents at risk for experiencing adverse side effects, receiving unnecessary medications, medical complications, and a diminished quality of life.Findings included . Review of the facility's policy titled, Medication Regimen Review, revised on 03/02/2020, showed, Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR. The policy further showed, If an irregularity does not require urgent action but should be addressed before the consultant…

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 interview and record review, the facility failed to ensure physician's orders with parameters were followed when administering medications for 2 of 5 residents (Residents 5 & 19), reviewed for unnecessary medications. This failure placed the residents at risk for side-effects related to the medications, medical complications, and a diminished quality of life.Findings included. Review of the facility's policy titled, Administering Medications, revised in April 2019, showed, Medications are administered in accordance with prescriber orders, including any required time frame. Medications errors are documented, reported, and reviewed by the QAPI [Quality Assurance and Performance Improvement] committee to inform process changes and or the need for additional staff training. It further showed to check and verify vital signs (measurements of the body's essential functions) if necessary, prior to administering medications. RESIDENT 5BLOOD SUGAR MONITORING AND INSULIN ADMINISTRATIONReview of Resident 5's…

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 medications and/or biologicals were discarded when expired for 1 of 2 medication carts (Team-One Second Floor Medication Cart), reviewed for medication storage. This failure placed the residents at risk of receiving compromised medications and related complications.Findings included.Review of the facility's policy, Medication Labeling and Storage, revised in February 2023, showed, multi-dose vials that have been opened or accessed (e.g. [example], needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. The policy further showed, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.Review of the online manufacturer's recommendations titled, Insulin [medication that regulates sugar in the blood] Lispro Kwikpen [or Humalog…

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 interview and record review, the facility failed to provide the required specialized rehabilitative services for 1 of 2 residents (Resident 15), reviewed for rehabilitation services. This failure placed the resident at risk for decline in function, unmet care needs and a diminished quality of life.Findings included .Review of the facility's policy titled, Scheduling Therapy Services, revised in July 2013, showed, Therapy Services shall be scheduled in accordance with the resident's treatment plan.Review of the admission Minimum Data Set (an assessment tool) dated 10/24/2025, showed that Resident 15 was admitted to the facility on [DATE] and that they were cognitively intact.On 01/06/2026 at 12:25 PM, Resident 15 stated that the last time they received Physical Therapy (PT) was two weeks ago.Review of Resident 15's physician's orders showed an order PT/OT [Occupational Therapy] to eval [evaluate] and treat. Partial WBAT [partial weight bearing as tolerated] with an order date of 12/04/2025.Review of…

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 interview and record review, the facility failed to ensure the 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) vaccine was offered to 1 of 5 residents (Resident 5), reviewed for immunizations. The failure to educate and offer the COVID-19 vaccination placed the resident at risk for contracting the COVID-19 virus and related complications.Findings included.Review of the facility's policy titled, Coronavirus (COVID-19)-Vaccination of Residents, revised in June 2022, showed that Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident has already been immunized. It showed that Vaccine recommendations and schedules are consistent with the Centers for Disease Control and Prevention (CDC).Review of the CDC online document titled, Staying Up to Date with COVID-19 Vaccines, dated 11/19/2025, recommended a 2025-2026 COVID-19…

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 interview and record review, the facility failed to provide written notice of transfer/discharge to the resident and/or their representative and failed to notify the Office of the State Long Term Care Ombudsman (an advocate for residents of nursing homes who protect and promote resident rights under federal and state law and regulations), describing the reason for transfer/discharge for 1 of 2 resident (Resident 2), reviewed for discharges. These failures placed the resident at risk for not having opportunities to make informed decisions about transfer/discharge.Findings included.Review of the facility's policy titled, Transfer or Discharge Notice, revised in March 2021, showed that Residents and/or representatives are notified in writing, and in a language and format they understand. It showed that the resident and/or representative are notified of the specific reason for the transfer or discharge, date of the transfer or discharge, the location of where they are being transferred or discharged , and an explanation of the resident's rights to appeal the transfer or…

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 provide adequate supervision and accurately assess risk of elopement for 1 of 1 resident (Resident 1), reviewed for accident hazards. This failure placed the resident at risk for elopement, falls, and injury.Findings included.Review of the facility's policy titled, Wandering and Elopements, revised in September 2022, showed, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.Review of the admission Minimum Data Set (an assessment tool), dated 07/21/2025, showed that Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a group of conditions characterized by impairment with brain functions, such as memory loss and judgement). It further showed in Section E (Behavior), that Resident 1 wandered 1 [one] to 3 [three] days during the seven-day look back period.Review of the Electronic Health…

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 interview and record review, the facility failed to ensure staff followed and implemented abuse and neglect policies and procedures for the protection of residents during an abuse investigation for 1 of 3 residents (Resident 1), reviewed for abuse allegations. This failure placed the residents at risk for lack of protection from abuse. Findings included . Review of the facility's policy titled, Abuse Prevention Program, dated November 2017, showed, the administration/designee will: Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual and develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. The policy showed the investigation would identify and interview all involved persons, including the alleged victim, alleged perpetrator,…

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 interview and record review, the facility failed to ensure local law enforcement was notified for reasonable suspicion of abuse for 1 of 4 residents (Resident 1), reviewed for abuse. This failure placed the resident at risk for lack of protection from potential abuse and diminished quality of life. Findings included . Review of the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition, showed that incidents involving staff-to-resident concerns must be reported to law enforcement. It further showed that circumstances where findings were made against licensed, certified, or registered health care workers the State Department of Health must be notified. Review of the facility's policy titled, Abuse Investigation and Reporting, dated November 2017, showed, All alleged violations involving abuse .will be reported by the facility Administrator, or his/her designee, to the following persons or agencies, as applicable and per Washington State and federal regulations .law enforcement officials. Review of a grievance form dated 02/13/2025, showed Resident 1…

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 nurse staffing information postings were posted in prominent locations for 1 of 2 floors (Second Floor), reviewed for Nurse Staffing Information. This failure placed residents and visitors at risk for not being fully informed of current nurse staffing levels and resident census information. Findings included . Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, dated August 2018, showed that within two hours of the beginning of each shift, the number of Licensed Nurses and the number of unlicensed nursing personnel directly responsible for patient care will be posted in prominent location (accessible to patients and visitors) and in a clear and readable format. Observations on 10/10/2024 at 2:01 PM, on 10/11/2024 at 9:30 AM, on 10/14/2024 at 10:50 AM, on 10/15/2024 at 11:07 AM, and on 10/16/2024 at 8:06 AM, showed the nurse staffing information was posted on the first floor by the administration office. Observations on 10/14/2024 at 10:55 AM, on 10/15/2024 at 11:12 AM,…

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 foods were handled appropriately in accordance with professional standards of food safety for 1 of 1 kitchen, for 4 of 5 staff (Staff O, P, Q & C), and for 2 of 2 floors (First Floor and Second Floor), reviewed for food services. The failure to date and discard food items, perform hand hygiene, use appropriate hair covering and ensure food items were covered during meal delivery placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the facility's policy titled, Food Receiving and Storage, dated July 2018, showed, All food stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Review of the undated online document titled, Washington State Food Worker Manual, showed to wash your hands after you enter the kitchen and handle garbage, dirty dishes, money, or…

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 the survey result binder included the results for 1 of 2 years (2021) recertification and complaint surveys that resulted in citations. In addition, the facility failed to post notice of the availability of survey reports in areas of the facility that are prominent and accessible to the public. These failures prevented residents, residents' representatives and visitors from exercising their right to review past survey results and the facility's plan of corrections. Findings included . Review of the facility's undated document titled, Resident Rights and Responsibilities, showed that resident has the right to examine the facility's latest survey inspection results. During a residents' meeting on 10/11/2024 at 1:41 PM, Resident 2 and Resident 16 who routinely attended residents monthly meeting, stated they were not aware of the availability of survey reports. Observation of the first and second floor on 10/11/2024 at 1:55 PM, showed there was no posting or notice to show the availability of the…

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 interview and record review, the facility failed to develop a baseline care plan and/or provide a written summary of the baseline care plan to the residents and/or their representatives for 5 of 10 residents (Residents 94, 194, 15, 20 & 5), reviewed for baseline care plan. This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Plans - Baseline, dated June 2018, showed that a baseline plan of care to meet the patient's immediate needs shall be developed for each patient within forty-eight hours of admission. It further showed, the patient and their presentative will be provided a summary of the baseline care plan. RESIDENT 94 Review of the admission record printed on 10/16/2024, showed Resident 94 admitted to the facility on [DATE]. Review of the form titled, Patient [resident] Baseline Person-Centered Care Plan, dated 09/28/2024, showed that it was not marked for Patient and/or representative were…

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 develop and/or implement care plans for 4 of 20 residents (Residents 23, 193, 9 & 29), reviewed for comprehensive care plans. The failure to develop care plans for tilt in space wheelchair (a wheelchair that has reclining function) and Self-Administration of Medications, and the failure to implement dysphagia (difficulty swallowing foods or liquids) care plan placed the residents at risk for unmet care needs, related complications, and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated August 2018, showed a comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the patient's physical, psychosocial and functional needs is developed and implemented for each resident. Review of the facility's policy titled, Assistive Devices and Equipment, dated August 2018, showed that recommendations for the use of devices 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 failed to ensure the hallway carpet was safe for 1 of 2 floors (First Floor Hallway) and failed to provide adequate supervision for 1 of 1 resident (Resident 29), reviewed for accident/hazards. These failures placed the residents at risk for accidents, injury, and other negative outcomes. Findings included . FIRST FLOOR HALLWAYS Review of the facility's assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents), updated 06/14/2024, showed that the majority of our patients [residents] are short term and receive rehabilitative services. Observation on 10/11/2024 at 8:38 AM, showed multiple areas of bubbling [an area in the carpet where it lifts and creates a hill or bump in the floor] in the carpet in the first-floor hallways. It further showed one large area of bubbling in the hallway of room [ROOM NUMBER] to 143. Observations on 10/11/2024 at 1:58 PM and 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 failed to ensure expired medications were disposed timely and drugs were properly labeled and stored in accordance with current accepted professional standards for 2 of 2 medication carts (First Floor Team 1 & Team 2), reviewed for medication storage and labeling. These failures placed the residents at risk for receiving compromised and ineffective medications. Findings included . Review of the facility's policy titled, Storage of Medications, dated August 2018, showed, The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. FIRST FLOOR TEAM 1 MEDICATION CART A joint observation of the first floor Team 1 medication cart on 10/15/2024 at 1:32 PM, with Staff U, Licensed Practical Nurse, showed the following medications stored in the cart: - An open bottle of Senna plus (a stool softener) tablets, expired in September 2024. - An open bottle of Iron (a supplement) 27 milligram (mg) tablets, expired in April 2024. - An…

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 the facility was managed in a manner that utilized its resources to maintain the residents' highest practicable physical, mental, and psychosocial well-being. The failure to properly maintain the carpet placed the residents at risk for accidents, injuries, and a diminished quality of life. Findings included . Review of the facility's assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents), updated 06/14/2024, showed that the majority of our patients are short term and receive rehabilitative services. It further showed that the facility assessment was used to assess facility resources needed to provide competent care for our residents including .physical environment and building needs. Observation on 10/11/2024 at 8:38 AM, showed multiple areas of bubbling [an area in the carpet where it lifts and creates a hill or bump on the floor] in the…

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 hand hygiene practices and/or proper use of gloves were followed before, during, and after resident care and passing meal trays for 2 of 6 staff (Staff K & G), failed to implement Enhanced Barrier Precautions (EBP- precaution to protect residents from Multidrug-Resistant Organism [MDRO-a germ that is resistant to medications that treat infections]) for 3 of 3 residents (Residents 37, 193 & 5), and failed to ensure appropriate indwelling catheter (a semi-flexible tube inserted into the bladder to drain urine) care for 1 of 3 residents (Resident 37), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications. Findings included . HAND HYGIENE/GLOVE USE Review of the facility's policy titled, Handwashing/Hand Hygiene, dated July 2018, showed that all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of…

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 interview and record review, the facility failed to inform the resident and/or their resident representative before administering psychotropic (mind-altering) medication for 1 of 5 residents (Resident 5), 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 prior to administration. Findings included . Review of the facility's policy titled, Psychotropic Drug Utilization, last updated in November 2017, showed, In the event a psychoactive [mind-altering] medication is indicated in the plan of care, licensed staff will obtain informed consent for the use of the medication. Resident 5 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (an assessment tool) dated 09/25/2024 showed Resident 5 had moderately impaired cognition and received an antidepressant (medication for depression). Review of the order summary report as of 10/15/2024…

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 residents were evaluated, assessed, and obtained a physician order for safe administration of medications for 2 of 3 residents (Residents 193 & 34), reviewed for self-medication administration. The failure to complete a self-administration of medication assessment and obtain a physician's order placed the residents at risk for medication errors, adverse medication interactions, and complications. Findings included . Review of the facility's policy titled, Self-Administration of Medications, dated August 2018 showed the following: 1. As part of their overall evaluation, the staff and practitioner may assess the patient's [resident's] mental and physical abilities to determine whether self-administering medications is clinically appropriate for the patient. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the…

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 interview and record review, the facility failed to ensure allegations of abuse was reported to the State Agency as required for 1 of 1 resident (Resident 7), reviewed for abuse allegations. This failure placed the resident at risk for potential unidentified abuse and lack of protection from abuse. Findings included . Review of the facility's policy titled, Abuse Investigation and Reporting, dated November 2017, showed, All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies, as applicable and per Washington State and federal regulations .State Agency. It further showed, it will be reported immediately, but no later than twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious injury. According to the Nursing Home Guidelines, The Purple Book, dated in October…

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 interview and record review, the facility failed to identify an abuse allegation and failed to ensure the abuse allegation was thoroughly investigated for 1 of 1 resident (Resident 7), reviewed for abuse investigation. This failure placed the resident at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions. Findings included . Review of the facility's policy titled, Abuse Investigation and Reporting, dated November 2017, showed, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse, neglect, exploitation and misappropriation investigations will also be reported. Review of the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition) showed, All alleged incidents of abuse, neglect, abandonment,…

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 interview and record review, the facility failed to provide written notice of transfer/discharge to the resident and/or their representatives and failed to notify the Office of the State Long Term Care (LTC) Ombudsman (an advocacy group for residents), describing the reason for transfer/discharge for 1 of 1 resident (Resident 25), reviewed for hospitalization. These failures placed the resident at risk for not having opportunities to make informed decisions about transfer/discharge. Findings included . Review of the facility's policy titled, Transfers and Discharge Notices, dated June 2018, showed that the patient and/or representative will be notified in writing and the notice will be given as soon as it is practicable when an immediate transfer or discharge is required by the patient's urgent needs. In addition, it showed that a copy of the notice will be sent to the Office of the State Long-Term Ombudsman. Review of the discharge Minimum Data Set (an assessment tool) dated 09/05/2024, showed Resident…

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 interview and record review, the facility failed to transmit resident assessment data to the Centers for Medicare & Medicaid Services within the required timeframe for 1 of 3 residents (Resident 30), reviewed for discharge assessments. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the Long-Term Care Facility 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, revised in October 2024, showed discharge (non-comprehensive) Minimum Data Set (MDS-an assessment tool) assessments must be completed no later than 14 days after the discharge date (discharge date plus 14 days), and it must be submitted/transmitted within 14 days of the MDS completion date (Z0500 plus 14 days) to the database as required. Review of the nursing progress notes dated 06/30/2024, showed Resident 30 discharged to a community. Review of Resident 30's MDS schedule in their electronic health record on 10/09/2024 did not show that a…

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 interview and record review, the facility failed to accurately assess 2 of 21 residents (Residents 5 & 40), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding bladder continence and discharge status placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.18.11, dated October 2023, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that…

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 interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews (PASARR-an assessment to ensure individuals with Serious Mental Illness [SMI] or Intellectual/Developmental Disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) had the required Level II referral sent if residents had a positive Level I PASARR, or corrected/updated the resident's PASARR as needed for 1 of 5 residents (Resident 25), reviewed for PASARR. This failure placed the resident at risk for not receiving the care and services appropriate for their needs. Findings included . Review of the Department of Social and Health Services, Dear Nursing Home Administrator Letter, guidance titled, Clarification to the Pre-admission Screening and Resident Review (PASARR or PASRR) Level I Screening Process, dated 07/06/2024 and amended on 08/23/2024, showed a positive Level I PASARR screen (that would then require a referral for a Level II PASARR) was if Any…

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 interview and record review, the facility failed to conduct care conferences for 2 of 2 residents (Residents 37 & 193), reviewed for care planning. This failure placed the residents and/or their representatives at risk for not having input regarding care goals, unmet needs, and a diminished quality of life. Findings including . Review of the facility's policy titled, Patient [resident] Care Conferences-Social Services Procedures, dated June 2018, showed, After admission, an initial care conference will be scheduled by Social Services with the patient and responsible party (if the patient chooses) to be held within 7 [seven] days. The initial care conference is completed only for the first admission .The initial care conference will be documented on the Patient Care Conference form located in Point Click Care [Electronic Health Record (EHR)]). RESIDENT 37 Review of the admission record printed on 10/11/2024, showed Resident 37 admitted to the facility on [DATE]. Review of Resident 37's EHR (under…

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 1 of 3 licensed staff (Staff T) followed professional standards for proper insulin (a hormone that lowers the level of sugar) administration, and ensure medications were not left unattended for 1 of 1 resident (Resident 10), reviewed for medication administration. In addition, the facility failed to ensure blood pressure (BP), and heart rate (HR) were checked prior to blood pressure medication administration for 1 of 5 resident (Resident 25), reviewed for unnecessary medication. These failures placed the residents at risk for unmet care need, adverse effects and potential negative outcomes. Findings included . MEDICATION ADMINISTRATION According to the KwikPen (insulin pen) manufacturer's instruction, revised in July 2023 and approved by the U.S. Food and Drug Administration, priming insulin pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the insulin pen is working…

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, record review, and interview, the facility failed to provide necessary assistance with nail care and wheelchair transfer for 1 of 3 residents (Resident 20), reviewed for Activities of Daily Living (ADL). This failure placed the resident at risk for decreased self-esteem, decline in mobility and function, and a diminished quality of life. Findings included . Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting dated February 2018, showed, Patients [residents] who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Resident 20 admitted to the facility on [DATE] with diagnoses that included diabetes (a disease that occurs when the body can not properly regulate blood sugar levels), muscle weakness, and need for assistance with personal care. Review of the admission Minimum Data Set (an assessment tool) dated 10/07/2024, showed Resident 20 had…

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 interview and record review, the facility to provide care and services consistent with professional standards for significant weight gain and use of diuretic medication (that helps to reduce fluid buildup in the body) for 1 of 1 resident (Resident 20), reviewed for quality of care. In addition, the facility failed to implement the bowel management protocol when indicated for 1 of 2 residents (Resident 9), reviewed for bowel management. These failures placed the residents at risk of unmet care needs, medical complications, and diminished quality of life. Findings included . RESIDENT 20 Resident 20 admitted to the facility on [DATE] with diagnosis that included heart failure (occurs when the heart muscle does not pump blood as well as it should, and blood often backs up and causes fluid to build up in the lungs and in the legs). Review of the October 2024 Medication Administration Record (MAR) showed Resident 20 had an order for Torsemide (a drug used to treat edema [swelling] and excess fluid held in…

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 services were consistently provided to increase Range of Motion (ROM) and/or to prevent decrease in ROM for 1 of 1 resident (Resident 145), reviewed for restorative services. This failure placed the resident at risk for a decline in ROM, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Patient Mobility and Range of Motion, dated August 2018, showed patients [residents] with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. Review of the annual Minimum Data Set (an assessment tool) dated 07/19/2024, showed Resident 145 admitted to the facility on [DATE]. It further showed that Resident 145 had limited ROM in their upper extremity on one side. Review of the mobility care plan revised on 09/13/2024, showed Resident 145 was on a restorative program. Review of the facility's document titled, Nursing Rehab…

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 label/date and properly store nebulizer (a small machine that turns liquid medication into a mist that can be inhaled to treat respiratory conditions) treatment set for 1 of 3 residents (Resident 193), reviewed for respiratory care. This failure placed the resident at risk for respiratory infections and related complications. Findings included . Review of the facility's policy and procedure titled, Administering Medication through a Small Volume (Handheld) Nebulizer, dated August 2018, directed staff to change the equipment and tubing every seven days. Resident 193 admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a common lung disease that makes it difficult to breathe). Review of the order summary report as of 10/11/2024, showed Resident 193 had an order for Albuterol Sulfate Nebulization Solution (a breathing treatment used to prevent and treat wheezing and shortness of breath…

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 develop and implement a care plan and interventions to address dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life) care needs for 1 of 1 resident (Resident 25), reviewed for dementia care. This failure placed the resident at risk for having unidentified and/or unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Dementia-Clinical Pathway, dated June 2018, showed that for the individual with confirmed dementia, the IDT [Interdisciplinary Team] will identify a patient [resident]-centered plan to maximize remaining function and quality of life. Review of the quarterly Minimum Data Set (an assessment tool) dated 08/13/2024, showed Resident 25 admitted to the facility on [DATE] with diagnoses that included dementia. Review of Resident 25's comprehensive care plan, printed on 10/10/2024,…

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 interview and record review, the facility failed to ensure residents were free from unnecessary medication for 2 of 5 residents (Residents 20 & 25), reviewed for unnecessary medications. This failure placed the residents at risk for side-effects related to the medications, medical complications, and a diminished quality of life. Findings included . RESIDENT 20 Resident 20 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS - an assessment tool) dated 10/07/2024, showed Resident 20 had intact cognition and was on PRN (as needed) pain medication. A review of the October 2024 Medication Administration Records (MAR) showed Resident 20 had an order for oxycodone (an opioid drug used to treat moderate to severe pain) 2.5 milligram every four hours PRN for severe pain rated 7 to10 on the pain scale 1 to 10. Further review of the MAR showed Resident 20 received oxycodone for pain level less than 7 on the following days: - On 10/02/2024 for pain level 5 - On 10/03/2024 for pain…

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 interview and record review, the facility failed to ensure resident was free of unnecessary psychotropic (a drug that affects behavior, mood, thoughts, or perception) medication for 1 of 5 residents (Resident 5), reviewed for unnecessary medications. The failure to ensure licensed pharmacist's monthly Medication Regimen Reviews (MRRs) and physician recommendations were carried out in a timely manner placed the resident at increased risk for receiving medications they no longer needed, adverse side effects, and negative outcomes. Findings included . Review of the facility's policy titled, Medication Regimen Review, revised on 03/14/2019, showed that a designated facility staff member should monitor for weekly reports to ensure recommendations are completed in a timely manner and prior to patient discharge. Resident 5 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (an assessment tool) dated 09/25/2024 showed Resident 5 had moderately impaired cognition. Review of the order…

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 interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) had the required twelve hours of training, including dementia (memory loss) management training annually for 1 of 5 staff (Staff N). This failure placed the residents at risk for potential negative outcomes and unmet care needs. Findings included . Review of the facility's assessment, updated on 06/14/2024, showed Required in-service training for nurse aides [will] be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year. It further showed that all staff will be required to complete Care/management for persons with dementia, annually. Review of the facility's employee record for Staff N, CNA, showed they were hired on 01/09/2023. It further showed no documentation that Staff N received the required 12 hours of annual training, including dementia management training. In an interview and joint record review on 10/17/2024 at 12:40 PM, Staff E, Staff Development, stated that CNAs needed 12 hours of training yearly. A joint record…

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 interview and record review, the facility failed to accurately assess 1 of 2 residents (Resident 1), reviewed for Minimum Data Set (MDS - an assessment tool). The failure to ensure accurate assessments regarding active diagnosis placed the resident at risk for unidentified or unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents), Version 1.18.11, dated October 2023, showed 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). It further showed Urinary Tract Infection (UTI - bladder infection) has a…

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 interview and record review, the facility failed to provide a safe environment for 1 of 3 residents (Resident 1), reviewed for accident hazards. The failure to ensure disinfecting wipes were stored properly placed the residents at risk for allergic reaction, injury, and other negative health outcomes. Findings included . Resident 1 was admitted to the facility on [DATE]. Review of the facility's incident report dated 02/19/2024, showed Resident 1 complained of burning on their throat and was observed holding wipes in their hands. The wipes that Resident 1 was holding were Microdot Minute Wipes [a pre-soaked disinfectant (a substance that destroys bacteria, fungi, virus)]. He [the resident] also had 2 [two] packages of regular bed bath wipes (cleansing wipes [safe for body use]) in drawer. Patient [resident] reported he had pulled them from his drawer at bedside and had washed his face and neck with them. Immediately staff had got him up into W/C [wheelchair] and over the sink, removing his shirt 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 interview and record review, the facility failed to provide showers for 2 of 3 residents (Residents 1 & 2), reviewed for Activities of Daily Living (ADL). This failure placed the residents at risk for poor hygiene, decreased self-esteem, and a diminished quality of life. Findings included . RESIDENT 1 Resident 1 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS-an assessment tool) dated 11/26/2023, showed Resident 1 required partial assistance (helper does less than half the effort) to shower/bathe self. Review of the ADL care plan initiated on 11/21/2023, showed Resident 1 had self-care deficit for bathing related to decreased mobility and weakness. Review of the facility's form titled, Documentation Survey Report for November 2023 showed Resident 1 received one shower on 11/29/2023 during their 12 days stay at the facility. In a joint record review and interview on 02/07/2024 at 1:48 PM with Staff C, MDS Nurse, showed Resident 1 had no refusals with showers. Staff C…

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 interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for pain management was provided pain medications for severe (7 to 10 pain scale) pain. Resident 1, who experienced severe and unrelieved pain during the first 12 hours of their admission when the prescribed pain medication and/or effective alternative to relieve severe pain was not provided. This failure placed the resident at risk for uncontrolled pain and a diminished quality of life. Findings included . Resident 1 admitted to the facility on [DATE] with a diagnosis that included multiple pelvic (bony structure at the lower part of the trunk) fractures (break in a bone). Review of Resident 1's admission pain assessment dated [DATE], showed the resident had postoperative (post-surgery) pain intensity of seven out of 10 (7/10). Resident 1's pain was frequent, limited their day-to-day activities and made their concentration difficult. Further review of the pain assessment showed that one of the plans for…

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 interview and record review, the facility failed to notify law enforcement for an allegation of potential abuse for 1 of 1 resident (Resident 1), reviewed for abuse reporting. This failure placed the resident at risk for unidentified abuse, potential ongoing abuse, and a diminished quality of life. Findings included . According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book) Book) dated October 2015, stated that sexual abuse means any form of nonconsensual sexual contact (such as, staff asking resident for sexual touching, kissing, intimate hugging, & dating) between a staff person of a facility and a vulnerable adult living in that facility whether or not it is consensual. Resident 1 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (an assessment tool) dated 08/18/2023 showed Resident 1 was cognitively intact. Review of the clinical progress note dated 10/23/2023, showed Staff B, Director of Nursing Services, documented that Resident 1 reported…

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 interview and record review, the facility failed to provide abuse and neglect training for 1 of 1 staff (Staff C), reviewed for required staff training. This failed practice had the potential of not identifying and preventing abuse and/or neglect. Findings included . Staff C, Certified Nursing Assistant was hired on 04/19/2022. Review of the facility's employee record showed abuse and neglect training were not provided upon hire and annually. On 11/02/2023 at 1:52 PM, Staff C stated that they did not remember if they had abuse and neglect training during their first year of hire. On 11/02/2023 at 2:49 PM, Staff B, Director of Nursing Services, stated that Staff C received their yearly abuse and/or neglect training. Staff B checked their records and stated that they were unable to find Staff C's annual abuse and neglect training. On 11/02/2023 at 3:07 PM, Staff A, Administrator, stated that they were unable to find Staff C's abuse and neglect training. Reference: (WAC) 388-97-1680 (2)(b) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY [NAME]-[NAME], Glen Based on observation, interview and record review, the facility failed to accurately assess 5 of 15 residents (Residents 15, 12, 680, 129 and 26) reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding the use of a walker, dental, diagnoses, vision, and discharge (DC) 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: 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…

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 foods stored in the kitchen were labeled/dated when first opened and food products discarded on or before use by date. 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 . FOOD ITEMS IN THE DAIRY REFRIGERATOR On 07/10/2023 at 8:27 AM, during an observation and interview on with Staff J, Kitchen Manager, showed the dairy refrigerator had a clear plastic container of red jelly that was undated and unlabeled. Staff J stated that the container of jelly should have been labeled and dated. FOOD ITEMS IN THE WALK-IN FREEZER On 07/10/2023 at 8:42 AM, another observation and interview on with Staff J, showed the walk-in freezer had one box of unopened beef taquitos with a use by date of 09/20/2022. Staff J stated that the food item should have been should have been thrown away. Reference: (WAC) 388-97-1100 (3) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform the resident and/or the resident representative before administering psychotropic (mind altering) medication for 1 of 5 residents (Resident 680) reviewed for unnecessary medications. This failure placed the resident and/or resident representative at risk of not being fully informed of the risks and benefits before making decisions about their medication. Findings included . Review of the facility's policy titled, Psychotropic Drug Utilization, updated in November 2017, showed that in the event a psychoactive [affecting the mind] medication is indicated in the plan of care, licensed staff will obtain informed consent for the use of the medication. Resident 680 admitted to the facility on [DATE] with a diagnosis of depression (a mental disorder that can cause persistent feelings of sadness, loss of interest, low self-esteem and other emotional or physical problems). Review of the June 2023 and July 2023 Medication Administration Record showed that…

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 interview and record review, the facility failed to ensure bed hold notice was provided at the time of transfer for 1 of 2 residents (Resident 681) reviewed for hospitalization. This failure placed the resident at risk for lack of knowledge regarding the right to hold their bed while in the hospital. Findings included . Review of the facility's policy titled, Bed Holds and Returns, dated June 2018, showed that prior to transfers and therapeutic leaves, patients or resident representatives will be informed in writing of the bed hold policy and return policy. Resident 681 admitted to the facility on [DATE]. Review of Resident 681's Electronic Health Record (EHR) showed Resident 681 was sent to the hospital on [DATE] and readmitted back to the facility on [DATE]. Further review of Resident 681's EHR showed no indication that a written bed hold notification was provided to Resident 681 or their representative. On 07/14/2023 at 11:07 AM, a joint record review with Staff F, Resident Care Manager, did not show…

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 interview and record review, the facility failed to ensure baseline care plans were developed within 48 hours of admission to ensure continuity of care and/or to ensure a summary/copy of the baseline care plan was provided to the residents and/or their representatives for 2 of 6 residents (Residents 629 & 129) 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 policy titled, Care Plans - Baseline, dated June 2018, showed that the baseline plan of care shall be developed within 48 hours of the resident's admission to assure that the resident's immediate care needs are met and maintained. It also showed that the resident, and their representative will be provided a summary of the baseline care plan. RESIDENT 629 Resident 629 admitted to the facility on [DATE]. On 07/12/2023 at 4:57 PM, Resident 629 stated that they did…

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, record review, and interview, the facility failed to develop care plans for 1 of 2 residents (Resident 14) reviewed for nutrition, and 2 of 5 residents (Residents 679 & 680) reviewed for unnecessary medications. These failures placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated August 2018, showed that the comprehensive, person-centered care plan will describe services that are to be furnished to attain or maintain the patient's highest practicable physical, mental, and psychosocial well-being and describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. Additionally, it showed that the care plan will incorporate risk factors associated with identified problem. RESIDENT 14 Resident 14 admitted to the facility on [DATE] with diagnoses…

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 interview and record review, the facility failed to ensure Care Plans (CPs) were maintained, revised, and updated for 1 of 11 residents (Resident 11) whose CPs were reviewed. This failure placed residents at risk for unmet needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated August 2018, showed that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the patient's physical, psychosocial, and functional needs is developed and implemented for each patient. It also showed assessments of patients are ongoing and care plans are revised as information about the patients and the patients' conditions change. RESIDENT 11 Resident 11 admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease (brain disorder that causes problems with memory, thinking and behavior). Review of Resident 11's quarterly Minimum Data Set (MDS - an assessment tool) assessment…

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 meet professional standards of practice to ensure pharmacy Medication Regimen Review (MRR) and physician order parameters were followed for Atenolol (a medication to treat Hypertension [high blood pressure]) for 1 of 5 residents (Resident 12) reviewed for unnecessary medications. Additionally, the facility failed to ensure 1 of 3 licensed staff (Staff G) observed for medication administration follow medication administration practices. These failures placed the resident at risk for potential negative outcomes and possible medication error. Findings included . Review of the facility's policy titled, Administering Medications, dated August 2018, showed that medications must be administered in accordance with the orders, including any required time frame and the individual administering the medication must sign the patient's Medication Administration Record (MAR) after giving medications. Review of the facility's policy titled, Consultant…

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 interview and record review, the facility failed to ensure a safe discharge for 1 of 3 residents (Resident 26) who chose to leave the facility Against Medical Advice (AMA). This failure placed the resident at increased risk for hospital readmission, infection, and a diminished quality of life. Findings included . Review of the facility's policy titled, Discharging Against Medical Advice, revised in June 2018, showed that should a patient (resident), or their representative require an immediate discharge, the patient's attending physician will be promptly notified. RESIDENT 26 Resident 26 admitted to the facility on [DATE] with diagnoses of failure to thrive and Fibromyalgia (chronic pain). Review of the Minimum Data Set (MDS- an assessment tool) dated 04/22/2023 showed that Resident 26 had two stage 2 (partial thickness loss) bed sores to bilateral (both) buttocks. Review of Resident 26's clinical record showed that they discharged home AMA on 04/22/2023, but no documentation that risks and benefits…

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 interview and record review, the facility failed to ensure resident-centered care and treatment were provided in accordance with professional standards of practice when facility staff failed to follow physician bowel medication orders for 1 of 5 residents (Resident 11) reviewed for unnecessary medications. This failure placed the resident at risk for discomfort or bowel impaction and a diminished quality of care. Findings included . Resident 11 admitted to the facility on [DATE] with history of constipation. Review of Resident 11's clinical notes showed that Resident 11 was sent to the emergency room on [DATE] for constipation not improved with medications. Review of Resident 11's bowel record for June 2023 showed that the resident did not have a bowel movement (BM) from 06/18/2023 to 06/25/2023 (total 8 days). Review of the June 2023 Medication Administration Record (MAR) showed the following as needed (PRN) orders: -Bisacodyl Laxative Suppository 10 milligrams, insert 1 suppository rectally every 24…

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.