Colville Health and Rehabilitation of Cascadia

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform residents and/or their representatives about their right to have their bed held while hospitalized for 2 of 4 sampled residents (Residents 51 and 19), reviewed for hospitalizations. This failure precluded the residents and/or their representatives to participate in decisions regarding their right to return to the same facility upon hospital return, and the right to know how much the facility would charge for holding their bed. Findings included . Review of a revised April 2025 facility policy titled Bed-Hold Readmission showed, the facility issued two notices related to bed-hold policies. The first notice was given well in advance of any transfers such as information in the admission packet, and the second notice provided to the resident and/or the resident representative at the time of transfer to the hospital, or in cases of emergency transfer, within 24 hours of transfer. <Resident 51> Review of a 05/04/2025 admission assessment showed…

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 repeatedly implement the facility abuse prevention policy to include identification of potential instances of abuse, reporting allegations to the State Survey Agency as required, thoroughly investigate allegations, review interventions for effectiveness, revise interventions as needed, and communicate, coordinate, review, and track allegations of abuse through the Quality Assurance and Performance Improvement (QAPI) program for 1 of 11 sampled resident (Resident 19), reviewed for abuse. This failure placed residents at risk of abuse, psychosocial harm, and diminished quality of life. Findings included . Review of the facility policy titled, Preventing Abuse revised August 2023 showed, the facility would identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property was more likely to occur. Staff were to observe residents, visitors and staff to identify inappropriate behaviors and deploy sufficient staff on each shift to meet the needs of the residents. The policy…

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 coordinate with the State designated authority to ensure residents with a mental disorder received integrated care based on their needs for 3 of 7 sampled residents (Residents 34, 37, and 40) reviewed for Pre-admission Screening and Resident Review (PASRR, a two part screening; Level I determined presence of a Severe Mental Illness, SMI, or Developmental Disability and if present required a Level II evaluation by a specialized evaluator to determine if nursing home placement was the appropriate level of care, and what behavioral health or other community services were recommended. A Level II was required to be completed prior to nursing home admission.) Specifically, the facility failed to ensure Resident 34's PASSR level II recommendations were implemented, Resident 40's Level II evaluation was completed timely, and Resident 37's Level I screening was not completed correctly prior to admission. These failures placed the residents at risk…

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 provided consistently and routinely met professional standards of practice for 2 of 4 sampled residents (Resident 51 and 19), reviewed for hospitalizations. Specifically, the facility failed to repeatedly ensure resident hospital transfer documentation was completed as required to include the basis for hospital transfer, specific resident needs unable to be met by the facility, facility attempts to meet the needs, services available at the receiving facility to meet needs, and what information was conveyed to the receiving provider. This failure placed residents at risk of potential delays in emergent hospital treatment, unmet care needs, and potential complications. Findings included . Review of the facility policy titled, Documentation of Resident Health Status Needs and Services revised October 2022 showed, staff were to document in a resident's medical record as soon as the encounter concluded to ensure accurate recall…

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 staff notified the provider for 3 of 3 sampled residents (Resident 34, 40 and 61) reviewed for change in condition. Specifically, the staff failed to notify the provider when Resident 34 experienced extremely low blood sugars, Resident 40 experienced significantly low blood pressures (BP), and Resident 61 experienced elevated blood sugars. This failure precluded the provider's involvement in coordinating care and placed the residents at risk of further adverse or deteriorating clinical outcome. Findings included . The 11/28/2017 facility policy Resident Change of Condition documented that upon recognition of a potentially life-threatening condition or significant change in status, the nurse was to communicate with other health care providers. The physician was to be informed at the time of the event as soon as possible. Notification should occur immediately if any symptom, sign or apparent distress is sudden in onset, or 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.

Based on interview and record review, the facility failed to develop and implement a system to evaluate staff competencies in skills and techniques related to diabetes management, medication administration, Post Traumatic Stress Disorder (PTSD), Substance Use Disorders (SUD), Gradual Dose Reductions (GDR), trauma informed care, fall management, or incident root cause analysis to ensure staff provided necessary care and responded to each resident's individualized needs for 8 of 10 sampled staff (Staff P, L, AA, BB, CC, DD, EE, and FF), reviewed for nursing services. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, unmet care needs, and diminished quality of life. Findings included . Review of the facility assessment reviewed May 2025 showed, the facility provided care to residents who were diabetic, received blood thinners, had histories of SUD, trauma/PTSD, anxiety, cognitive impairment, and other medical conditions related to mental health. The facility provided person-centered/directed care by building…

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 behavioral health services were provided for 2 of 3 sampled residents (Residents 34 and 40), reviewed for mood and behavior. This failure created risk for residents to experience a decline in their psychosocial well-being. Findings included . <Resident 34> The [DATE] admission assessment documented Resident 34 had diagnoses that included end-stage kidney disease dependent on dialysis (a mechanical way of ridding a body of toxins when the kidneys no longer function), diabetes, and alcohol dependence. Resident 34 was cognitively intact, made their own decisions regarding their care, had no behaviors and did not reject their care. A Level II Behavioral Health Preadmission Screen and Resident Review (PASRR, a screening completed prior to skilled nursing facility admissions that determined a need for behavioral health services for residents) Notice of Determination dated [DATE] documented Resident 34 had a mental health diagnosis, met…

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 appropriate medically related social services were provided to meet residents' needs at the time of transfer to the hospital or discharge to the community. Specifically, Social Services failed to ensure the basis for discharge was supported by documentation in the medical record for 1 of 4 sample residents (Resident 4), reviewed for discharge. This failure placed the resident at risk of placement in an unsuitable environment, increased risk of harm, and psychological distress. Additionally, Social Services failed to notify the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes who protect and promote the resident rights under federal and state law and regulations) of 37 transfers to the hospital for 5 of 5 months (January, February, March, April and May 2025) reviewed. Failure to notify the Ombudsman of hospital transfers, precluded the Ombudsman from effectively advocating for the residents' rights…

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 staff performed the required hand hygiene (HH) during meal service for 1 of 2 dining rooms (DR) observed. This failure placed the residents at risk for foodborne illnesses. Findings included . An observation on 05/12/2025 at 12:23 PM showed Staff KK, Agency Nursing Assistant (NA), placed clothing protectors on nine residents. During the application of the clothing protectors, Staff KK touched the residents' hair, neck, or clothing. No HH was observed between residents. Staff KK proceeded to the take a bag of clothing protectors and placed it on a counter behind the DR's entry door closest to the kitchen. Staff KK then walked out then right back in from the other entry door (farthest from the kitchen), touched a male resident in a wheelchair (wc) and walked out of the DR without completing HH. Staff KK then returned to the DR, went over to a female resident, touched their wc and left arm, went over to attend to another resident's request for Kleenex, went to get the Kleenex on the counter and did not…

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 governing body acted with disregard to the well-being of the residents of the facility; by not providing adequate oversight and monitoring of the appointed Corporate Officers/Administrator and/or the Director of Nursing. Failure to identify potential incidents of abuse, provide adequate nursing staff to supervise residents and complete care timely, provide mental health services, administer medications as prescribed, address and follow up timely on identified concerns, and implement appropriate infection control measures created multiple situations that caused harm to residents, and two separate situations of an immediate jeopardy (IJ: a situation that had occurred that could result in harm, serious injury and/or death). related to abuse and accident hazards. Findings included . Refer to F600 CFR 483.12, Freedom from Abuse and Neglect The governing body failed to identify, report and assess a pattern of abuse related to resident-to-resident altercations by Resident 19. In addition, the governing body failed to identify, assess or implement…

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 maintain minimum documentation that staff were educated regarding risks and benefits of the COVID-19 (a viral illness that caused fever, difficulty breathing or possibly death) vaccine, were offered the vaccine, and the COVID-19 vaccine status of the staff as required for 1 of 1 staff reviewed. This failure placed staff and residents at risk of and exposure to illness from COVID-19. Findings included . The revised 08/01/2023 facility policy COVID-19 Vaccination for Residents and Staff documented staff were educated of the risks and benefits associated with the COVID-19 vaccine so they could make an informed decision regarding immunization. Education and re-education was documented in the employee file. Staff have the opportunity to accept or refuse a vaccine or booster and may change their decision at any time. During an interview on 05/22/25 at 4:09 PM, Staff F, Infection Preventionist, Licensed Practical Nurse, was asked if they were the one that kept track of staff COVID vaccinations. Staff F stated the facility 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.

Based on interview and record review, the facility failed to ensure the mandatory Quality Assurance and Performance Improvement (QAPI) training was provided as required for 10 of 10 sampled staff (Staff P, L, AA, R, BB, K, CC, DD, EE, and FF) reviewed for training requirements. This failure placed all residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's 05/08/2025 QAPI plan showed the facility had a process in place to recognize, assess, and implement steps to improve the quality of life, care and services at the facility, however, the plan did not specify or include the type of training the staff would receive or how often training would occur. Review of the following employee files found no documentation that showed the facility provided the mandatory QAPI training: - Staff P, Licensed Practical Nurse - Staff L, Registered Nurse - Staff AA, Licensed Practical Nurse - Staff R, Nursing Assistant, Registered - Staff BB, Licensed Practical Nurse - Staff K, Nursing Assistant - Staff CC, Nursing Assistant - Staff DD,…

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 the mandatory Compliance and Ethics training was provided as required for 9 of 10 sampled staff (Staff P, L, AA, R, BB, K, CC, DD, EE, and FF) reviewed for training requirements. This failure placed all residents at risk for unmet care needs and a diminished quality of life. Review of the following employee files found no documentation that showed the mandatory Compliance and Ethics training had been provided: - Staff P, Licensed Practical Nurse - Staff L, Registered Nurse - Staff AA, Licensed Practical Nurse - Staff R, Nursing Assistant, registered - Staff K, Nursing Assistant - Staff CC, Nursing Assistant - Staff DD, Nursing Assistant - Staff EE, Nursing Assistant - Staff FF, Nursing Assistant In an interview on 05/21/2025 at 1:49 PM, documentation was requested from Staff A, Administrator, that showed the facility had provided the mandatory Compliance and Ethics training. In an interview on 05/23/2025 at 9:36 AM, Staff A, stated they expected staff to receive adequate training in order to have adequate skills 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.

Based on interview and record review the facility failed to maintain financial information in a secure manner to prevent unauthorized access for 1 of 2 sampled residents (Resident 49), reviewed for personal property. This failure placed residents at risk of misappropriation, financial exploitation and diminished quality of life. Findings included . According to the 04/22/2025 quarterly assessment, Resident 49 had moderate cognitive impairment and was able to clearly verbalize their needs. Review of the 04/19/2024 care plan showed Resident 49 was impulsive and utilized the services of a payee (an appointed person to manage finances when an individual was unable to do so). The care plan showed Resident 49 was inclined to send money to their family, but it was not in Resident 49's best interest. Additional record review found a front and back color copy of a bank card with four numbers handwritten below the card, scanned into Resident 49's electronic clinical health record accessible to any nursing staff with access to the health record. In an interview on 05/22/2025 at 8:37 AM, Staff…

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 and interview, the facility failed to ensure a homelike and safe environment and equipment that was in good repair for 2 of 2 halls and 2 residents (Resident 36 and 50). Failure to ensure floor tiles were replaced, the ends of metal wheelchair brake extenders were covered, and room walls and base board heater paint were intact, placed the residents at risk of injury and a diminished quality of life. Findings included . <Resident 36> An observation of Resident 36's room (room [ROOM NUMBER]) on 05/13/2025 at 12:28 PM showed the wall behind the resident's bed was gouged and dented from the headboard. The baseboard between the resident's bed in the room was scuffed with the paint peeling off. <Resident 50> An observation of Resident 50's wheelchair on 05/12/2025 at 10:52 AM showed bilateral metal wheelchair brake extenders with no rubber protectors on the tip. Rubber protectors served to cover the metal end and prevent injury. <B Unit> An observation on 05/13/2025 at 12:28 PM of the floor near…

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 a resident was not administered as needed injectable antipsychotics (medication that affected the brain, emotions, or behaviors) unless the medication was necessary to treat a specific condition documented in the clinical record for 1 of 6 sampled residents (Resident 19), reviewed for unnecessary medications. This failure placed residents at risk of side-effects from the medications, unnecessary chemical restraints, and a diminished quality of life. Findings included . According to the 04/10/2025 quarterly assessment, Resident 19 had severe cognitive impairment with inattention and disorganized thinking. The assessment further showed Resident 19 exhibited worsening verbal and physical behaviors directed towards others that significantly interfered with Resident 19's care, participation in activities or social events, placed others at significant risk for physical injury, significantly intruded on the privacy or activity of others and significantly disrupted care or the living environment. Review of October 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.

Based on interview and record review the facility failed to identify, assess, and address potential signs and/or symptoms of Post Traumatic Stress Disorder (PTSD) for 1 of 8 sampled residents (Resident 19), reviewed for mood and behavior. This failure placed residents at risk of re-traumatization, unmet behavioral health needs, and diminished quality of life. Findings included . According to the website www.mayoclinic.org Post Traumatic Stress Disorder (PTSD) was a mental health condition that could develop after witnessing or being part of an extremely stressful or terrifying event. Symptoms could include flashbacks (feelings that the traumatic event was occurring again), nightmares (repeated disturbing dreams), intrusive thoughts, severe anxiety, avoidance (not wanting to think or talk about a traumatic event), changes in mood or thinking and physical and emotional reactions. These symptoms last more than one month, cause major problems in social or work situations and affect how well a person gets along with others. Review of the facility policy titled, Behavioral Health Services…

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 medications were labeled in accordance with accepted professional standards and expired medications were removed from inventory. Specifically, insulin pens were not labeled with the date opened in one of two medication carts, and expired Bisacodyl suppositories (a medication to treat constipation) were found in one of two medication carts and the only medication room. This failed practice placed residents at risk of receiving expired medications, that may not have been fully effective. Findings included . According to Medscape.com, insulin pens must be discarded 28 days after opened. The facility policy titled Medication Management, revised 10/15/2022, documented medications were to be discarded by the expiration date or earlier. <Rehab Medication Cart> During an inspection of the Rehab medication cart on 05/21/2025 at 12:31 PM, the following was noted: 1) An opened Lantus (a long-acting insulin) pen for Resident 47, without a date of when the pen was opened. 2) An opened Novolog (a fast-acting insulin)…

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 for 1 of 3 sample residents (Resident 1) reviewed for elopement. The facility failed to adequately monitor a resident, who had expressed the desire to leave the facility. This placed the resident at risk for exiting the building without staff knowledge, and potential injury. Findings included . According to an assessment dated [DATE], Resident 1 had diagnoses which included Rt. femur fracture, dementia with behavioral disturbance, muscle weakness, and a history of falling. He required substantial assistance with activities of daily living and was able to self-propel in his wheelchair within the facility. According to an initial CSCD-Wandering/Elopement Risk Evaluation dated 11/25/2024, Resident 1 was assessed at a level 2 (high-risk), risk for elopement, and 15-minutes safety checks were recommended. On 12/16/2024, a quarterly CSCD-Wandering/Elopement Risk Evaluation was completed for Resident 1and was…

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 notify the police of an allegation of sexual abuse. This failure placed residents at risk for potential abuse and a diminished quality of life. Findings included: In review of the facility incident report #581 dated 10/21/2024 it documented Staff A, Hospitality aide informed Staff B, Director of nursing of an allegation of sexual abuse of Resident 1, allegedly perpetrated by Staff C, aide on 10/19/2024. It further documented the facility notified the state agency on 10/22/2024, and the resident representative on 10/23/2024, of the allegation. No documentation of local law enforcement notification was found in this document. In an interview on 11/27/2024 at 3:42pm, Staff D Administrator stated they did not notify the police of the allegation of abuse because they felt there was no immediate danger and they did not feel the allegation was legitimate. They stated they assumed Staff A had already notified the police. In an interview on 12/3/2024 at 2:46pm, Staff D stated they spoke with the local police department and was…

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 consistently provide showers for 4 of 5 sampled residents (Resident 1, 2, 3, 4), reviewed for bathing. This failure placed residents at risk for poor hygiene and a diminished quality of life. Findings included . <Resident 1> Review of a facility assessment, dated 06/16/2024, showed Resident 1 had diagnoses which included a disorder of movement and muscle tone. The resident was able to make their needs known. Resident 1 was dependent on staff for showers. According to Resident 1's care plan, dated 01/21/2020, Resident 1 was an extensive assist for showers and preferred two showers per week. It was noted the resident would sometimes resist showers and for staff to encourage the resident to shower and notify the nurse if they continued to refuse. Review of shower records from 06/17/2024 to 07/17/2024 showed Resident 1 had refused showers on 06/26/2024, 07/03/2024 and 07/13/2024. The resident had a shower on 07/16/2024, one shower in a month. Review of nurse progress notes from 06/17/2024 to 07/17/204 showed no documentation…

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 2 of 6 sample residents (10, 20), reviewed for Pre-admission Screening and Resident Review (PASARR) [an assessment completed prior to admission into a skilled nursing facility to determine whether a resident with a diagnosis of a serious mental illness needed specialized mental health services] was completed accurately and if indicated, a referral for additional screening had been made. This failure placed the residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet mental health care needs. Findings included . <Resident 10> Per the 03/31/2024 admission assessment, Resident 10 admitted to the facility from the hospital and had diagnoses which included depression and schizophrenia (a chronic, severe mental disorder that affected the way a person thought, acted, expressed emotions, and perceived reality). On 05/08/2024 at 10:45 AM, Resident 10 was observed sitting in their wheelchair 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.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan, to address a resident with wounds for 1 of 3 sample residents (33), whose care plans were reviewed. This failure placed the resident at risk for unmet care needs. Findings included . Per the 04/03/2024 significant change in condition assessment, Resident 33 had diagnoses which included peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), congestive heart failure (a condition that occurs when the heart can't pump enough blood to meet the body's needs), diabetes (a condition in which the body has trouble controlling blood sugar and using it for energy) and was at risk for skin breakdown. A review of Resident 33's skin evaluations documented the following: - 03/28/2024, the resident had an open area on their left buttock. - 04/09/2024, the resident had an open area to their right lower leg - 04/12/2024, the resident had a blister to their left leg. Review of Resident 33's care plan dated 12/12/2023, documented…

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

Based on observation, interview, and record review, the facility failed to provide assistance during mealtimes for 1 of 1 sampled resident (16), reviewed for activities of daily living. This failure placed the resident at risk for decreased food and fluid intake, and possible unintended weight loss. Findings included . The 03/02/2024 significant change assessment documented Resident 16 was severely cognitively impaired, delusional and had Alzheimer's dementia (a decline in mental ability severe enough to interfere with daily life). In addition, the assessment also documented the resident required partial to moderate assistance from staff for eating. The 03/26/2024 nutritional care plan documented Resident 16 was at risk for nutritional problems related to Alzheimer's dementia. The care plan instructed staff that Resident 16 required supervision, set-up assistance, and cueing at mealtimes to facilitate food and fluid intake. On 05/08/2024 at 12:38 PM, Resident 16 was observed sitting in their wheelchair near the front entrance of the dining room facing the wall, perpendicular to 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.

Based on observation, interview and record review, the facility failed to ensure one of two sample residents (15) reviewed for activities, was engaged in meaningful activities that met their interests. Failure to engage the resident in meaningful activities placed the resident at risk for boredom and diminished quality of life. Findings included Review of the 02/10/2024 comprehensive assessment showed Resident 15 had severe cognitive impairment, was unable to direct their care, and had diagnoses which included dementia and failure to thrive. The assessment showed the resident was dependent with care, including transport in their wheelchair. A staff assessment of activity preferences documented that Resident 15 enjoyed listening to music. Review of the 08/25/2022 care plan showed Resident 15 was dependent on staff for meeting all emotional, intellectual, physical, and social needs. Activity interventions included people watching, sensory stimulation, and music. The following continuous observations were made: On 05/09/2024, from 9:44 AM to 12:12 PM, Resident 15 was awake, sitting up…

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

Based on observation, interview and record review, the facility failed to provide effective bowel management for 2 of 3 residents (26, 37), reviewed for constipation. These failures placed residents at risk of unmet care needs and resulted in an emergency room visit for Resident 26, for further medical treatment. Findings included . According to an undated Bowel Protocol policy, staff was to initiate the following if a resident did not have a bowel movement (BM) in 72 hours: 1) Give Milk of Magnesia (MOM) or Miralax (types of laxatives, given by mouth) on evening shift. 2) Administer a suppository (laxative medication inserted into the rectum) on night shift 3) Administer an enema (liquid laxative medication, instilled into the rectum) on day shift. <Resident 26> According to an admission assessment, dated 05/01/2024, Resident 26 had diagnoses which included diabetes and septicemia (a life-threatening infection.) The resident was able to make decisions regarding their care. In addition, Resident 26 was incontinent of bowel and required maximum staff assistance with positioning 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.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assess a resident for smoking safety for 1 of 2 sampled resident (37), reviewed for accidents. Findings included: The 02/20/2024 quarterly assessment documented Resident 37 was able to make decisions regarding their care, had diagnoses which included stroke, which resulted in weakness and paralysis on their right side. In addition, the assessment documented the resident required set-up to substantial/maximal assistance from staff to complete activities of daily living. On 05/09/2024 at 1:02 PM, Resident 37 was observed smoking, using the left hand. While smoking, Resident 37 dropped a lit cigarette, and it rolled down by their foot. Resident 6 picked up the cigarette and handed it back to them. Resident 37 took a puff of the cigarette and dropped it again. The cigarette rolled down the front of their sweatshirt and onto their right sleeve and then bounced onto the left thigh area of their sweatpants. Resident 37 then picked up the cigarette and continued smoking. The 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 provide needed pain management for 1 of 3 sampled residents (6), reviewed for pain. This failure placed residents at risk of uncontrolled pain and a diminished quality of life. Findings included . According to the 03/29/2024 quarterly assessment, Resident 6 was admitted with diagnoses which included osteoarthritis, migraines and chronic pain syndrome and was able to make their needs known. Additionally, the assessment documented the resident had pain frequently that would impact their sleep and day to day activities. In an interview on 05/08/2024 at 3:37 PM, Resident 6 stated they had been out of their Hydrocodone 5 milligram (mg) tablets (a narcotic used to treat pain) for about three days and was not offered anything else for pain relief. The resident stated they were told by nursing staff that there was nothing else they could do. A review of the Medication Administration Records for May 2024, documented physician orders for acetaminophen (Tylenol) every four hours as needed (PRN) for pain, Hydrocodone 10/325 mg…

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 consistently collaborate care with the dialysis center, and accurately monitor the fluid restriction for 1 of 1 sampled resident (33) reviewed for dialysis care. These failures placed residents at risk of unrecognized complications, unmet care needs and a diminished quality of life. Findings included . Review of the Long Term Care Facility Outpatient Dialysis Services Coordination Agreement, between the facility and the dialysis center dated 10/15/2022, documented there should be documentation of collaboration of care and communication between the long-term care facility and the dialysis center. According to the 04/03/2024 significant change in condition assessment, Resident 33 had a diagnosis of end stage renal disease (kidneys stop working and are not able to remove waste or extra water from the blood) and was dependent on dialysis. Resident 33 was able to make their needs known. The 12/21/2023 dialysis care plan instructed nursing staff to send the Dialysis Communication form to the dialysis clinic for each visit…

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 recommendations from the pharmacist were addressed in a timely manner, for 1 of 5 sample residents (30), reviewed for unnecessary medications. These failures placed residents at risk for receiving an inaccurate dosing of medication, adverse side effects, and the risk of receiving a medication longer than medically necessary. Findings included . The Consultant Pharmacy Report, dated 01/2024, documented Resident 30 received Peridex mouth wash and it was recommended the resident should not brush their teeth, rinse mouth, eat or drink following the rinse to be added to the Medication Administration Record (MAR). The same recommendation was made for 02/2024 and again for 03/2024. A review of Resident 30's record showed no response from the provider or nursing regarding the recommendation until 03/04/2024 (two months after the recommendation was made). In an interview on 05/16/2024 at 10:38 AM, Staff C, Resident Care Manager, stated the pharmacy recommendations were received and if it pertained to nursing, the nurse…

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 a medication error rate of less than 5 percent for 2 of 4 sampled residents (2, 9), observed during medication pass. Specifically, 2 errors were made during 27 medication administration opportunities, resulting in an error rate of 7.41 percent. Errors in medication administration placed residents at potential risk for not receiving the full therapeutic effect of the medication. Findings included . According to Medscape.com, the warnings section for both Brimonidine Eye Drops and Refresh Eye Drops shows to wait five minutes between instilling eye drops, if more than one product is administered. <Resident 2> During an observation on 05/15/2024 at 7:22 AM, Staff R, Registered Nurse (RN) prepared medications for Resident 2. The resident had two different eye drop medications ordered, Brimonidine (medication to treat elevated pressure in the eye) one drop in the left eye, and Refresh eye drops (lubricant, for dry eyes), two drops to each eye. Staff R administered the Brimonidine eye drops, then immediately…

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 and interview, the facility failed to ensure appropriate hand hygiene was performed during the meal service for 1 of 2 dining rooms. These failures placed the residents at risk for infections and unmet care needs. Findings included . During a lunch observation on 05/08/2024 at 12:22 PM in the assisted dining room, Staff W, Admissions Coordinator, prepared coffee for the residents, touched their straws with bare hands, touched the tablecloth and clothing protectors, adjusted a resident's glasses, and served another cup of coffee without performing hand hygiene in between. In an observation at 12:25 PM, Staff W gave a cleansing wipe to a resident to wash their hands, passed a tray, touched a resident's clothing protector, and without hand hygiene being performed, opened food items for a resident and passed another tray. During an observation on 05/08/2024 at 12:34 PM, Staff W was assisting four residents to eat at the same table. Staff W rubbed the arm of a resident to wake them up and gave them bites of food. Staff W touched the resident's wheel on their…

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 that direct care staffing information was correctly electronically submitted to the Centers for Medicare and Medicaid Services (CMS), for Quarter 3 of 2023, reviewed for Payroll Based Journal (PBJ mandatory reporting of staffing information based on payroll data) submission. This failure caused the CMS to have inaccurate data related to nursing home staffing levels and had the potential to impact resident care and services. Findings included . Review of the Certification and Survey Provider Enhanced Reports (CASPER) Payroll-Based Journal Staffing Data Report showed the facility reported data for Quarter 3, 2023 (July 1, 2023, through September 31, 2023), at a level lower than required by mandated staffing levels. During an interview on 03/20/2024 at 11:05 AM, Staff A, Administrator, stated the Human Resource (HR) Manager was responsible for submitting the PBJ information. The HR Manager confirmed the numbers submitted for Quarter 3, 2023 as those in the CASPER. Staff A stated the facility had not added Registered…

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 follow physician orders for 2 of 3 sampled residents (Resident 1 and 2), reviewed for urinary catheters (a tube inserted in the bladder that allowed urine to drain). This failure placed the residents at risk for possible urinary tract infections (UTI's). Findings included . Review of the facility policy Indwelling Catheters, revised on 04/12/2022, showed urinary catheters and drainage bags were to be changed as necessary or unless specified by a physician's order. <Resident 1> According to the facility assessment, dated 01/30/2024, Resident 1 had diagnoses to include a stroke. Resident 1 was able to make their needs known and had a urinary catheter. Review of Resident 1's care plan, dated 01/24/2024, showed the resident was to have their catheter changed as ordered by the physician and/or changed as needed for infection or obstruction. The resident was to be monitored for signs and symptoms of a UTI. Review of provider progress notes showed Resident 1 was seen by a urologist (a provider that specializes in care 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.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program that provided a safe and sanitary environment, and helped prevent the spread of communicable diseases such as COVID-19 (a highly infectious virus that causes respiratory illness, possible difficulty breathing, pneumonia, hospitalization, or death) for 6 of 13 residents (17, 22, 18, 25, 37, 42), assisted during a meal service. In addition, the facility failed to ensure hand hygiene was completed and gloves were changed between clean and dirty tasks for 2 of 2 sampled residents (35, 18), reviewed for incontinence care and toileting. This failure to correctly use personal protective equipment (PPE-masks and gloves), and to complete hand hygiene, placed residents at risk for infectious diseases, potential serious infections, and a decreased quality of life. Findings included . PPE/Policy: According to the 11/03/2022 Washington State Department of Health Guidance Update, healthcare settings were required to follow the Washington State Secretary of Health Mask…

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 activities of daily living (ADLs) services for 2 of 5 sampled residents (7, 32), reviewed for dependence on staff for care. Resident 7 was not supervised or cued during oral care and had large amounts of food debris stuck on their dentures, and Resident 32 was not provided grooming for long, thick nasal hairs. These failures placed the residents at risk for a decreased quality of life. Findings included: Resident 7 Resident 7's record and 01/16/2023 assessment showed diagnoses including stroke with difficult speaking and swallowing. The assessment also showed Resident 7 was severely cognitively impaired and required supervision of one staff for their activities of daily living (ADLs) including personal hygiene. The 01/22/2020 comprehensive care plan showed the resident had oral/dental health problems, and was to be supervised and cued for oral care. On 02/02/2023, the Nursing Assistant (NA) tasks documentation for Resident 7'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.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards by implementing a system for securing and storing hazardous potentially toxic chemicals in an area in 2 of 2 shower rooms (1 & 2), 1 of 2 soiled utility rooms (1), and the boiler room. This failure placed residents at risk for avoidable injury. Findings included . The 11/28/2019 revised Resident's Environment Policy showed the facility would ensure materials that posed a hazard to residents would be identified and properly secured to prevent unauthorized access, including chemicals used by the facility staff in the course of their duties (housekeeping chemicals), chemicals or other materials brought into the facility by staff or visitors, and drugs/therapeutic agents. An observation on 01/29/2023 at 3:01 PM showed an unoccupied, unattended shower room (1) on the B-wing with the door unlocked, and without a locking mechanism on the door handle. A sign on the outside of the door said, Keep door closed and LOCKED at all times. Inside the shower room…

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

Based on observation, interview, and record review, the facility failed to ensure resident's food was stored and served in a sanitary manner and in accordance with professional standards for food service safety. The failure to ensure 1 of 1 nourishment unit refrigerators was free of expired, unlabeled, and undated food products, and failure to ensure staff performed adequate hand hygiene during resident meal assistance placed residents at risk for unsavory food, food-borne illness, and communicable disease. Findings included . Meal Service Observations The facility's revised 02/22/2022 Hand Hygiene policy showed staff would perform hand hygiene using soap and water or alcohol-based hand rub before handling food, and before touching another resident's utensils when helping multiple residents with meals. An observation on 01/29/2023 at 12:22 PM showed Staff L, Nursing Assistant (NA), touched the inside lip of a resident's specialized scoop plate with an ungloved hand while they were being served. An observation on 01/29/2023 at 12:54 PM showed Staff K, Licensed Practical Nurse (LPN),…

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 resident nurse call light system was functional and accessible in toilet and bathing rooms. The failure to ensure nurse call pull cords were no more than six inches from the floor in 5 of 7 sampled resident bathrooms (Rooms 42, 43, 45, 46, 14) and 2 of 2 shower rooms (1, 2), as well as to ensure the same 2 shower rooms had both a visible nurse call light outside the room and a functioning audible alert sound that could be heard in a centralized care area, placed residents at risk for unmet care needs and a delay of staff assistance in the event of an emergency. Findings included . Policy According to the facility's 11/28/2017 Resident Room Requirements policy, the facility would ensure resident rooms would be adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area. Review of the facility'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.