Puget Sound Transitional Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete the comprehensive assessments within the regulatory timeframes for 1 of 2 (Residents 64) supplemental residents, and 2 of 3 resident (Resident 18 & 93) reviewed as closed records for assessments and timing. The failure to ensure comprehensive admission Minimum Data Set (MDS - an assessment tool) assessments were completed timely hindered the care planning process necessary to provide the appropriate resident care and services, and placed residents at risk for unidentified care needs, delayed services, and a decreased quality of life. Findings included. <Resident Assessment Instrument (RAI - instructional guidelines for MDS completion) Manual>The October 2019 RAI Manual outlined an admission MDS was a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1. The manual outlined an Annual MDS was 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 observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) accurately reflected the status of the resident for 2 of 19 sampled residents (Residents 53 and 71). This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included .<Resident 53>According to the 05/08/2025 Quarterly MDS Resident 53 had a condition where the bladder muscles and nerves did not function properly due to damage to the nervous system. The MDS showed Resident 53 used an indwelling catheter (tubing to assist with bladder drainage). The MDS showed Resident 53 was always incontinent of bladder.Observation on 08/20/2025 at 9:28 AM showed Resident 53 lying in bed. Resident 53's catheter was attached to the bed frame below the resident.In an interview on 08/27/2025 Staff I (MDS Coordinator) stated it was important for MDS assessments to be accurate as they were the basis for care planning for residents. Staff I stated because Resident 53 used an indwelling catheter, his incontinence status should have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) level 2 comprehensive evaluation (a process to determine what mental health services residents required after a level 1 PASRR identified potential indicators of Serious Mental Illness - SMI) were obtained for 2 of 5 residents (Residents 1 & 3) whose PASRRs were reviewed. This failure placed residents at risk for not receiving the necessary mental health care and services they needed, frustration, and unmet mental health needs. Findings included. <Policy>According to the facility's revised 09/2018 PASRR policy, a PASRR would be completed upon admission rather than prior to admission as required. The policy showed based on assessment, residents would be referred to the state PASRR office for evaluation for specialized mental health services. The policy showed the facility's social services office was responsible for communication with the PASRR office.<Resident 1> According 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.

Based on observation, interview, and record review the facility: failed to ensure physician's orders were followed for 3 of 19 (Residents 11, 62, & 5) sampled residents; failed to ensure nurses only signed for treatment once provided for 1 of 19 (Resident 1) sampled residents; failed to ensure physician's orders were clarified as needed for 1 of 19 (Resident 1) sampled residents; ensure physician's orders were in place prior to care for 2 of 19 (Residents 1 & 53) sampled residents. These failures placed residents at risk for unmet needs, and ineffective and/or delayed treatments. Findings included.<Following Orders> <Resident 11> According to the 08/07/2025 Quarterly Minimum Data Set (MDS – an assessment tool) Resident 11 was at risk of pressure ulcers. The MDS showed Resident 11 had a pressure reducing device for their bed. Review of Resident 11’s 08/19/2025 Pressure Ulcer Development related to Impaired Functional Abilities Care Plan (CP) showed an intervention of a pressure relieving/reducing device for the resident’s bed. The CP also included an intervention of an air mattress…

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 (Resident 1) of 1 sample residents reviewed for communication was provided with a functional communication system. Failure to identify and provide services to maintain effective communication placed residents at risk for unmet care needs, social isolation, and a diminished sense of well-being. Findings included . <Facility Policy>On 08/25/2025 at 1:13 PM, Staff A (Executive Director) stated they did not have language and communication policy for residents with English as a second language. <Resident 1>According to the 06/25/2025 admission Minimum Data Set (MDS - an assessment tool), Resident 1 admitted to the facility on [DATE] with multiple medical conditions and had no memory issues. The MDS showed Resident 1 was Asian, had clear speech and made self-understood and able to understand others. The MDS showed Resident 1's preferred language was not English and needed interpreter to speak with health care staff. Observations 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs - bathing, grooming, getting up, oral hygiene etc.) to residents dependent on staff assistance for ADL for 4 of 6 (Residents 10, 2, 11, & 13) residents reviewed for ADLs and 1 supplemental resident (Resident 53). The failure to provide assistance with showers, dressing, oral hygiene, and getting out of bed left residents at risk for frustration, poor hygiene, embarrassment, and diminished quality of life. Findings included. <Facility Policy>According to the facility's revised 07/2015 ADL policy, Certified Nursing Assistants (CNAs) would provide ADL assistance to residents according to their individualized Care Plans (CPs). The policy showed CNAs would document the ADL assistance provided in the residents' medical records<Resident 10> According to the 07/22/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 10 admitted to the facility on [DATE] with medically complex…

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 offer and provide individualized activities plans and to document the refusals for 2 of 3 residents (Resident 11 & 2) reviewed for activities. Failure to consistently offer and provide meaningful individual activity plans left residents at risk of boredom, frustration, isolation, and a diminished quality of life.Findings included. According to the facility's 04/2025 Activities Programming policy, the facility would ensure activities were available for all residents to meet resident's needs and interest that would support the physical, mental, and psychosocial well being of the resident. The policy showed the facility would conduct an activity evaluation at admission time to determine resident's preferences and interests including cultural preferences and spiritual preferences. The facility staff would make efforts to accommodate resident's preferences according to activity calendar. The policy showed the facility would provide assistance…

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 residents' skin was assessed weekly as ordered, monitored, and treated as required for 2 (Residents 9 & 10) of 4 residents reviewed for non-pressure skin. These failures placed all residents at risk for delay in treatment, worsening condition, unmet care needs, and a decreased quality of life. Findings included . <Facility Policy>Review of the facility's 04/2025 Skin and Wound Monitoring and Management revised policy showed the facility would provide care and services to prevent the development of new skin issues. The policy showed staff would perform weekly head-to-toe checks for all residents, document the findings in resident's record, and notify the provider to obtain treatment orders as needed. The policy showed nursing staff would implement the ordered interventions and develop a Care Plan (CP) for staff to consistently implement the care.<Resident 9> According to the 07/27/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 9 had memory impairment, was understood, and able to…

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 admitted with Indwelling Catheters (I/C - a flexible tube inserted into the bladder) were assessed for the continued need for a I/C, attempted to remove the I/C as soon as possible for 1 (Resident 9) of 3 residents reviewed for the I/C. These failures placed residents at risk for urinary tract infections, decreased bladder tone (muscle strength), urethral erosion (gradual destruction of the tissues), and dignity issues. Findings included .According to the facility's 01/2025 Indwelling Catheter Care policy, Staff would provide catheter care to each resident with an I/C every day and as needed to promote hygiene, comfort and decrease the risk of infection.<Resident 9>According to the 07/27/2025 admission 5-day Minimum Data Set (MDS - an assessment tool), Resident 9 admitted to the facility on [DATE] and was assessed as cognitively impaired and had the indwelling catheter during the assessment period. In an interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to complete safety assessments for a bed against the wall and fall mats on the floor for 2 of 7 residents (Residents 3 & 2) and a tilt-in-space wheelchair for 1 of 8 residents (Resident 77) reviewed for accident hazards. This failure placed residents at risk for injury, entrapment, and other negative health outcomes.Findings included.<Facility Policy>According to the facility's revised 03/2016 Physical Restraints policy, placing a resident's bed close enough to the wall to prevent the resident from getting out of bed was considered a restraint. The policy showed when a restraint was assessed to be necessary, a physician's order should be in place and the risks and benefits explained to the resident and/or their representative (the Informed Consent process).<Resident 3> According to a 05/22/2025 Quarterly MDS Resident 3 had no memory impairment. The MDS showed Resident 3 had no restraints in place. Review of Resident 3’s health records 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 observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 percent (%). Failure of 2 of 4 nurses (Staff U & V - Registered Nurses) to properly administer 2 of 32 medications for 1 (Resident 38) of 4 residents observed during medication pass resulted in a medication error rate of 6.25%. This failure placed residents at risk for adverse side effects and/or not receiving prescribed medications as ordered. Findings included . <Facility Policy>According to the facility's revised 01/2025 Medication Administration policy, Medications would be accurately prepared, administered, and documented per physician order. The policy showed staff would check the medication label with the Medication Administration Record (MAR) to verify resident name, medication name, form, dosage, route, and time.<Resident 38>Observations on 08/20/2025 at 8:59 AM showed Staff U administered a blood thinner medication enteric coated (protective coated delays pills dissolution) to Resident 38 related to heart issues. Review of Resident 38's August 2025…

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 were returned or discarded when expired or when residents discharged for 1 of 1 medication rooms (200 Unit Medication Room) and 2 of 2 medication carts (200 North and 300 North medication carts) observed. The failure to ensure unneeded medications were returned to the pharmacy or destroyed upon resident discharge or expiration placed the residents at risk for receiving unauthorized, compromised, and/or ineffective medications. Findings included . <Facility Policy>According to the facility's revised [DATE] Storage and Expiration of Medications and Biologicals policy, the facility would ensure all medications and biologicals were stored in an organized manner in cabinets, drawers, carts, and refrigerators with sufficient space to prevent crowding and inaccessible to visitors and residents. The policy showed medicines and biologicals that exceeded their use by date must be stored separately and returned to the pharmacy 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 complete Antibiotic (ABO) Stewardship to promote appropriate use of ABOs and reduce the risk of unnecessary ABO use for 2 of 4 residents (Residents 10 & 93) reviewed for unnecessary ABOs. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate/unnecessary use of ABOs.Findings included.<Policy>According to the facility policy titled, Infection Prevention and Control Program - ABO Stewardship, dated 03/2023, the Infection Preventionist (IP) or designee would be responsible for infection surveillance and multidrug resistant organism tracking. The policy showed the IP would collect and review all supporting labs and tests for ABO usage.<Resident 10>Review of Resident 10's health records showed they were admitted to the facility on [DATE] with an ABO prescribed for Sepsis (a life-threatening response to an infection). Review of Resident 10's records showed no supporting labs or test results for the ABO…

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 toilets were functioning properly on 2 of 3 floors (Second and Third Floor) and failed to ensure call lights were functioning on 1 of 2 floors where residents lived (Third Floor). These failures placed residents at risk for a less-than-homelike environment, skin tears, the inability to call for help when needed, and frustration.Findings included. <Facility Policy>According to the facility's 10/04/2016 Resident Rights policy, residents had the right to a safe, clean, comfortable, and homelike environment.<Second Floor Family Room Bathroom> Observations on 08/25/2025 at 10:30 AM, 08/26/2025 at 11:13 AM, and 08/27/2025 at 9:30 AM showed the second-floor family room bathroom broken and not flushing adequately to clear its contents. <Sensory Room Bathroom> Observations on 08/20/2025 at 8:38 AM, and 11:14 AM showed the toilet in the sensory room broken and not thoroughly flushing adequately to clear its contents. In an interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 3 of 7 staff (Staff C, D, & E) reviewed and 1 supplemental staff (Staff F) had the appropriate knowledge, competencies, and skill sets to provide nursing and related services, including Cardio-Pulmonary Resuscitation (CPR - an emergency procedure consisting of chest compressions combined with giving breaths of air), to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as determined by resident assessments, individual plans of care, and the facility assessment. Failure of the nursing staff to demonstrate a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics needed to successfully perform work roles or occupational functions resulted in deficiencies related to the competency of nursing staff and placed residents at risk for unmet care needs including not receiving CPR if/when needed, a diminished quality of life, 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 implement their abuse prohibition policy for 1 of 2 residents (Resident 1) reviewed for abuse and/or neglect. The failure to report to the appropriate agencies as required by State and Federal laws regarding Resident 1's unexpected death placed residents at risk for exposure to potential abuse/neglect, unmet care needs, and a diminished quality of life. Findings included . <Facility Policy> Review of the facility policy titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, revised [DATE], showed if there was an allegation or suspicion of abuse, the facility would make a report to the appropriate agencies including the State Survey Agency (SSA). The policy showed if the event(s) that caused the allegation resulted in serious bodily injury, the reporting requirement was to immediately report the incident, no later than two hours from the incident. The policy included the results of the investigation must be reported 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 implement their abuse prohibition policy for 1 of 2 residents (Resident 1) reviewed for abuse and/or neglect. The facility failed to completely and thoroughly investigate Resident 1's unexpected death. The failure to initiate, conduct a thorough investigation, and correct actual or potential alleged violations left residents at risk for unidentified and/or repeated incidents of abuse/neglect and a decreased quality of life. Findings included . <Facility Policy> Review of the facility policy titled, Abuse: Prevention of and Prohibition Against, revised [DATE], showed all allegations of abuse, neglect, misappropriation of resident property and exploitation would be promptly and thoroughly investigated by the Administrator or their designee. The policy showed the investigation would include information obtained from interviews with the person(s) reporting the incident, residents, witnesses, and staff across all shifts. The policy showed a review 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 and interview, the facility failed to keep the kitchen environment clean and sanitary and failed to ensure food was stored, prepared, and served under sanitary conditions for 1 of 1 kitchen observed. Facility staff failed to: Label and date food; discard damaged/expired/spoiled food (including after thawing); and perform Hand Hygiene (HH) when handling raw eggs during food preparation. These failures contributed to an unsanitary and unsafe storage and preparation of food, and placed residents at risk for life-threatening food-borne illness and a decreased quality of life. Findings included . <Facility Policy> Review of an undated facility provided document, Food Procurement, Storage and Distribution, showed the facility staff would keep track of when to discard perishable foods including covering, labeling, and dating of all food items stored in the refrigerator and/or freezer as indicated. The document showed the facility staff would inspect food items from safe transport and quality upon receipt and would ensure proper storage of food. The facility policy, Egg…

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 obtain and/or offer assistance to residents and/or their representatives to formulate Advance Directives (AD) for 8 of 17 residents (Residents 11, 59, 65, 80, 24, 77, 48, & 62) reviewed for ADs. These failures placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care. Findings included . <Facility Policy> The facility policy, Care and Treatment - Advance Directives, revised November 2016, showed the staff should inform and provide residents written information to formulate an AD. The policy showed, prior to, upon, or immediately after admission, the admission Nurse or Social Service staff would ask residents and/or their family members about the existence of any AD and should they indicate that they had one, the facility would require that a copy of such AD be included in the medical record. <Resident 11> According to the 05/09/2024 admission Minimum Data Set (MDS…

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

Based on interview and record review the facility failed to ensure residents were provided an opportunity for a Care Conference (CC) for 5 of 17 sampled residents (Resident 44, 46, 2, 37, & 48). Failure to ensure residents were given the opportunity to participate in care conferences left residents at risk for unmet care needs, lessened participation in care planning, and a diminished quality of life. Findings included . <Resident 44> According to a 03/04/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 44 had complex medical conditions including heart failure, end stage kidney disease, and depression. The assessment showed Resident 44 had no memory impairment and could make themselves understood and understand others without difficulty. In an interview on 06/05/2024 at 10:40 AM Resident 44 stated they could not remember ever having a CC. Review of Resident 44's medical records on 06/10/2024 showed no documentation to support staff performed quarterly CC's. <Resident 46> According to a 03/20/2024 Quarterly MDS, Resident 46 had complex medical conditions including…

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 Physician's Orders (POs) for 5 of 17 residents (67, 64, 24. 44, 46) reviewed for acquiring, implementing, and documenting physician orders. These failures left residents at risk for not receiving care they required, potential for new skin issues, and negative health outcomes. Findings included . <Air Mattress> <Resident 67> According to the 05/03/2024 Quarterly Minimum Data Set (MDS- an assessment tool), Resident 67 admitted to the facility with a pressure ulcer and had pressure reduction mattress on their bed. Observations on 06/05/2024 at 8:41 AM, 06/06/2024 at 11:23 AM, and on 06/10/2024 at 9:37 AM showed Resident 67 lying in bed with an air mattress set at patient weight 320 lbs [pounds]. (The resident's weight is one of the parameters staff should enter on the air mattress pump to ensure the air mattress was safely installed for the specific resident and help alleviate pressure to prevent pressure ulcers) Review of Resident 67's Care Plan (CP) revised on 06/03/2024 showed Resident 67 had pressure…

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 with Activities of Daily Living (ADL), related to cleanliness and grooming for 5 (Residents 15, 44, 2, 80, & 24) of 17 sample residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with bathing (Residents 15, 44, & 2), shaving (Residents 24 & 80), and nail care (Resident 24), placed the residents at risk for poor hygiene, long facial hair, embarrassment, and diminished quality of life. Findings included . <Bathing Assistance> <Resident 15> According to a 03/22/2024 Quarterly Minimum Data Set (MDS - an assessment tool), it was very important for Resident 15 to choose between a tub bath, shower, bed bath, or sponge bath. Review of a revised 05/15/2024 Care Plan (CP) on 06/11/2024, Resident 15 preferred to have a shower once weekly and required staff assistance with bathing. This CP showed Resident 15 required one staff max assistance with moving in bed/repositioning, they used a wheelchair for locomotion, one staff max assistance with…

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 implement ongoing communication and care coordination with the dialysis (a procedure to clean and filter the body's waste products) facility regarding treatment and services for 2 of 2 residents (Residents 24 & 11) reviewed for dialysis care. This failure placed residents at risk for unmet care needs, unidentified medical complications, adverse health outcomes, and a decreased quality of life. Findings included . <Facility Policy> The facility's 03/2016 Specialty Care - Dialysis Services policy showed a contract and plan would be developed between the dialysis center and the facility in order to coordinate care and services. The policy showed the dialysis center would be asked to provide information with regards to the resident's visit, weights, and other pertinent information and a facility dialysis documentation form would accompany the resident to all appointments. <Resident 24> According to the 05/02/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 24 had clear speech, understood others…

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 (%). Failure to properly administer 16 of 26 medications for 2 of 4 residents (Residents 28 & 15) observed during medication pass resulted in a medication error rate of 61.54%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of Physician Ordered (PO) medication. Findings included . <Facility Process> On 06/04/2024 at 8:52 AM Staff B (Director of Nursing) stated the facility's process was medications were expected to be administered within 1 hour prior to scheduled time until one hour after the scheduled time. <Resident 28> Observation of medication pass on 06/10/2024 at 7:01 AM, showed Staff M (Licensed Practical Nurse) enter Resident 28's room and administered the resident's morning medications. Review of resident 28's records on 06/10/2024 showed a PO with an immeasurable dose of one unit into each eye. 7 of the 12 medications administered to Resident 28 were not to be…

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 residents and/or their representatives were informed of the nature and implications of entering into a binding Arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) Agreement (AA) for 2 of 3 residents (Residents 37 & 67) reviewed for arbitration. The facility failed to explain the AA in a form or manner that the resident and/or their representative understood (Resident 37) and failed to ensure the Durable Power of Attorney for Financial (DPOA-F) was the signatory on the AA (Resident 67) on behalf of the resident as required. These failures placed Residents 37 and 67 and other residents at risk of lacking understanding of the legal document signed, forfeiture (loss or giving up of something) of the right to a jury or court, and a diminished quality of life. Findings included . <Resident 37> Review of Resident 37's AA showed the contract was signed by the resident's DPOA-F on 05/29/2024. In an interview on 06/12/2024 at 11:38 AM, Resident 37'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 a safe, clean, and comfortable environment was provided to residents. Facility failure to maintain a homelike and odor-free environment left residents at risk for an unpleasant living situation, infectious diseases, and a decreased quality of life. Findings included . <Resident Rooms> Observations on 06/04/2024 at 9:01 AM showed in room [ROOM NUMBER] A had gouges on the wall at the head of the resident's bed and a deep gouge on the bathroom wall. Observations on 06/04/2024 at 8:55 AM showed room [ROOM NUMBER] A had deep gouges on the wall at the head of the resident's bed. Observations on 06/04/2024 at 9:08 AM showed room [ROOM NUMBER] A had gouges on the wall at the head of the resident's bed and had multiple white paint patches on the wall. Observations on 06/04/2024 at 8:44 AM showed room [ROOM NUMBER] with the lower part of the bathroom door had gouges. Observations on 06/04/2024 at 9:20 AM showed room [ROOM NUMBER] with 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 a system by which residents and Long-Term Care Ombudsman Office (LTCO) received required written notices at the time of transfer/discharge, or as soon as practicable, for 3 of 4 residents (Residents 48, 64, & 59) reviewed for hospitalization. Failure to ensure a written notification was provided to the resident and/or representative of the reasons for the discharge and in a language and manner the resident and/or representative understood placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Failure to ensure a notification was provided to LTCO of the reason for transfer/discharge prevented the LTCO the opportunity to educate residents and advocate them regarding the discharge process. Findings included . <Facility Policy> The facility policy, Discharge and Transfer/Washington State revised 02/2016, showed staff should notify the resident and/or representative in writing 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 interview and record review the facility failed to encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe, for 2 of 2 residents (Residents 6 & 68) reviewed for timeliness in encoding and transmission of Minimum Data Set (MDS - an assessment tool). This failure affected federal health information data gathering and placed residents at risk for inaccurate monitoring of the residents' decline or progress over time, untimely comprehensive review of residents' health data/information, and a diminished quality of life. Findings included . <Resident Assessment Instrument - RAI> According to the October 2023 Long-Term Care Facility RAI 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents), a discharge (death) MDS assessment must completed within seven days and submitted within 14 days from the date of discharge or death. The manual showed a discharge return anticipated MDS assessment must be…

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 Minimum Data Set (MDS - an assessment tool) of 3 of 17 residents (Residents 80, 48, & 67) were completed accurately to reflect the resident's condition and overall health status. The facility failed to assess and identify the presence of loose dentures (Resident 80), a fall while in the facility (Resident 48), and a Range of Motion (ROM) limitation (Resident 67). These failures placed residents at risk for aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident), fall triggers, decreased mobility, contractures, unidentified and/or unmet care needs, and a decreased quality of life. Findings included . <Facility Policy> The facility policy, Resident Assessment and Associated Processes, revised December 2023, showed residents would be assessed comprehensively and accurately using the Resident Assessment Instrument (RAI) manual and the findings would be documented in 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 observation, interview, and record review, the facility failed to develop comprehensive Care Plans (CP) for 2 of 17 residents (Residents 37 & 65) whose comprehensive CPs were reviewed. Failure to develop and implement a CP to address a resident's pain (Resident 37), provided care instructions regarding leg immobilizer device use (Resident 65), and establish individualized CPs with identified goals that accurately reflected the resident's condition placed residents at risk for unmet care needs. Findings included . <Facility Policy> The facility's Care and Treatment - Comprehensive Person-Centered Care Planning policy, revised August 2017, showed the interdisciplinary team would develop a comprehensive person-centered CP for each resident that included measurable objectives and timeframe's to meet a resident's medical and nursing needs. <Resident 37> According to a 06/10/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 37 received scheduled pain medication during the assessment period and required additional pain medications for breakthrough pain. 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 activity programs met the needs of each resident for 1 of 1 resident's (Residents 2) reviewed for activities. Failure to provide residents with meaningful activities left residents at risk for boredom, frustration, and a diminished quality of life. Findings included . <Resident 2> According to a 05/05/2024 Significant Change Minimum Data Set (MDS - an assessment tool) showed Resident 2 preferred listening to music, attending group activities, and participating in religious activities. The assessment showed Resident 2 had severe cognitive impairment. The MDS showed Resident 2 had diagnoses of dementia, a stroke with left sided paralysis, seizure disorder, depression, psychotic disorder, schizophrenia, a cognitive communication disorder, and a need for assistance with personal care. Review of a revised 05/06/2024 Care Plan (CP) showed Resident 2 was dependent on staff for activities related to their physical limitations. The CP showed Resident 2 would participate in activities five to seven times a week.…

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 2 of 4 residents (Residents 64 & 59) reviewed for non-pressure skin alterations and 1 of 4 residents (Resident 2) reviewed for constipation were provided quality care and services. The failure to ensure resident skin issues were assessed, treated, and/or monitored, and the failure to initiate facility bowel care protocol left residents at risk for unmet care needs, pain/discomfort from constipation, and a decreased quality of life. Findings included . <Facility Policy> The facility's Skin and Wound Monitoring and Management policy, revised December 2023, showed a licensed nurse would assess/evaluate a resident's skin at least weekly and areas identified must be documented in the appropriate weekly assessment form. The policy showed skin monitoring would be captured daily via medication and treatment administration records. <Resident 64> Observations on 06/05/2024 at 11:18 AM, 06/06/2024 at 2:49 PM, and on 06/10/2024 at 10:09 AM showed Resident 64 had multiple scattered dark purple bruises 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 observation, interview, and record review the facility failed to ensure 3 of 6 sampled residents (Residents 44, 46, & 67) reviewed for Restorative Nursing Program (RNP) services received the care and services they were assessed to require. These failures placed residents at risk for a decline in Range of Motion (ROM), increased dependence on staff, and a decreased quality of life. Findings included . <Facility Policy> Review of the facility policy titled, Restorative Care, dated 05/2016, showed restorative care would be provided to each resident according to their individual needs and as determined by the interdisciplinary team. The policy showed documentation of RNP would be in each resident's electronic health record when it was offered, if a resident refused, or when a resident was not available to participate in their RNP. <Resident 44> According to a 03/04/2024 Quarterly Minimum Data Set (MDS- an assessment tool), Resident 44 had no memory impairment. The assessment showed Resident 44 had diagnoses of, but not limited to, depression, generalized muscle weakness, 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 fall prevention interventions were in place for 1 of 4 sampled residents (Resident 37) reviewed for falls. This failure placed residents at risk for potential injuries that could affect the resident's quality of life and safety. Findings included . <Facility Policy> Review of the facility policy titled, Fall Best Practice Guidelines, dated 03/2016, showed the facility would implement interventions to minimize the potential for injury. This policy showed prevention protocol would be initiated based on each category and individualized plan of care. The policy showed nursing would conduct shift to shift reports with walking safety rounds following report checking on high fall risk residents. <Resident 37> According to a 06/10/2024 admission Minimum Data Set (MDS - an assessment tool), Resident 37 had a history of falls in the last month. The MDS showed Resident 37 had a fall with right hip fracture that required surgical repair. The MDS showed Resident 37 had moderate memory impairment and diagnoses 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 observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe environment to prevent placing residents at risk for facility acquired infections. The facility staff failed to follow Transmission Based Precautions (TBP) recommendations for 2 (room [ROOM NUMBER] & 325) of 2 rooms on contact precautions reviewed, and ensure indwelling catheter (tubing to facilitate urinary drainage) bags were secured. These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . <room [ROOM NUMBER]> Observations on 06/06/2024 at 9:00 AM showed a contact precaution sign outside of room [ROOM NUMBER] that instructed staff to don (apply) Personal Protective Equipment (PPE) as follows; don gown, glove, and mask prior to entering room [ROOM NUMBER]. Observation and interview on 06/06/2024 at 12:33 PM showed Staff Y (receptionist) and Staff D (MDS…

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

Based on observation, interview, and record review, the facility failed to ensure staff followed processes designed to prevent contamination in food storage and preparation areas for 3 of 4 staff (Staff N- Dishwasher/Tray Prep, Staff M- Dishwasher/Tray Prep and Staff L- Dishwasher/Tray Prep). The failure of staff to 1) always wear a hair restraint, 2) keep personal belongings and personal drinks out of the kitchen, 3) perform hand hygiene, use gloves correctly, dispose soiled paper towels appropriately, 4) use unclean thermometers when checking food temperatures, increased the risk of cross contamination of foodborne pathogens and placed all residents, who consumed food prepared in the facility's kitchen, at risk of food-borne illness and diminished quality of life. Findings included . <Hair Restraint> The 10/17/2019 facility policy Food Safety Requirements showed dietary staff must wear hair restraints (e.g., hairnets, hat, and /or beard restraints) to prevent hair from contacting food. Observation in the facility kitchen on 05/16/2023 at 8:45 AM, Staff N came out of the walk-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 observation, interview and record review, the facility administration failed to manage the facility in a way to ensure substantial compliance with federal regulatory requirements. The Administration failed to ensure there was active and engaged oversight and monitoring of systems related to social services, infection control and prevention, Nutrition/Hydration, Quality of care in showers, edema and bowel management, care planning, resident rights, medication services. 1) The failure to employ a qualified social worker to coordinate and oversee resident rights, mental, psychosocial and behavior needs of residents consistent with the person-centered, individualized care plan and, 2) the failure to supervise and ensure nursing staff identified, assessed, developed a comprehensive person-centered care plan, and implemented the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care, placed residents at risk for errors in care, inaccurate care…

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 3 of 6 residents and 1 supplemental resident (Residents 16, 48, 35, and 61) reviewed for Care Plans (CP). The failure to include residents and/or their representatives in development or revising their person-centered CP prevented residents from exercising their right to participate in the development of, being informed of, and request changes in, their individual CP. Findings included . Review of the 02/2021 facility policy titled Resident Participation- Assessment / Care Plans, showed the resident and/or representative had the right to participate in the development and implementation of their person-centered CP. The CP included the assessment of resident strengths and needs and incorporated the personal and cultural preferences of the resident when establishing the goals of care. The facility supported and encouraged resident/representative participation in the CP process by holding CP meetings. The social services staff was responsible 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 observation, interview, and record review the facility failed to ensure the accuracy of Minimum Data Set (MDS, an assessment tool) assessments for 3 of 20 (Residents 2, 19, and 14) sampled residents. The facility failed to accurately assess physical restraints, active diagnoses, and psychotropic medications which placed residents at risk of having unmet care needs and a diminished quality of life. Findings included . <Restraints> Review of the 10/2019 Resident Assessment Instrument (RAI) Manual 3.0 defines Physical Restraints are any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. <Resident 2> The 04/16/2023 Annual MDS showed Resident 2 was admitted to the facility on [DATE]. The MDS showed Resident 2 was assessed to use a restraint daily when in bed. Resident 2's 01/26/2004 Care Plan (CP) for safety showed Resident 2 used 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 ensure Pre-admission Screening and Resident Review (PASRR, a screening process for residents who have indicators of intellectual disability or serious mental illness) assessments accurately reflected residents' mental health conditions for 3 of 7 residents (Residents 6, 33, & 61) reviewed for PASRR. The failure to review and revise PASRR assessments on admission and with a change of mental health condition placed residents at risk for not receiving the appropriate and timely mental health services, not receiving a Level II evaluation if indicated, potential for inappropriate placement, and diminished quality of life. Findings included . The 11/19/2019 facility policy Resident Assessment-Coordination with PASRR Program, showed all residents to would be screened with a PASRR Level I assessment for Serious Mental Disorders (SMI). A PASRR Level I-initial pre-screening will be completed prior to admission . a PASRR Level II determines whether 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.

Based on interview and record review the facility failed to ensure a baseline care plan was completed within 48 hours of admission for 1 of 1 resident (Residents 61) reviewed for care plans and two supplemental residents (Residents 14 & 62). The failure to complete a baseline care plan and discuss care goals and interventions with residents on admission placed the residents at risk for being uninformed of care provision, complaints regarding care and unmet care needs. Findings included . Review of the 03/2022 facility policy Care Plans-Baseline, showed the Baseline Care Plan (BCP) was developed for each resident within 48 hours of admission and met the resident's immediate health and safety needs. The BCP included instructions to staff to provide effective, person-centered care and would include the minimum healthcare information to properly care for the resident. The resident and/or their representative were provided a written summary of the BCP that included the stated goals and objectives of the resident's care; a summary of the resident's medications, dietary instructions,…

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 interviews, the facility failed to employ a qualified social worker on a full-time basis. This failure placed residents at risk of having unmet psychosocial needs. Findings included . According to federal regulations, any facility with more than 120 beds must employ a qualified social worker (SW) on a full-time basis. A qualified social worker is defined as an individual with a minimum of a bachelor's degree in social work or a bachelor's degree in a human services field and one year of supervised social work experience in a health care setting working directly with individuals. In an interview on 05/18/2023 at 3:43 PM, Staff A (Administrator) stated the facility did not have a social worker for the past few months, and was trying to hire a social worker. Refer to: F645 PASRR Screening for MD & ID F740 Behavioral Health Services F758 Free from Unnecessary Psychotropic Medications REFERENCE WAC: 388-97-0960. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that the transfer of trust funds in a resident trust fund occurred within 30 days following death or discharge for 2 of 5 residents (Residents 117 & 118) reviewed for trust fund. The failure to reconcile resident accounts and provide reimbursement to the resident or the State Office of Financial Recovery (OFR), placed resident's funds at risk of misuse and the state department at risk for loss of funds and the interest accumulated. Findings included . <Resident 117> In an interview and record review on [DATE] at 12:37 PM, Staff S (Business Office Manager) provided the [DATE] Trust Fund Balance Sheet. The balance sheet showed Resident 117 had a current balance of $350.00. Staff S stated Resident 117 discharged over 30 days ago and the balance should have been refunded. Staff S stated a refund was not done. <Resident 118> In an interview and record review on [DATE] at 1:55 PM, Staff S reviewed the [DATE] Trust Fund Balance Sheet. The balance sheet…

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 Skilled Nursing Facility Advance Beneficiary Notices (SNF-ABN) to 2 of 3 residents (Resident 1 & 57) reviewed for beneficiary notifications. The failure to provide residents the information regarding changes in their Medicare services, including potential financial liability and appeal rights, deterred residents from exercising their right to decide on continuation of skilled services and costs associated, as required by the Medicare Program. Findings included . On 05/17/2023 at 9:26 AM, the facility provided the Beneficiary Notice worksheet of residents, discharged in the last six months, who had Medicare benefit days remaining. Staff S (Business Office Manager) was asked to provide the SNF-ABN notices for Residents 1 and 57. No documentation was provided. In an interview on 05/18/2023 at 12:37 PM, Staff S stated the SNF-ABN notifications were provided to residents by the social services staff. Staff S stated since there was no social worker, the business office staff was supposed to notify residents when there…

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 with Activities of Daily Living (ADLs) for 2 of 3 (Residents 47 & 54) residents. Failure to provide help with bathing to residents who are dependent on staff for assistance, placed residents at risk for poor hygiene, diminished self-image, embarrassment, and decreased quality of life. Findings included . <Resident 47> The 09/01/2022 Quarterly Minimum Data Set (MDS- an assessment tool) showed Resident 47 had medically complex diagnosis including an amputation to the left lower extremity, and was assessed to required physical assistance of one staff in bathing. In an interview on 05/18/2023 at 11:58 AM Resident 47 stated they prefer a bath/shower two times a week. Resident 47 stated they only received a bath/shower once a week since their admission. The resident's last shower was on 05/11/23. Review of Resident 47's 04/15/2022 Care Plan (CP) showed preference of bathing twice a week. In an interview on 05/18/2023 at 12:03 PM, Staff B (Regional Nurse Consultant) stated they were not aware 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 observation, interview, and record review the facility failed to ensure residents were monitored and received the treatment they were assessed to require for 2 of 2 (Residents 37 & 54) residents reviewed for constipation and diarrhea and 3 of 4 (Residents 54, 6, & 19) residents reviewed edema (swelling) management. The failure to monitor and implement interventions for bowel and edema management placed residents at risk for pain, decline in medical status, unmet care needs and discomfort. Findings included . <Bowel Monitoring> <Resident 37> The 05/01/2023 Quarterly Minimum Data Set (MDS- an assessment tool) showed Resident 37 admitted to the facility on [DATE] with complex medical diagnosis including stroke, heart failure, kidney failure, and the inability to move one side or the other. The assessment showed Resident 37 required extensive assistance of two people for toileting and bed mobility. Review of the 05/12/2022 Bowel and Bladder Retraining Assessment showed Resident 37 was incontinent of bowel…

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 system by which staff would routinely offer/supply water for 2 of 2 residents (Residents 59 &31). The facility staff's failure to offer residents water routinely placed residents at risk for dehydration and a decreased quality of life. Findings included . <Resident 59> According to the 05/01/2023 admission/5day Minimum Data Set (MDS, an assessment tool), Resident 59 admitted with complex medical conditions including a primary diagnosis of bladder infection, high blood pressure, blood sugar disorder, traumatic brain injury, and malnutrition. During interviews on 05/16/2023 at 12:49 PM, 05/17/2023 at 1:02 PM, 05/18/2023 at 9:37 AM, and 05/18/2023 at 1:10 PM Resident 59 stated the staff do not provide residents with water. Resident 59 stated they bought their own water but must ask staff for ice, which is difficult to obtain, the staff tell them that's not their job and to go find a Certified Nursing Assistant (CNA). Observation on 05/16/2023 at 12:49 PM, and 05/18/2023 9:37 AM showed Resident 59 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 observation, interview, and record review the facility failed to ensure residents with behavioral health needs maintained the highest practicable mental and psychological well-being. The facility's failure to recognize and monitor individualized behavior triggers, implement, assess, and document non-pharmacological (non-medication) interventions to minimize behaviors, develop an individualized behavior Care Plan (CP) based on individual resident needs, and monitor psychotropic medication use with required diagnoses and consent for use, for 2 of 4 residents (Residents 14 & 61) reviewed for behaviors. These failures placed residents, with behavioral needs, at risk for unidentified behavior triggers, unmet behavioral needs, refusal of care, lack of behavioral services and support, and diminished quality of life. Findings included . <Resident 61> The 04/13/2023 admission Minimum Data Set (MDS, an assessment tool) showed Resident 61 had diagnoses including anxiety, depression, post-traumatic stress disorder (PTSD), adjustment disorder, and attention-deficit hyperactivity…

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 implement a system to manage drug regimen reviews by the facility pharmacist for 1 of 5 residents (Resident 14) reviewed for unnecessary medications. The failure of the physician to respond timely and implement recommendations by the pharmacist or provide a clinical rationale for not implementing the recommendations, and the failure of the facility to follow up on pharmacist and/or practitioner recommendations, placed residents at risk for unnecessary medications, adverse side effects and diminished quality of life. Findings included . <Diagnosis Clarification> Review of the 12/12/2022 physician order (PO) showed Resident 14 was prescribed an antipsychotic medication for behavioral disturbance. Review of the 12/29/2022 Pharmacist recommendation form showed behavioral disturbance was not a supportive diagnosis and recommended an appropriate diagnosis for the antipsychotic medication. The practitioner signed the recommendation form on 01/11/2023, 13 days later, and commented Please FF to MH [Mental Health] provider. Review…

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, record review, the facility failed to ensure that 1 of 2 (Resident 35) sampled residents reviewed for insulin administration was free of a significant medication error. The failure to follow the manufacturer's instructions and prime the insulin pen is considered a significant error, as it may result in the resident receiving the incorrect dose of insulin, placing the resident at risk for blood glucose complications. Findings included . Review of the (undated) manufacturer's instructions for the insulin pen used to administer this medication showed the needle unit was to be primed (remove air in the needle) with two units of insulin prior to dialing the dose of insulin to be administered to the resident. Priming of the insulin needle is required to ensure an accurate dose of insulin is administered. <Resident 35> Record review showed Resident 35 had a diagnosis of diabetes with a physician order for Lantus insulin, 8 units, to be administered to the resident. Observation on 05/18/2023 at 2:34 PM, showed Staff H (Registered Nurse) cleaned the top 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.

Based on observation and interview, the facility failed to ensure staff performed hand hygiene between glove changes, before, after and during wound care for 1 of 3 (Resident 48) sampled residents reviewed for wound care. This failure placed the resident at risk for the spread of infection. Findings included . Review of the 12/10/2022 facility policy Infection Prevention and Control Program, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .Standard Precautions .Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. <Resident 48> The 03/16/2023 Annual Minimum Data Set (MDS, an assessment tool) showed Resident 48 had no pressure ulcers or skin issues identified. Record review showed a 05/03/2023 Physician Order (PO) to cleanse left buttock open area with normal saline, apply a foam dressing twice daily, apply an ointment to the right buttock,…

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 promote antibiotic stewardship by ensuring the appropriate use of antibiotics for 1 of 4 (Resident 315) sampled residents reviewed for urinary tract infections. This failure placed the resident at risk for potentially adverse outcomes. Findings included . According to the 12/2016 facility policy Antibiotic Stewardship, the purpose of their Antibiotic Stewardship Program is to monitor the use of antibiotics in their residents. The admitting nurse reviews discharge and transfer paperwork for the current antibiotic/anti-infective orders when a resident is admitted from an emergency department, acute care facility, or other care facility. The nurse admitting the resident is to check that appropriate indications for use of the antibiotics are included, criteria met for clinical definition of active infection or suspected sepsis, and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy began while culture is pending).…

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.