Columbia Basin Hospital

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to comprehensively assess and identify side rails attached to resident beds as a physical restraint for 2 of 2 residents (Residents 8 and 7) reviewed for physical restraints. This failure placed the residents at risk for injury and poor quality of life. Findings included . Record review of a facility policy titled, Long-Term Care Residents Physical Restraints, revised 12/31/2024 showed, . Physical restraints are identified as .side rails that keep the resident from voluntarily getting out of bed. Procedure: A. A Safety Device Assessment will be completed by the licensed staff for the need of the restraint related to a medical symptom. B. The resident's consent will be obtained .and documented on the assessment form. C. A physician's order will be obtained prior to the use of the restraint. D. Family will be consulted by nursing or social services in the event the resident is unable to give consent. E. Multidisciplinary care planning [NAME] 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 interview and record review the facility failed to notify the Office of the State Long-Term Care Ombudsman of the discharge of 1 of 1 resident (Resident 5) reviewed for transfer/discharge notifications. This failure placed the residents at risk for decreased protection from being inappropriately discharged and lack of access to an advocacy group whom could inform them of their rights and options. Findings included . <Resident 5> Review of the resident's medical record showed they were admitted with diagnoses that included congestive heart failure (the heart is unable to keep up with the demands of the body), and history of a cerebral vascular accident (also known as a stroke when oxygen is cut-off from a part of the brain). Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact and required substantial assistance with their activities of daily living (basic skills required to care for oneself). Review of Resident 5's progress notes showed the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a system was in place to provide a written notice of a bed-hold at the time of discharge to the hospital prior to a hospital transfer for 1 of 1 resident (Resident 5) reviewed for hospitalization. This failure placed the resident at risk for lack of knowledge regarding their right to hold their bed on the long-term care unit while in the hospital. Findings included . <Resident 5> Review of the resident's medical record showed they were admitted to the facility with diagnoses that included congestive heart failure (the heart is unable to keep up with the demands of the body), history of a cerebral vascular accident (when oxygen is cut-off from a part of the brain) and chronic urinary retention. Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact and required substantial assistance with their activities of daily living (basic skills required to care for oneself). Review of Resident 5's progress notes…

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 an effective and individualized Infection Prevention and Control Program (IPC) for long-term care (LTC) residents that met the Center for Medicaid and Medicare Services federal regulatory requirements included monthly surveillance, monitoring/tracking of infectious diseases. This failure disallowed the designated Infection Preventionist (IP) the ability to identify trends and implement interventions. The failure placed residents at risk for infectious diseases and deterioration in their health status. Findings included . Record review of the October 2024 through March 2025 infection control process and reports which included all infections the hospital showed the LTC unit infectious diseases had not been tracked or reviewed for trends and infection rates. During an interview on 03/13/2025 at 10:11 AM, Staff Q, IP, stated they were the IP for the long-term care unit and the hospital. Staff Q stated they did not identify infection trends or rates specific to the LTC unit and had no surveillance reports or…

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

Based on interview and record review the facility failed to ensure the designated Infection Preventionist (IP) responsible for the facility's Infection Control Program met the education qualifications for certification prior to accepting the role as the IP in a long-term care facility. This failure placed residents at risk for not having an adequate oversight of infection control issues specific to long-term care. Findings included . During an interview on 03/13/2025 at 10:17 AM, Staff Q, IP, stated they had been hired as the IP for the hospital and the long-term care unit. Staff Q stated they had not completed the required infection control training for certification as an IP. No one told me I needed to be certified so I have not taken any of the trainings for long-term care. During an interview on 03/13/2025 at 2:36 PM, Staff B, Resident Manager, stated they were not aware that there were specific training requirements for the IP to be certified and stated they understood why it was important for the IP to have the training. Reference: WAC-388-97-1320(1)(a)

Based on interview and record review, the facility failed to perform an annual review of the Facility Assessment (FA, an evaluation that determine what resources are required to meet each resident's care/service needs with the facility's resident population) and did not include a representative of the governing body or medical director in the development of the FA. Additionally, the FA failed to address the staffing competencies necessary to provide the level and types of care needed for the resident population. These failures placed all residents at risk of unidentified and/or unmet care and service needs. Findings included . Review of the 02/03/2023 Centers for Medicare and Medicaid Services (CMS) State Operations Manual - Appendix PP, showed, CFR 483.70(e) Facility assessment. The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update the assessment, as necessary, and at least annually . Additionally, 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 interview and record review the facility failed to; 1) maintain a Quality Assessment and Assurance (QAA) committee that included the medical director, or their designee, to participate in the committee's effort for 3 of 3 quarterly (Q, every three months) meetings (Q1, Q2, Q3 2023) reviewed for the QAA process, and 2) ensure that a thorough analysis of the high risk/adverse events were acted upon, and, a good faith attempt was made (once the facility had become aware of the adverse event) to correct quality deficiency and care concerns identified by the facility's infection control committee (which information was submitted to the facility's QAPI committee) for 2 of 3 quarterly meetings (Q2 and Q3 2023), reviewed for QAPI and infection control concerns identified on survey. This failure placed all residents at risk for unidentified complications and prompt corrective action in resident care/services areas. Findings included . Review of the facility's policy titled, Performance Improvement Plan, dated 08/09/2022, showed that the administrator, a representative of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control interventions intended to mitigate the risk of exposure and transmission of COVID-19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing, that could result in severe impairment or death) were consistently implemented during a COVID-19 outbreak [two or more facility-acquired cases with epi-linkage (an overlap on the same unit or other patient location, or having the potential to have been cared for by common healthcare professionals (HCP) within a seven day time period of each other)]. The facility failed to implement infection control interventions for: • personal protective equipment (PPE - protective clothing, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) use for 8 of 9 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, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan that addressed the resident's medical, physical, mental, and psychosocial needs for 5 of 7 residents (Resident 3, 2, 112, 6, and 7) reviewed for urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) use, medication use, and transfers. These failures placed the residents at risk for not receiving care and services to meet their individualized needs. Findings included . <Urinary Catheter Use> <Resident 3> Review of the medical record showed Resident 3 was admitted to the facility on [DATE] with diagnoses including a stroke with right sided weakness, atrial fibrillation (an irregular heart rate that causes poor blood flow), obstructive uropathy (a disorder of the urinary tract that occurs due to obstruction in urinary flow), neurogenic bladder (a number of urinary conditions in people who lack bladder control due to a brain, spinal…

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 nursing staff had the appropriate competencies (a series of knowledge, abilities, skills, experiences and behaviors, which leads to effective performance of staff regarding resident cares), and skill sets, which included an assessment of the staff's demonstration of competency in the skills needed to provide care and services for the facility's resident population, for 5 of 5 nursing staff (Staff I, K, O, P and Q) reviewed for staff competencies. This failure placed residents at an increased risk of adverse effects regarding the quality of care provided to the residents and unmet care needs. Findings included . Review of the facility's document titled, Facility Assessment Tool, dated 01/17/2021, showed the Facility Assessment [(FA) a tool used to determine the resources necessary to care for residents during both day-to-day operations and emergencies] had not been completed for the 2023 to 2024 year. Additionally, the document showed the type of care the resident population would require included, .indwelling or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were given the opportunity to formulate an Advanced Directive (AD) and/or periodically reviewed/notified residents of their right to formulate an AD for 1 of 4 residents (Resident 2) reviewed for ADs. This failure denied residents the right to make an informed decision regarding formulation of an AD and placed residents at risk for losing the right to have their preferences and choices honored regarding emergent/end-of-life care. Findings included . Review of the facility's policy titled, Advance Directives, dated 02/06/2020, showed upon admission, and periodically thereafter, residents would be informed of their right to make health care decisions and advance directives. Additionally, if a resident wished to formulate an AD, then social services would assist in the process. <Resident 2> Review of the medical record showed the resident was admitted on [DATE] with diagnoses including respiratory failure, and a lung infection. 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 interview and record review the facility failed to develop an abuse prohibition policy and procedures regarding the incorporation of Quality Assurance and Performance Improvement program (QAPI). This failure disallowed the QAPI committee determination regarding abuse investigations. Findings included . Review of the facility's policy titled Protection of Residents from Mistreatment, Neglect, and/or Misappropriation of Property, revised 03/03/2020, showed the facility did not develop written policies/procedures related to coordination with QAPI. During an interview on 02/02/2024 at 12:50 PM, Staff A, Administrator, stated QAPI should be included in the Abuse policies. Reference: WAC 388-97-0640

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report alleged violations related to abuse to include injuries of unknown source within the required time frame to the State Agency (SA) for 1 of 1 resident (Resident 10), reviewed for abuse and neglect. This failure placed residents at risk for unidentified abuse and neglect and the continued exposure to abuse and neglect. Findings included . Review of the facility's policy titled, Guidelines for Staff Reporting Resident Abuse or Neglect-Long Term care, revised on 4/28/2022, showed all employees are considered mandated reporters. According to the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), a nursing home employee (or other mandated reporter) is required to make a report immediately where there is a reasonable cause to believe abuse, neglect, abandonment, mistreatment, personal and/or financial exploitation, or misappropriation of resident property has occurred. Substantial injuries of unknown source must be reported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to conduct a thorough investigation regarding allegations of abuse and/or neglect for 1 of 1 resident (Resident 10) reviewed for investigations. The failure to complete a thorough investigation placed residents at risk for abuse, neglect, and unmet care needs. Findings included . Review of the facility's policy titled, Guidelines for Staff Reporting Resident Abuse or Neglect-Long Term care, revised on 04/28/2022, showed the facility will follow the Purple Book for investigating reported incidents of resident abuse, neglect, injuries of unknown source. According to the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), all incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated. A thorough investigation is a systematic collection of review of evidence/information that describes and explains…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 1 resident (Resident 3), reviewed for care and use of a urinary catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag) received appropriate care and services by positioning the catheter drainage bag below the level of the bladder to prevent infection. This failure placed the resident at risk for additional urinary tract infections (UTI) and serious medical complications. Findings included . Review of the Centers for Disease Control and Prevention Guidelines titled, Prevention of Catheter-Associated Urinary Tract Infections 2009, dated 06/06/2019, showed the Proper Techniques for Urinary Catheter Maintenance, included the catheter drainage bag must be kept below the level of the bladder. <Resident 3> Review of the medical record showed Resident 3 was admitted to the facility on [DATE] with diagnoses including a stroke with right sided weakness, obstructive uropathy (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 residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice for 2 of 2 residents (Resident 2 and 9) reviewed for trauma informed care. The facility failed to assess, monitor, and care plan residents' experiences and preferences regarding potential triggers (a stimulus that could prompt a recall of a previous traumatic event even if the stimulus itself is not traumatic or frightening) that may cause re-traumatization (a reliving of the traumatic experience). This failure placed the resident at risk for unidentified triggers and re-traumatization. Findings included . <Resident 2> Review of the medical record showed the resident was admitted on [DATE] with diagnoses including respiratory failure with a lung infection, Post Traumatic Stress Disorder (PTSD, a disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous…

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 consistently offer substantial nutritional snacks in the evening for 6 of 9 residents (Residents 112, 8, 9, 3, 6, and 7) reviewed for evening snacks. This failure placed the residents at risk for hunger and unmet nutritional needs. Findings included . Review of an undated, facility provided document titled, Service Cart Delivery Times, showed the dinner meal for Dining Room B was scheduled for 5:00 PM and the breakfast meal was scheduled for 8:00 AM (15 hours between the evening and breakfast meal). <Resident 112> Review of the medical record showed Resident 112 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbances (a disease that effects a person's personality and habits that may lead to changes in their behavior including agitation and anxiety) and adult failure to thrive (a syndrome weight loss, decreased appetite and poor nutrition, accompanied by dehydration and depressive symptoms). The 01/26/2024…

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 observation and interview, the facility failed to ensure the proper disposal of trash for 1 of 1 dumpster (Dumpster 1) reviewed for outdoor refuse storage. The failure to ensure Dumpster 1 was covered, placed the facility at risk of attracting bugs, rodents, and an unsanitary environment. Findings included . A concurrent observation and interview on 01/31/2024 at 10:19 AM with Staff F, Dietary Manager (DM), showed a tan dumpster with a wire mesh cover that was operated by a hand crank. The mesh cover was in the open position with bags of trash visible above the top of the dumpster. Staff F stated the cage top was always open so staff could put trash into the dumpster. An observation on 02/01/2024 at 7:37 AM, showed the same tan dumpster with the mesh cover in the open position. There were trash bags visible above the top of the dumpster and a cardboard box on the ground in the back corner of the dumpster enclosure. During an interview on 02/02/2024 at 9:50 AM, Staff F stated they reviewed the regulation and were not aware that the facility was responsible for 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 interview and record review, the facility failed to conduct a Performance Improvement Project (PIP) that focused on a high risk or problem prone areas of the resident population annually for 3 of 3 quarterly (Q, every three months) meetings (Q1, Q2 and Q3) reviewed for the Quality Assurance and Performance Improvement (QAPI) process. This failure placed residents at risk regarding quality care improvement, unidentified complications, and prompt corrective action towards high-risk/problem prone areas. Findings included . Review of the facility's policy titled, Performance Improvement Plan, dated 08/09/2022, showed that a PIP's focused on .areas of high risk, high volume or prone components of care ., and that the Administrator was to manage the QAPI program. Review of the facility's 2023 QAPI meeting minutes (Q1, Q2, Q3), showed that a PIP was not implemented in any of the quarters reviewed. During an interview on 02/02/2024 at 12:32 PM, Staff A, Administrator, stated they monitored, analyzed, and evaluated high-risk problem prone resident care areas, but don't remember 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 offer and/or provide an influenza (a common viral infection that attacks the lungs, nose, and throat) immunization (a vaccine that protects against infection by influenza viruses) for 2 of 5 residents (Resident 1 and 3) reviewed for immunizations. This failure placed the residents at risk for illness and transmission of a communicable disease. Findings included . Review of the Centers for Disease Control and Prevention (CDC) guidance titled, Influenza (flu); Flu Season, dated 09/20/2022, showed flu season usually occurs in the fall and winter. While influenza viruses spread year-round, most of the time flu activity peaks between December and February. Review of the undated Washington State Department of Health guidance titled, What's new for flu for 2023 - 2024 advised obtaining an influenza vaccination before October, although the vaccine was available through the winter months. Review of the facility provided policy titled, Flu and Pneumonia…

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.