Columbia Crest Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents on psychotropic medications (a collective term used for medication classes that affect brain activities associated with mental processes, emotions and behavior, like antipsychotics or anxiolytics) were being monitored for individualized behaviors prior to administration to reflect the adequate need of the medication for 1 of 2 residents (Resident 4) reviewed for psychotropic medication side effects. This failure placed residents at an increased risk for experiencing medication-related adverse side effects, and unmet care needs. Finding included . Review of the facility's policy titled, Behaviors: Management of Symptoms, revised 09/15/2025, showed that residents behavioral symptoms would be individually evaluated to identify the underlying causes that may contribute to the resident's behavior. The policy showed the facility would implement and monitor individualized, person-centered behaviors of residents on psychotropic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide the resident and their representative with a summary of a baseline care plan that included the initial goals of the residents, a summary of the residents medications and dietary instructions and services and treatments to be administered by the facility staff for 2 of 4 newly admitted residents (Residents 35 and 37) reviewed for baseline care plans. This failure placed the residents and their representatives at risk for a lack of knowledge regarding the initial care plan for delivery of care and services and unmet care needs.Findings included .Resident 35Review of the resident's medical record showed Resident 35 was admitted to the facility on [DATE] with diagnoses including a fracture of the left foot, a history of falls, chronic pain and diabetes. Review of Resident 35's comprehensive assessment dated [DATE] showed they were cognitively intact and required maximum assistance with bed mobility and transfers.During an interview with Resident 35…

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 1 of 5 residents (Residents 25) reviewed for activities of daily living (ADLs), received adequate dressing, grooming, nail, and oral care according to the resident's care plan. This failure placed the residents at risk for unmet hygiene needs.Findings included.Review of the resident's medical records showed they admitted to the facility with diagnoses to include Multiple Sclerosis (MS, a chronic disease where the immune system mistakenly attacks the protective covering of the brain and spinal cord nerve fibers that leads to communication issues between the brain and the rest of the body). The 11/12/2025 comprehensive assessment showed Resident 25's cognition was moderately impaired and required substantial to maximum assistance for their oral and personal hygiene needs and was dependent on staff for dressing. During an interview and a concurrent observation on 01/05/2026 at 12:17 PM, Resident 25 was lying in bed, dressed in a hospital gown, with a black, horseshoe-shaped neck pillow being used as 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 consistently offer or provide repositioning for a dependent resident for 1 of 2 residents (Resident 25) reviewed for quality of care. This failure placed all residents at risk for discomfort, skin breakdown, and negative health outcomes. Findings included.Review of the resident's medical records showed they were admitted to the facility with diagnoses to include Multiple Sclerosis (MS, a chronic disease where the immune system mistakenly attacks the protective covering of the brain and spinal cord nerve fibers that leads to communication issues between the brain and the rest of the body) and hemiplegia (severe or complete loss of use of one side of the body) to the right side. The 11/12/2025 comprehensive assessment showed Resident 25's cognition was moderately impaired and was dependent on staff for their positioning needs. During an observation and concurrent interview on 01/06/2026 at 9:51 AM, Resident 25 was lying in bed on their back and stated their bottom was hurting. Resident 25 stated they needed 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.

Based on observation, interview, and record review the facility failed to provide specialized services for footcare for 1 of 2 residents (Resident 25) reviewed for activities of daily living (ADLs). This failed practice placed residents at risk of skin breakdown, infections, and discomfort.Findings included.Review of the resident's medical records showed they admitted with diagnoses to include Multiple Sclerosis (MS, a chronic disease where the immune system mistakenly attacks the protective covering of the brain and spinal cord nerve fibers that leads to communication issues between the brain and the rest of the body). The 11/12/2025 comprehensive assessment showed Resident 25's cognition was moderately impaired and required staff assistance for personal hygiene. During an interview on 01/05/2026 at 12:17 PM, showed Resident 25 lying in bed on their back with a visitor at their bedside. The Collateral Contact (CC) stated they visited Resident 25 often and the Nursing Assistant (NA) staff did not provide Resident 25 with good nail care. The CC stated if they wanted the nails 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 observation, interview, and record review, the facility failed to ensure a resident was consistently supervised during smoking for 1 of 2 sampled residents (Resident 52) reviewed for smoking. This failure placed the resident at risk for avoidable accidents, injuries, and the potential risk of fire.Findings included.Review of a 02/24/2025 policy titled Smoking showed the staff responsible for supervising smoking would be in the direct area of the smoker, within eye contact and able to respond to emergency situations. The policy showed the resident's smoking materials would be maintained by the nursing staff and kept in the Nurse's station. Review of the resident's medical records showed they admitted with diagnoses to include a stroke (a complication when blood supply to the brain is blocked or reduced which can lead to brain damage) and seizure disorder. The 10/23/2025 comprehensive assessment showed Resident 52's cognition was moderately impaired and used a wheelchair independently for their mobility. An observation on 01/07/2026 at 10:07 AM, Resident 52 was observed…

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 and ensure their system of records for controlled substances (CS, categories of drugs, regulated and classified based on their potential for abuse and potential to cause physical or mental dependence) disposition (the process of returning and/or destroying unused medications) and accurate reconciliation (a system of recordkeeping that ensures an accurate inventory of CS received, administered or destroyed) was completed in sufficient detail to enable the accurate accounting with these types of medications for 1 of 2 medication carts/CS logbooks (West hallway medication cart) reviewed for storage/disposition of controlled medications. This failure placed residents at risk for potential financial loss, uncontrolled pain, and possible drug diversion (the abuse of prescription drugs used for purposes other than intended by the prescriber). Findings included .Review of the facility's policy titled, Controlled Medication Storage, dated January of 2025, showed that at each shift change two Licensed nurses…

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 provide a sanitary environment by not providing scheduled maintenance services for cleaning for ceiling vents for 1 of 1 kitchen. This failed practice placed the residents at risk for cross contamination, food borne illness, and negative health outcomes.Findings included .During an observation on 01/05/2026 at 10:06 AM, the two 24 by 24 inches air vent in the kitchen located on the overhead in the middle ceiling over the food preparation areas had fuzzy brown substances that were unclean around the 24 by 24 inches square air vent grill. The air vent grill, located on the ceiling over the cook area, had multiple areas of a dark brown and grayish fuzzy substances. The 24 by 24 inches air vent grill, over the staff handwashing sink in the kitchen had accumulated brown fuzzy dust. The ceiling by the wall across the kitchen room had two 24 by 24 inches dirty air vents which had fuzzy gray dust hanging and brown dust located on the air vents.During an interview on 01/05/2026 at 10:20 AM, Staff K, Dietary Manager visualized 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 establish a valid basis for discharge for 2 or 3 residents (Resident 1 and 2) who were not permitted to return to the facility after hospitalization and/or therapeutic leave. This deficient practice displaced residents from a safe home and placed them at risk for unmet care needs.Findings included.Review of the facility policy, Discharge and Transfer, revised on 06/11/2025, showed residents transferred to a hospital for unplanned, acute reasons must be permitted to return to the Center.Review of the facility policy Leave of Absence/Therapeutic Leave: Patient, revised on 07/15/2025, showed therapeutic leave was described as absences from the facility other than hospitalizations and cannot be a means of involuntarily discharging the patient.Resident 1Review of the medical record showed Resident 1 admitted to the facility, on 12/22/2023, with diagnoses of Chronic Obstructive Pulmonary Disease [(COPD) a progressive lung disease that blocks airflow, making…

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 maintain resident rooms and bedside urinals in a sanitary and homelike manner for 2 of 3 residents (Resident 1 and 2) reviewed for environment. This deficient practice placed residents at risk for compromised dignity, diminished quality of life and potential infection control issues.Findings included.Review of the facility policy, Nursing Department Infection Control Guidelines: Care of Patient Care Equipment, dated 02/28/2021 showed Personal Care Equipment such as urinals were for single patient use only, to be cleaned and disinfected after each use, discarded if heavily stained or worn, and to be covered when being stored.Resident 1Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease [(COPD) a group of lung diseases that cause long-term breathing problems], cachexia (condition that causes significant weight loss and muscle loss), and major depressive…

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, monitor effectiveness, modify, and supervise interventions meant to reduce the risk of avoidable accidents related to alcohol consumption for 1 of 3 residents (Resident 3) reviewed for accidents and hazards. This deficient practice placed the resident at risk for negative outcomes related to over consumption of alcohol including driving a motor vehicle while under the influence.Findings included.Review of the facility policy Alcoholic Beverages, revised on 02/01/2023, showed an order from a medical provider was needed for alcohol consumption, alcohol supplies were to be stored in a secure location, a specified staff member would dispense the alcohol to the resident, and documentation of consumption would be completed on the Medication Administration Record (MAR) or Treatment Administration Record (TAR).<Resident 3>Review of the medical record showed Resident 3 was admitted to the facility on [DATE] with diagnoses of alcohol dependence,…

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 able to use personal possessions in their room, specifically a personal refrigerator, that did not infringe on the rights of other residents for 1 of 3 residents (Resident 2) reviewed for resident rights. This deficient practice placed residents at risk of feeling emotional distress and retaliated against. Findings included . Review of the facility policy, Refrigerators: Patient In-Room, revised 08/07/2023 showed residents could have a small [two cubic feet (unit of measurement) or less] personal refrigerator in their room, and the document In Room Refrigerator Acknowledgment would be provided to inform the resident of their right to store food in the refrigerator and the process to do so. <Resident 2> Review of the medial record showed Resident 2 admitted to the facility on [DATE] with diagnoses of multiple sclerosis (a disorder in which the body's immune system attacks the protective covering of the nerve cells in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide supervision, monitoring and/or modification of interventions related to safe smoking for 1 of 2 residents (Resident 1) reviewed for accidents and hazards. This deficient practice placed Resident 1 at an increased risk for avoidable smoking accidents, injuries, and unmet care needs. Findings included . Review of the facility policy, titled Smoking, revised 02/24/2025, showed residents who smoked would have a care plan outlining the elements needed for supervision and physical assistance while smoking, and facility leadership would consider special accommodations on an individual basis. <Resident 1> Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of hemiparesis of the right side (paralysis of right side of body) from a stroke and epilepsy (a brain disorder causing repeated seizures). Review of the comprehensive assessment, dated 03/05/2025, showed Resident 1 had moderately impaired…

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 there were sufficient numbers of competent nursing staff to provide care and services for 12 of 12 residents (Resident 62, 26, 49, 8, 9, 14, 2, 51, 55, 5, 19, and 50) reviewed for resident rights, social services, activities, and restorative nursing programs. These failures placed residents at risk of not having their needs met and potential negative outcomes to their physical and mental health. Findings included . <Resident Rights> <F-550 Exercise Rights> The facility failed to ensure a process was in place to allow residents to exercise their constitutional right as a United States Citizen to vote in the 2024 Presidential Election. <Resident 26> During an interview on 11/13/2024 at 10:33 AM, Resident 26 stated they did not get to vote this year. They stated they had completed their ballot and had asked their nursing assistants and nursing staff to mail their ballot, but no one had mailed it for them. They stated it was important for them to vote, and they were disappointed that their ballot did not…

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

Based on observation, interview, and record review, the facility failed to ensure the contracted Dietary Manager (DM) was certified and qualified for that position. This failure placed residents at risk of receiving unsafe dietary services from staff that did not have the required competencies and skills to carry out food and dining services. Findings included . Review of a policy titled, Dining Service Department, dated 10/2022, showed the facility and the contracted dietary group would employ sufficient staff with appropriate competencies and skill sets. If the qualified dietician or other clinically qualified nutrition professional was not employed full time, a DM of food and nutrition services who met the necessary qualifications would be employed. During an interview on 11/17/2024 at 12:14 PM, Staff T, DM, stated they had not yet taken the test to become certified as a DM. Staff T stated they took the course a long time ago and just have not gotten around to taking the test. During an interview on 11/17/2024 at 12:53 PM, Staff A, Administrator, stated they were made aware 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.

Based on interview and record review, the facility failed to ensure a process was in place to ensure 4 of 6 residents (Resident 62, 26, 49, and 8) reviewed for resident rights, had the opportunity to exercise their constitutional right to vote as a citizen of United States during the 2024 Presidential election. This failure placed the residents at risk for disappointment, frustration, and psychological distress. Findings included . Review of a document titled, Washington Voting Rights for Residents, undated, showed individuals residing in long term care facilities retain their right to vote. The long-term care facility must work with the residents to ensure they were able to exercise their constitutional right to vote. The long-term care facility must not interfere with the resident exercising their right to vote or coerce them during the voting process. The facility must assist any resident to vote that has expressed the desire to vote and ensure staff did not make determinations about who was eligible to vote. The facility must help the resident register to vote, obtain ballots,…

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 State Long-Term Care Ombudsman [(ombudsman) an advocate for resident's rights in long term care) program was reviewed with residents and information was discussed on how to contact the ombudsman for 5 of 5 residents (Resident 31, 9, 11, 8, and 2) reviewed for required notices and contact information. The failure to not provide accessible ombudsman information left residents at risk for not having rightful resources and advocate available to them. Findings included . <Resident 31> Review of the medical record showed Resident 31 was admitted to the facility with diagnoses of dementia (a progressive disease that destroys memory and other important mental functions), depression, and anxiety. The 09/05/2024 comprehensive assessment showed Resident 31 was cognitively intact. <Resident 9> Review of the medical record showed Resident 9 was admitted to the facility with diagnoses including a stroke and heart disease. The 10/21/2024 comprehensive assessment had a moderately impaired cognition. Resident 9 was…

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

Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse/neglect for 6 of 11 residents (Resident 2, 62, 38, 4, 52, and 49) reviewed for allegations of abuse/neglect. Failure to thoroughly investigate the allegations of abuse/neglect placed the residents at risk for further abuse/neglect. Findings included . 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 an event or a series of events to determine what occurred and make necessary changes to resident's plan of care and services to prevent reoccurrence. The investigation should include the who, what, when, where, why and how, of the incident and establish a reasonable cause within 24 hours of the incident. <Resident 2> Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide, individualized, meaningful activities for 5 of 6 residents (Resident 5, 14, 26 ,41, and 51) reviewed for activity participation. This failure placed the residents at risk for boredom, social isolation, and depression. Findings included . Review of a policy titled, Rec202 Program Design, dated 08/07/2023, showed the facility ' s recreation (activities) program must provide, based on the comprehensive assessment and care plan of each resident, an ongoing program to support activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial wellbeing of each resident. <Resident 5> Review of the medical record showed the resident admitted with diagnoses to include Multiple Sclerosis (a chronic often disabling disease that attacks the central nervous system), and cerebellar ataxia (a condition that causes a loss of muscle coordination especially in the hands and legs). 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 restorative nursing services programs were implemented for 4 of 6 residents (Resident 5, 9, 19, and 50), reviewed for restorative nursing and limited range of motion [(ROM) the extent the joint can move within the expected (normal) range of values]. This failure placed the residents at risk for loss of ROM, deconditioning, pain, and contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen). Findings included . Record review of the facility policy titled, Restorative Nursing, dated 08/07/2023, showed the facility would provide restorative nursing programs for residents who .have restorative needs arise during the course of a longer-term stay .will benefit from restorative programs .to help the patient obtain and maintain optimal physical, mental, and psychosocial functioning . Further review of the policy showed restorative programs were coordinated by nursing and were resident specific based on individual needs. A licensed…

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 3 medication storage rooms (North, East, and [NAME] Hall) ensured proper disposal of expired and/or discharged resident's medications, and 1 of 3 medication carts (East Hall) were locked when left unsupervised by nursing staff. These failures placed residents at risk for receiving expired and/or compromised medications, access to potentially harmful medications, and negative health outcomes. Findings included . Review of the policy titled, Medication Administration, dated 01/2024, showed the medication cart was to be kept closed and locked when out of sight of the nurse, and when medications were administered, the medication cart was to be clearly visible when unlocked. Review of the policy titled Medication Storage, dated 01/2024, showed outdated, contaminated, and discontinued medications were to be removed immediately and disposed of. <Medication Cart> An observation and interview on 11/15/2024 at 10:57 AM, showed the East Hall medication cart unlocked and unattended by staff. At 11:03 AM,…

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

Based on interview and record review, the facility administrative staff failed to effectively manage the facility in compliance with state and federal regulatory requirements. The facility failed to ensure there was active and engaged oversight and monitoring of systems related to recognizing abuse/neglect, accident hazards, activities, restorative therapy programs, and sufficient staffing. These failures placed the residents at risk for continued abuse/neglect, injury, decline in physical function, and dissatisfaction with their quality of life. Findings included . Review of a job description titled, Administrator, dated 01/01/2016, showed the Administrator was responsible for creating an environment where staff were highly engaged and focused on providing the highest level of clinical care and compassion to residents and families. They were responsible and accountable for all activities and departments of the facility to ensure proper healthcare services were provided to the residents, according to regulations put forth by government agencies. The Administrator directs and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement infection control interventions intended to mitigate the risk for transmission of infectious diseases for 3 of 3 residents (Resident 320, 35, and 19) reviewed for infection control. This failure placed the residents at risk for cross contamination and transmission of infectious disease. Findings included . Review of the Centers for Disease Control (CDC) guidance, Guideline for Isolation Precautions: Preventing Transmission of Infections Agents in Healthcare Settings, updated 09/2024, showed contact precautions were intended to prevent transmission of infectious organisms, either by direct or indirect contact with the person or environment. The contact precautions included staff to wear gown and gloves for all interactions with the affected person and environment and wash their hands with soap and water. Review of the facility policy titled Clostridioides Difficile Infection [(CDI) a bacterial infection that can cause diarrhea,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a homelike dining room experience, including the choice to eat meals in the dining room, for 4 of 9 residents (Resident 9, 14, 51, and 2) reviewed for choices. This failed practice placed residents at risk for unmet care needs, isolation and weight loss. Findings included . Multiple observations of the dining room from 11/13/2024 through 11/19/2024 for all meals including breakfast, lunch, and dinner, showed no residents were provided meals in the dining room. <Resident 9> Review of the medical record showed the resident was admitted with diagnoses including a stroke (when blood flow to the brain is cut off, damaging brain tissue) and diabetes (a chronic disease in which there is too much sugar in the blood). The 10/21/2024 comprehensive assessment showed Resident 9's cognition was moderately impaired and required the assistance of one staff member with set-up for meals. Record review of Resident 9's care plan dated 07/20/2024 showed they…

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 return the balance of funds to the Office of Financial Recovery [(OFR) responsible for the recovery of financial, medical, social services, and food assistance overpayments from the Department of Social and Health Services clients] for 3 of 4 residents (Resident 232, 60, and 231) reviewed for conveyance (the legal process of transferring property from one owner to another) of personal funds. This failure placed the state department at risk for loss of funds and interest accumulated. Findings included . Review of a policy titled, Resident Funds, dated 01/16/2023, showed when a resident expired and had funds remaining in their trust account, refunds must be made via check and include a final accounting of those funds within 30 days of death. Timely processing of the refund check or in the case of death, the individual or probate jurisdiction administering the resident's estate in accordance with state regulations. <Resident 232> Review of the medical…

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 resident's right to privacy, security, and confidentiality, when a video/audio camera was placed in their room, for 1 of 2 residents (Resident 55) reviewed for privacy and confidentiality. This failed practice placed residents at risk for the loss of personal privacy. Findings included . Review of the policy titled Use of Audio/Video Devices (Cameras, Recording and/or Broadcasting), revised 05/01/2022, showed the Administrator would review the request for placement of an audio and/or video device for the needs of the resident. The policy further showed after the completed review, the Administrator could authorize use in accordance with state and federal laws. <Resident 55> Review of the medical record showed Resident 55 was admitted with diagnoses including chronic obstructive pulmonary disease [(COPD) a group of lung diseases that block airflow and make it difficult to breathe] with exacerbation (a sudden worsening) and anxiety. The 08/28/2024 comprehensive assessment showed Resident 55 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a sanitary and homelike environment for 3 of 3 shower rooms (North Hall, [NAME] Hall, and East Hall), 1 of 3 hall kitchenettes (East Hall), and 3 of 6 resident rooms (rooms [ROOM NUMBER]) reviewed for environment. These failures place the residents at risk of unpleasant living conditions and diminished self-worth. Findings included . Review of the policy titled, Resident Rights Under Federal Law, revised 02/01/2023, showed residents had the right to a safe, clean, comfortable and homelike environment and the facility would provide housekeeping and maintenance services to maintain a sanitary and comfortable environment. <Shower room> <North hall> An observation on 11/12/2024 at 7:02 PM, showed the North Hall shower room had a trash can that was overflowing with soiled resident briefs. The shower stall had a six inch (unit of measure), by three-inch mound of hard substance along the shower floor and wall. The mound had exposed grey, brown, 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 ensure the Pre-admission Screening and Resident Review [(PASARR) a federally required form that is used to help ensure individuals were not inappropriately placed in nursing homes for long term care] Level II comprehensive evaluation was obtained for 1 of 3 residents (Resident 41) reviewed for PASARR. This failure placed residents at risk for not receiving necessary mental health care and services. Findings included . Review of the policy titled Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patients, revised 02/16/2024, showed the social worker or designated staff would review resident ' s PASARRs, update per state requirements, and refer to the appropriate state designated authority. <Resident 41> Review of the medical record showed Resident 41 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive disease that destroys memory and other important mental functions), major depressive disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a baseline care plan, within 48 hours of admission, that documented resident-specific goals and treatment plans for 4 of 7 residents (Resident 62, 35, 26, and 55) reviewed for baseline care plans. Failure to develop a baseline care plan placed the residents at risk for unmet care needs and possible complications. Findings included . Review of a policy titled, Person-Centered Care Plan, revised 10/24/2022, showed a baseline care plan must be developed and implemented within 48 hours of admission/readmission. The baseline care plan must include the instruction needed to provide effective and person-centered care that met professional standards of care. The baseline care plan must include the minimum healthcare information necessary to properly care for a resident that included initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and Pre-admission Screening and Resident Review [(PASARR) 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 policies were implemented to ensure staff responsible for providing cardiopulmonary resuscitation [(CPR) an emergency procedure consisting of chest compressions combined with giving breaths of air] had current CPR certification for 2 of 9 staff (Staff C and G), reviewed for CPR. Additionally, the documentation on the CPR/automated external defibrillator (AED) - a medical device that can help restore a normal heart rhythm in someone experiencing sudden cardiac arrest) Flow Sheet was incomplete/inaccurate. The facility lacked current records of CPR certification status for all staff that responded to an emergent situation requiring CPR. This failure had the potential to result in a lack of staff that were properly trained in CPR, readily available to respond in an emergency. Findings included . Review of a policy titled, Cardiopulmonary Resuscitation (CPR), revised [DATE], showed CPR certified staff would be on duty at all times. Licensed nursing…

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 dialysis (the kidneys no longer function and require a process to remove waste and excess fluids from the blood stream) services met professional standards of care for 1 of 2 residents (Resident 27), reviewed for dialysis. The facility did not have an effective or coordinated process for communication between the facility and the offsite dialysis center for continuity of care. This failure placed residents receiving dialysis at risk for complications and unmet care needs. Findings included . Review of a policy titled Dialysis: Hemodialysis [(HD) a medical treatment that filters waste/excess fluid from the blood] Provided by a Certified End-Stage Renal Disease (ESRD) Facility, revised 08/07/2023, showed .the care of the patient receiving HD must reflect ongoing communication, coordination, and collaboration between the facility and dialysis staff .communication and responses will be documented in the medical record. <Resident 27> 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, 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 1 of 2 residents (Resident 62), reviewed for trauma informed care. The facility failed to accurately assess, monitor, and care plan Resident 62's experiences and preferences regarding their past trauma and potential triggers (a stimulus that could prompt a recall of a previous traumatic event, even if the stimulus itself was 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 62> Review of the medical record showed Resident 62 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a degenerative disease that causes movement problems) with dyskinesia (a side effect of Parkinson's disease…

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 obtain registry verification to ensure staff met competency evaluation requirements before allowing them to serve as a nursing assistant for 2 of 6 staff (Staff N and OO), reviewed for staff qualifications. This failure placed the residents at risk for abuse/neglect and unmet care needs. Findings included . The Washington State Nursing Assistant Registry [(OBRA) Omnibus Budget Reconciliation Act] is a database that includes the names of all individuals that meet the federal requirements to provide cares to residents of long-term care in Washington State. The OBRA registry also informs long term care facilities of individuals that are ineligible to work in long term care due to findings of abuse, neglect, or misappropriation of property. <Staff N> Review of Staff N's, Nursing Assistant (NA), personnel file showed their date of hire was 09/23/2024. The file showed no documentation of OBRA registry for Staff N. <Staff OO> Review of Staff OO's, NA, personnel file showed their date of hire was 05/20/2024. The file showed no…

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 meals that were palatable and served at an appetizing temperature for 3 of 3 residents (Resident 17, 13, and 19) reviewed for food. These failures resulted in residents expressing dissatisfaction with the food and placed residents at risk for inadequate nutritional intake and weight loss. Findings included . Review of a policy titled, Dining Service Department, dated 10/2022, showed food would be palatable and served at a safe and appetizing temperature. Hot foods would be held at a minimum of 135 degrees Fahrenheit [(F) a unit of temperature measurement] and cold foods would be held at a maximum of 41 degrees F. <Resident 17> Review of the medical record showed Resident 17 was admitted to the facility with diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), and cancer. The 10/18/2024 comprehensive assessment showed Resident 17 was dependent on one to two staff members for activities of daily living (ADLs), set up only for eating. The assessment also 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 honor food preferences for 2 of 2 residents (Resident 17 and 22) reviewed for dietary preferences. This failure placed the residents at risk for dissatisfaction with their dining experience and weight loss. Findings included . Review of a policy titled, Dining Service Department, dated 10/2022, showed the Dietary Manager (DM) was to interview each resident for individual food preferences, document them on the Food Preference Interview assessment, upload the assessment into the resident's medical record, and update their plan of care. <Resident 17> Review of the medical record showed Resident 17 was admitted to the facility with diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), and cancer. The 10/18/2024 comprehensive assessment showed Resident 17 was dependent on one to two staff members for activities of daily living (ADLs), set up only for eating. The assessment also showed the resident had a moderately impaired cognition. During an interview on 11/18/2024 at…

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

Based on interview and record review, the facility failed to develop and maintain a current hospice (a type of care that focuses on comfort and quality of life for people who were terminally ill or near the end of their life) plan of care (POC) in collaboration with contracted hospice services, that identified the provider responsible for performing each or any specific services/functions for 1 of 3 sampled residents (Resident 17) reviewed for hospice services. This failure placed residents at risk for not receiving necessary care and services. Findings included . Review of a policy titled Hospice, dated 03/01/2018, showed each resident's POC would include both the most recent hospice POC and the facility's POC to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. <Resident 17> Review of the medical record showed the resident admitted to the facility with diagnoses including esophageal (the muscular tube that moves food from the throat to the stomach) cancer. The 10/18/2024 comprehensive assessment showed Resident 17's cognition 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 observation, interview, and record review, the facility failed to provide the necessary care and services to ensure residents dependent on staff received assistance with activities of daily living (ADLs), related to bathing and grooming, for 5 of 7 residents (Resident 1, 2, 3, 4, and 5) reviewed for ADLs. This deficient practice placed residents at risk for unmet care needs, impaired skin integrity, and embarrassment. Findings included . Review of the facility policy titled, Activities of Daily Living, revised on 05/01/2023, showed each resident would be assessed to identify the amount of assistance needed to complete their ADLs, and their care plan would address the manner in which the care and services would be provided. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses of heart disease, dementia (a group of neurological conditions that cause a person to lose the ability to think, remember, and reason to the point that it interferes 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to thoroughly assess and monitor skin integrity concerns, in accordance with professional standards of practice, for 1 of 3 residents (Resident 2) reviewed for skin assessments. This deficient practice placed residents at risk for unmet care needs, discomfort, embarrassment, and the potential worsening of skin integrity conditions. Findings included . Review of the facility policy, titled Skin Integrity and Wound Management, revised on 10/15/2024, showed the facility's process for assessment of residents' skin health included documenting identified skin impairments in the residents' record, notifying the medical provider, and obtaining orders for treatment and monitoring. <Resident 2> Review of the medical record showed Resident 2 was admitted to the facility on [DATE] with diagnoses of amputation of right great toe, cellulitis (a bacterial infection that affects the skin and underlying tissues) of left leg, and diabetes (a condition that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly and accurately assess pressure related skin impairments, in accordance with professional standards of practice, for 1 of 3 residents (Resident 4) reviewed for pressure injuries. This deficient practice placed residents at risk for discomfort and potential worsening of pressure injuries. Findings included . Review of the National Pressure Injury Advisory Panel's (NPIAP, the leading expert in PIs/wounds) guidelines and definitions, dated September 2016, defined pressure injury stages as follows: Stage 1 PI has intact skin with a localized area of non-blanchable erythema (redness). Stage 2 PI is a partial thickness skin loss with exposed dermis (the top inner layers of skin). Stage 3 PI is a full thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer. Slough (dead tissue) and or eschar (dried blood and tissue) may be visible, granulation tissue and epibole (rolled or curled under edges) may include with undermining (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 provide staff in sufficient numbers to ensure residents' nursing and/or care needs were met in a timely manner for 15 of 15 residents (Residents 100, 41, 33, 23, 39, 300, 19, 1, 10, 32, 24, 9, 4, 35, 7 and 42) reviewed for care and services. This failure place residents at risk for unmet care needs and the inability to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being. Findings included . Review of the facility's resident roster, dated 10/10/2023, showed a census of 52, of which more than half of the residents required transfer assistance via a mechanical lift or required assistance of one to two staff. Record review of the Facility Assessment, dated 09/22/2023, showed the facility was licensed for 111 beds and had an average daily census of 52 residents. The assessment showed an average of eight to nine residents were dependent for dressing/bathing and more than half of the residents required one to two staff to complete their activities of daily living (dressing,…

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

Based on interview and record review, the facility failed to maintain an ongoing, effective, comprehensive, data-driven Quality Assurance and Performance Improvement Plan program (QAPI, a program that focused on the full range of care and services provided by the facility that included clinical care, quality of life and resident choice). The facility failed to demonstrate evidence of an ongoing QAPI program that was completed on at least a quarterly basis, was documented, included systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities for 1 of 1 sampled program (QAPI) reviewed. This failure placed residents at risk for ongoing unmet needs and a diminished quality of life. Findings included . Record review of the facility's policy titled, [Facility] QAPI Process, Effective Date 02/13/2016, showed the QAPI committee was comprised of: Center Executive Director, Center Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to consistently serve meals that were palatable, at the proper temperature, or ensure resident satisfaction for 6 of 9 residents (Residents 7, 8, 18, 24, 23, and 300) reviewed for food. The failure to provide palatable and appropriate temperature foods resulted in residents expressing dissatisfaction with the food and placed residents at risk for inadequate nutritional intake. Findings included . <Resident 7> Review of Resident 7's medical record showed, the resident admitted to the facility on [DATE] with a fracture to their left leg. The comprehensive assessment dated [DATE] showed, the resident was cognitively intact and required limited assistance with eating and set-up help with their meals. <Resident 8> Review of Resident 8's medical record showed, the resident admitted to the facility on [DATE] with diagnoses to include a stroke with impairment to one side of their body. The comprehensive assessment dated [DATE] showed, the resident'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 residents were provided with substitute meal choices for 4 of 4 residents (Residents 4, 24, 32, and 41) reviewed for nutrition. Additionally, the facility failed to ensure residents were provided with food preferences for 4 of 4 residents (Residents 1, 4, 10, and 32) reviewed for dining. This failed practice put residents at risk for decreased intake and nutritional complications. Findings included . <Substitutes> <Resident 4> Review of Resident 4's medical record showed, the resident admitted to the facility on [DATE] with diagnoses to include high blood pressure. The comprehensive assessment dated [DATE] showed the resident's cognition was intact and required assistance with meals. Observation on 10/16/2023 at 6:52 PM showed Resident 4's dinner arrived. Staff S, Nursing Assistant (NA), set up Resident 4's dinner which consisted of breaded fish, mashed potato, green beans, white roll, blonde brownie, milk, and tea. Resident 4 told…

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 implementation of their Respiratory Protection Programs (RPP) annual staff fit testing (a test that verifies specific respirators fit and seal to a staff member's face allowing the respirator to protect against exposure to harmful viruses and bacteria) for 6 of 6 staff (Staff V, W, Y, R, M and N) reviewed for a National Institute for Occupational Safety and Health (NIOSH) approved (N95) fitted respirator. These failures placed residents and staff at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included . Review of the Washington State Department of Health guidelines titled, Respiratory Protection Program for Long-Term Care Facilities, dated April 2023 showed an N95 respirator was used for respiratory protection, and it needed to be properly fitted to help protect against exposure to airborne (in the air) particles such as viruses and bacteria. Additionally, fit testing of N95 respirators needed to be completed on staff every…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to provide a safe, clean, and comfortable homelike environment regarding residents and staff for 1 of 1 laundry rooms (LR 1), and 2 of 4 resident care units (West and East) reviewed for a homelike environment. This failure placed residents at an increased risk for not feeling safe and secure with their environment and unmet care needs. Findings included . Observations of the facility LR 1 on 10/16/2023 at 11:57 AM showed a thick, white calcium crusted, metal water pipe that was attached/supplying water to one of the main washing machines utilized for laundering residents' clothes within the facility. It was noted that the pipe was continuously leaking out water. Directly below the leaking pipe was two large mop buckets with standing water placed to collected water from the leaking pipe. One mop bucket was three quarters full and the second was one quarter full of water. Further, the metal piping had a foam insulation (shielding that keep water pipes from…

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 7) reviewed for choices, was informed in writing, or given appropriate notice of a room change prior to the change. This failed practice placed the resident at risk of not being given the choice to make an informed decision, and placed them at risk for psychosocial decline and a diminished quality of life. Findings included . Review of the facility's policy, dated 08/07/2023, titled Room Transfers showed, the facility would provide notification in reasonable, required time frame to meet state regulation and to protect resident health. The policy further showed the resident was to receive an explanation of the reason for the room change and their right to refuse if the room move was not emergent. The policy further showed the resident should receive a copy of the Room Transfer/New Roommate Change Form and one should be kept in the resident's record. <Resident 7> Review of Resident 7's medical record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to comprehensively assess and monitor the need for a physical restraint (any physical, mechanical device or equipment that limits a resident's freedom of movement) when applying foam wedges under the resident's bed linen which prevented the resident from getting out of bed, for 1 of 1 resident (Resident 23) reviewed for physical restraints. This failure placed the resident at risk for the inhibition of free movement and/or activity and at an increased risk for injury when attempting to get out of bed. Findings included . <Resident 23> Review of the medical record showed Resident 23 was admitted to the facility on [DATE], with a diagnosis of stroke with paralysis and weakness affecting the resident's left side. The 09/01/2023 comprehensive assessment showed that the resident had severe cognitive impairment, and no physical restraints were implemented. Review of Resident 23's care plan showed, .has impaired communication as evidence by language…

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 report allegations of potential abuse and/or neglect to their State Agency, for 2 of 2 residents (Residents 42 and 40), reviewed for abuse/neglect. This failure placed the residents at risk for unidentified abuse/neglect, and the potential continued exposure to abuse and/or neglect. Findings included . Review of facility's policy titled, Abuse Prohibition Policy and Procedures, dated 02/23/2021, showed that allegations involving abuse or neglect were to be reported to their state agency .no later than (2) hours after the allegation is made if the event results in serious bodily injury .within twenty-four (24) hours if the event does not result in serious bodily injury . <Resident 42> Review of the medical record showed Resident 42 was admitted to the facility on [DATE] with diagnoses including fractured right hip and, kidney disease (damage to the kidneys that impairs the filtering of blood). The admission comprehensive assessment, dated 03/13/2023,…

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 conduct a thorough investigation regarding allegations of abuse and/or neglect for 2 of 2 residents (Resident 42 and 40) reviewed abuse/neglect. This failure placed the resident at risk for unidentified abuse, unmet care needs, and the potential continued exposure to abuse and/or neglect. Findings included . Review of facility's policy titled, Abuse Prohibition Policy and Procedures, dated 02/23/2021, showed that allegations involving abuse and/or neglect were to have an investigation initiated, .only an investigation can rule out abuse, neglect or mistreatment .initiate an investigation within 2 hours of an allegation of abuse that focuses on .whether abuse or neglect occurred and to what extent .interventions to prevent further injury . <Resident 42> Review of the medical record showed Resident 42 was admitted to the facility on [DATE] with diagnoses including fractured right hip and, kidney disease (damage to the kidneys that impairs…

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 Pre-admission Screening and Resident Review (PASARR, a screening process for individuals with serious mental illness [SMI] and/or intellectual disability/developmental disability [ID/DD]) assessment was accurately completed upon or prior to admission to the facility or updated during a change in condition for 2 of 6 residents (Residents 15 and 32) reviewed for PASARR. This failed practice placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health and/or developmental disability care needs. Findings included . Review of the facility's policy, dated 01/15/2021, titled Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patients showed, all residents will be screeded, prior to admission, for SMI or II/DD indicators. If indicators are identified, residents should have been evaluated to ensure care and services are being provided in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents dependent on staff for activities of daily living (ADLs) received assistance with eating, for 2 of 3 sampled residents (Residents 39 and 41), reviewed for ADLs. This failure placed the residents at risk for weight loss, choking, and aspiration (when food, liquid, or other material enters a person's airway or lungs) complications. Findings included . <Resident 39> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including stroke and dysphagia (difficulty swallowing). The 09/30/2023 comprehensive assessment showed the resident required extensive assistance of two persons with repositioning, transferring, and ADL set-up with one person assistance with eating. The resident was assessed to have moderately impaired cognition. Record review of the care plan, dated 08/09/2022, showed Resident 39 was at risk for decreased ability to perform ADLs, which included eating, and they…

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 had an ongoing activity program that met the resident individual needs for 2 of 5 residents (Residents 23 and 39) reviewed for activities. This failure increased the resident's risk to become bored and not being provided with meaningfully engagement throughout the day. Findings included . <Resident 23> Review of the medical records showed that they were admitted on [DATE] and had a diagnosis of stroke with paralysis and weakness affecting the resident's left side. The 09/01/2023 comprehensive assessment showed that the resident had severe cognitive impairment, never/rarely made decisions, was dependent on staff for transferring in/out of their wheelchair and need staff to assistance for moving around in their wheelchair. Also, the assessment showed that Resident 23's activity preferences, showed very important, included going outside to get fresh air when the weather was good and be able to participate in religious…

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' environment remained free of accident hazards for 3 of 4 residents (Residents 41, 100, and 33) reviewed for smoking. The facility failed to provide supervision, monitoring and/or modification of interventions related to safeguarding residents who had chosen to smoke within the facility's designated smoking area. This failure placed the resident at an increased risk for avoidable smoking accidents, significate injury, and unmet care needs. Findings included . Review of the facility's policy titled, Smoking, dated 08/07/2023, showed that a purpose of the facility's policy was to .ensure that patients who choose to smoke will do so safely . Further, that smoking would only be permitted in the designated area, .oxygen use is prohibited in smoking area ., a smoking evaluation would be completed and residents who smoked would have a care plan that included elements for, .supervision or physical assistance while smoking and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure culturally competent, trauma-informed care related to assessing for trauma and identifying triggers for residents with a history of sexual assault and Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops from experiencing a traumatic event) for 2 of 2 residents (Residents 7 and 15) reviewed for mood and behavior. This failed practice put residents at risk for re-traumatization, unidentified triggers, and unmet care needs. Findings included . <Resident 7> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include diabetes (a group of diseases that affect how the body uses blood sugar (glucose)) and anxiety (an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events). The comprehensive assessment, dated 08/24/2023, showed the resident's cognition was intact and required…

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 as needed (PRN) psychotropic medication (drugs that affect a person's mental state) were not ordered beyond 14 days or had the appropriate evaluation and documentation to extend it greater than the14 days for 1 of 5 residents (Resident 32) reviewed for unnecessary medications. The facility failed to assess pharmacist recommendations timely; and attempt non-pharmacological interventions prior to the administration of a psychotropic medication. This failed practice increased the risk of medical complications and unneeded medication use. Findings included . Review of the facility's policy, titled Psychoactive Drug Management dated 09/20/2022 showed, PRN psychotropic medications needed a 14-day date unless re-evaluated by provider for continued use. The policy further showed non-pharmacological interventions were to be documented. <Resident 32> Review of Resident 32's medical record showed they admitted to the facility on [DATE] 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure arbitration agreements provided the selection of a convenient venue (a location that agreed upon and suitable for both the resident or their representative and the facility) for 1 of 3 residents (Resident 12), reviewed for arbitration. This failure placed residents at an increased risk for an unfair arbitration proces and the resident or their representative not being able to exercise their rights under the agreement. Findings included . Review of the facility's undated document titled, Voluntary Binding Arbitration Agreement, showed .arbitration shall be conducted at a place that is within 15 miles of the facility . <Resident 12> Review of the medical records showed they were admitted on [DATE] and had signed/accepted the facility's arbitration agreement on 02/02/2023. Further review showed that Resident 12's arbitration agreement document include that the arbitration venue would be conducted within 15 miles of the facility. During an interview…

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

Based on interview and record review, the facility failed to ensure that abuse training which included recognizing, reporting, and preventing resident abuse was completed for 4 of 7 staff (Staff K, M, AA, and BB) reviewed for abuse training requirements. This failure placed residents at increased risk for unidentified abuse/neglect, and inadequate care from unqualified staff. Findings included . Review of the facility's policy titled, Abuse Prohibition Policy and Procedures, dated 02/23/2021, showed that all staff would have abuse training on recognizing, reporting, and preventing resident abuse. Additionally, that abuse training for all staff was a minimum of annually. Review of Staff K, M, AA, and BB training records from 10/18/2022 to 10/17/2023 showed that none of the staff had completed the required abuse training. During an interview on 10/16/2023 at 2:13 PM, Staff A, Administrator, stated that Staff K, M, AA, and BB did not have the required abuse training completed. Staff A stated they did not currently have a good process in place and would be fixing it. Reference: WAC…

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 documented evidence of the required annual 12-hours of in-service training for 1 of 9 sampled Nursing Assistants (Staff O) of reviewed employee files. This failure placed residents at risk of being cared for by inadequately trained staff, and unmet care needs. Findings included . Record review of employee files, on 10/18/2023, showed Staff O, Nursing Assistant (NA), hired on 02/28/2017, did not show documentation of the required annual 12-hours of in-service training. During an interview on 10/18/2023 at 10:11 AM, Staff CC, Human Resources/Payroll, stated that it was unlikely they had NAs annual performance evaluation and training documentation because the system fell apart. During an interview on 10/18/2023 at 12:52 PM, Staff E, Staffing Coordinator/NA, and Staff B, Director of Nursing, stated that there was no system in place to ensure needed annual performance reviews, trainings and competency reviews were completed. Reference: WAC 388-97-1680(2)(a-c)