Sequim Bay Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on interview and record review the facility failed to assist with scheduling and/or coordinating notary public services (a public officer whose function it is to administer oaths; to attest and certify, by their hand and official seal, certain classes of documents, in order to give them credit and authenticity) for 2 of 2 residents (Residents 7 & 70) reviewed for advanced directives (written instruction for the provision of health care when the individual is incapacitated, such as a living will or durable power of attorney for health care) who required notarization. This failure placed residents at risk of not having their identified healthcare decisions and preferences honored.Findings included .1) Resident 7 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 08/12/2025, showed the resident was cognitively intact. A Social Services note, dated 08/30/2023, documented Resident 7 had completed an Advanced Directive form, and the Social Services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based on observation, interview, and record review the facility failed to ensure residents received timely specialized rehabilitative services for 1 of 2 residents reviewed for therapy services (Resident 45). This failure to complete a Speech Therapy evaluation and provide services, placed residents at risk for unmet care needs and a diminished quality of life.Findings included .Resident 45 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated 06/16/2025, documented the resident had a diagnosis of dysphagia (difficulty or inability to swallow) and was moderately cognitively impaired. The MDS documented Resident 45 required set up or clean-up assistance with eating and was on a mechanically altered diet. On 08/20/2025 at 7:46 AM Resident 45 was observed in the dining room eating breakfast and being assisted by staff.A review of Resident 45's electronic health record showed 2 orders dated 06/10/2025: -Speech Therapy to evaluate and treat-Regular diet easy to chew…

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 to the state agency and/or log allegations of abuse/mistreatment by staff on the reporting log within five working days for 1 of 3 residents reviewed for abuse and neglect. This failure placed residents at risk for repeated incidents, unmet care needs and unidentified abuse and/or neglect. Findings included . Review of Nursing Home Guidelines, The Purple Book, dated October 2015 showed on page 7 that the facility should report via telephone and via the reporting log any act where there is reasonable cause to believe the act caused fear of imminent harm. Review of the undated facility policy titled, Prevention and Reporting: Resident mistreatment, Neglect, Abuse ., showed that facility staff were to report to the Director of Nursing or Executive Director any allegation of abuse, neglect or mistreatment, who would then immediately report to the state agency. All alleged violations involving abuse or mistreatment would be reported within 2 hours of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide routine cleaning services to support a clean and homelike environment for 2 of 5 sampled residents (Resident 1 and 2) reviewed for clean, homelike environment. This failure placed residents at risk for a less than homelike environment, diminished quality of life and potential infection control issues. Findings included . Review of the undated facility policy titled, Healthcare Cleaning Policy, showed the purpose was to maintain cleanliness in the healthcare setting and included that floors, furniture, and bathrooms should be free from visible streaks or stains and that high touch surfaces would be cleaned and disinfected with hospital grade disinfectant. Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 06/27/2024, documented Resident 1 was cognitively intact and required substantial to maximal assistance from staff for completion of activities of daily living (ADLs) On 08/28/2024 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services as evidenced by information provided in Resident/Surveyor interviews for 6 residents (Residents 67, 55, 11, 24, 65 and 2) interviewed, and 6 staff (Staff B, J, H, M, N & 1 anonymous staff) interviewed. The facility had insufficient staff to ensure residents received assistance with Activities of Daily Living and restorative services. These failures placed residents at risk for unmet care needs, decreased physical abilities and a diminished quality of life. Findings included . Resident 67 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 06/13/2024, documented Resident 67 had severe cognitive impairment, was medically complex and dependent on staff for activities of daily living (ADLs). The care plan, initiated on 06/06/2024, showed Resident 67 required two person assist with mechanical lift for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide Care Conferences (a conference where staff and residents/families talk about life in the facility, review the progress of each patient and make adjustments, as needed, to their care), for 5 of 5 sampled residents (Residents 13, 17, 23, 28, and 44) reviewed for provision of care conferences, and failed to ensure care plans were reviewed, revised, and accurately reflected resident care needs for 3 of 31 sample residents (Residents 68, 69 and 31) reviewed for care plan timing and revision. These failures placed residents at risk of not feeling involved in the development of their plan of care, unmet needs, decreased quality of care and a diminished quality of life. Findings included . <Care Conferences> <Resident 13> Resident 13 was admitted to the facility on [DATE] with diagnoses including chronic kidney failure (damaged kidneys that cannot filter the blood the way it should) and hypertension (high blood pressure). The Quarterly Minimum Data…

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 consistent restorative services were provided for 4 of 6 sampled residents (Residents 17, 23, 28, and 65) reviewed for range of motion (ROM) and mobility. This failure placed residents at risk for avoidable decline and diminished quality of life. Findings included . <Resident 65> Resident 65 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (disrupted blood flow to the brain cells depriving them of vital nutrients which can cause parts of the brain to die off) and hemiplegia (paralysis of one side of the body). The Quarterly Minimum Data Set (MDS), an assessment tool, dated 08/01/2024, documented the resident was cognitively intact and was dependent to needing partial assistance with Activities of Daily Living (ADLs). The care plan, initiated 01/23/2024, included restorative program interventions initiated on 05/02/2024 for transfers related to self-care performance deficit and the care plan,…

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 Intravenous (IV) services were provided in accordance with professional standards of practice and facility policy for 2 of 2 residents (Resident 69 & 31) reviewed for IV therapy. The facility failed to provide Peripherally Inserted Central Catheter (PICC, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) care, maintenance and monitoring to include changing needleless injection caps, flushes, dressing changes, monitoring the external length to verify the line had not migrated, and monitoring insertion site for signs and symptoms of infection. These failures placed the resident at risk for loss of vascular access, infection, and other potential negative health outcomes. Findings included . <Facility Policy> Review of the facility's Central Vascular Access Device (CVAD) Dressing Change, Needleless Connector Change, and Flushing and Locking policies, all revised 06/…

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 menu was followed for 4 of 4 residents (Residents 28, 50, 67 & 2) with mechanical soft or puree diets, whose meals were observed during tray line. Failure to provide accurate portion sizes, placed residents at risk of unmet nutritional needs, and potential negative outcomes. Findings included . Review of the facility's menu showed for lunch on 08/12/2024 smothered chicken, parslied rice, brussels sprouts and a dinner roll would be served. >Portion Sizes< Review of the menu showed residents on D1 pureed diets would receive: A #8 (4-5 ounces) scoop of pureed chicken. A #12 (2.5-3 ounces) scoop of pureed brussels sprouts. A # 16 (2-2.5 ounces) scoop of pureed dinner roll D2 mechanical soft diets would receive: A #12 (2.5-3 ounces) scoop of pureed brussels sprouts. Observation of the steam table on 08/12/2024 at 11:20 AM showed the pureed chicken, pureed brussels sprouts, and pureed dinner roll had a #8 scoops in them for serving. Observation of tray line from 10:49 AM - 11:20 AM, showed dietary 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 observation, interviews, and record review, the facility failed to prepare and serve foods in a manner that conserved nutritive value, palatability and that ensured meals served were appetizing and at the proper temperature for 5 of 8 (Residents 17, 23, 28, 32, and 8) sampled residents reviewed for dining and 2 of 2 residents (Residents 2 and 57) on pureed diets.The failure to ensure meals were served at appropriate temperatures, with a good presentation, and that were palatable, placed residents at risk for decreased satisfaction with meals, poor intake, weight loss, and a diminished quality of life. Findings included . <Observation> On 08/05/2024 at 11:45 AM, a cart with five meal trays was brought out of the kitchen and placed in the assisted dining room. At 12:02 PM, Staff K, Nursing Assistant (NA), said the cart was for residents for the north hall. At 12:08 PM, Staff N, NA, said the cart was for south hall residents who were supposed to eat in the dining room. At 12:11 PM, Staff were observed removing the cart (which had sat without plate warmers for 23 minutes) 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 interview and record review, the facility failed to inform the resident and/or their legal representative, in advance, of the risks and benefits associated with the use of psychotropic medications (medications capable of affecting the mind, emotions, and behavior) and obtain informed consent prior to administering the medications for 1 of 5 residents (Resident 77) reviewed for unnecessary medications. These failures prevented residents and/or legal representatives from making informed decisions about the use of multiple antidepressant medications, and precluded them from exercising their right to refuse/decline the proposed medications. Findings included . Resident 77 admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 07/28/2024, showed the resident had moderate cognitive impairment, a diagnosis of depressive disorder and received antidepressant medication. Review of the electronic health record showed Resident 77 had orders, dated 07/21/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to have a system in place which ensured the Office of the State Long-Term Care Ombudsman (an advocacy group for residents in a nursing homes) received required resident discharge information for 2 of 5 residents (Resident 43 & 31) reviewed for hospitalization. These failures placed residents at risk for being inappropriately discharged , not understanding their rights, and prevented the Ombudsman from having the opportunity to educate and advocate for residents during the discharge process. Findings included . 1) Resident 43's Discharge Minimum Data Set (MDS, an assessment tool), dated 04/30/2024, showed the resident had an unplanned transfer to an acute care hospital on [DATE], with return anticipated. Review of Resident 43's electronic health record (EHR) showed there was no documentation present showing the State Ombudsman Office was provided a written notice detailing the reasons for transfer as required. On 08/12/2024 at 3:24 PM, Staff D, Social…

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 residents/resident's representatives bed hold notices at the time of transfer, or within 24 hours of an emergent transfer for 1 of 5 residents (Resident 43) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Resident 43 admitted to the facility on [DATE]. Review of Discharge Minimum Data Set (MDS, an assessment tool), dated 04/30/2024, showed the resident had an unplanned transfer to the hospital on [DATE]. Review of Resident 43's electronic health record (EHR) showed there was no documentation present to show the resident, or their representative were provided a bed hold notice upon transfer as required. On 08/12/2024 at 3:39 PM, when asked if there was documentation to show Resident 43 or their representative were provided a written bed hold notice at the time of transfer, Staff B, Director of Nursing Services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to accurately assess 2 of 28 sampled residents (Residents 69 & 43) whose Minimum Data Sets (MDS, an assessment tool) were reviewed. Failure to accurately identify active diagnoses, the presence and type of intravenous access, the administration of IV medications, and to assess a resident's cognitive patterns, placed residents at risk for unidentified and/or unmet care needs. Findings included . <Resident 69> Resident 69 re-admitted to the facility on [DATE] with a Peripherally Inserted Central Catheter (PICC) to right upper arm and orders for ceftriaxone (an antibiotic) intravenously (IV) daily for a bone and bone marrow infection (osteomyelitis), with direction to infuse via valved single lumen PICC, and an order for vancomycin (antibiotic) IV daily for osteomyelitis Resident 69's July 2024 Medication Administration Record (MAR) showed Resident 69 was administered the IV Vancomycin and the IV ceftriaxone on 07/18/2024. Review of the 07/18/2024 5-day…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 3 of 28 sample residents (Residents 132, 69 & 43) reviewed for professional standards. The failure to follow and/or clarify incomplete physician's orders, and to only sign for tasks that were completed, placed residents at risk for medication errors, unidentified and/or delayed treatment of complications related to intravenous (IV) therapy, and other potential negative health outcomes. Findings included . 1) Resident 132 admitted to the facility on [DATE] with orders to use a Continuous Positive Airway Pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open while you sleep) at night. The CPAP orders included: apply CPAP at bedtime, CPAP settings per resident's home settings; and wash CPAP mask and tubing with soap and water daily and let air dry. On 08/05/2024 at 3:42 PM, when asked what their home CPAP settings were, Resident 132 said 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 enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered in accordance with physician's orders and professional standards of practice for 1 of 1 resident (Resident 43) reviewed for enteral nutrition. The facility failed to accurately record the amount of enteral formula and water flushes administered, to identify and clarify incomplete enteral orders to include route of administration (e.g., gastric tube), method of delivery (gravity, via pump etc.) and the time the enteral formula infusion was to start and finish. These failures placed residents at risk for receiving inadequate nutrition, hydration, weight loss and other potential adverse health outcomes. Findings included . <Facility Policy> Review of the facility's Enteral Tubes policy, revised 12/23/2023, showed 60 ml piston syringes and open system top fill feeding bags, should be replaced every 24…

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

Based on observation and interview the facility failed to ensure staff compliance with current infection control guidelines and standards of practice for donning (putting on) of personal protective equipment (PPE) for 1 of 4 residents (Resident 40), reviewed for infection control. This failure placed residents at an increased risk for exposure to cross contamination (harmful spread of illness), transmission of diseases and a diminished quality of life. Findings included . Facility policy titled Enhanced Barrier Precautions (EBP) Policy and Procedure, dated 08/2023, showed Enhanced Barrier Precautions (EBP) expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs [Multidrug-resistant Organisms] to staff hands and clothing. Examples of high-contact resident care activities requiring gown and glove use for EBP include: o Dressing o Bathing/showering o Transferring o Providing hygiene o Changing linens o Changing briefs or assisting with toileting o Device care or use: central line,…

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 initiate a resident grievance for 1 of 1 sampled resident (Resident 1) reviewed for grievances. This failure placed residents at risk of not receiving a grievance resolution, a denial of personal rights and a diminished quality of life. Findings included . Review of the facility policy entitled, Grievances, revised 02/2024, documented staff were to receive the grievance form or help the resident fill one out, and immediately turn the form into the executive director or director of nursing, The grievance was to be discussed at the morning stand up meeting and logged into the electronic system for tracking. The grievance should be addressed within five days and the resident should be followed up with to ascertain satisfaction. The facility should provide a written resolution to the resident/representative if requested. Resident 1 was readmitted to the facility on [DATE]. The Minimum Data Set, an assessment tool, dated 04/04/2024, documented the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview, and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 6 sampled residents (Resident 1) reviewed for quality of care. The facility failed to act timely on a physician order referring the resident for additional diagnostic testing and a spine specialist. This failure placed residents at risk for health complications, prolonged pain, and decreased quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnosis of spondylosis (a painful condition of the spine resulting from the degeneration of the intervertebral disks) of the lumbar region and low back pain. The admission Minimum Data Set, an assessment tool, dated 01/04/2024, documented Resident 1 was cognitively intact and required staff assistance for activities of daily living. The care plan, initiated 12/19/2023, documented Resident 1 had potential for acute and chronic pain related to chronic physical disability and chronic back pain. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review the facility failed to provide care and services to prevent urinary tract infection (UTI) for 1 of 3 residents (Resident 1) reviewed for quality of care. The facility implemented an external urinary catheter system without assessing for appropriateness, training staff in the use of the device, care planning the system and failed to ensure adequate hydration. These failures placed residents at risk for infection, dehydration, and medical complications. Findings included . Review of the external female catheter system package insert showed the catheter should only remain in place for eight to 12 hours and should not be used if there is bowel incontinence. Resident 1 admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 02/23/2024, documented the resident was cognitively intact, medically complex, required substantial/maximum staff assistance for toileting, did not have an internal or external catheter, was frequently incontinent of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure care plans were updated to reflect current care needs for 1 of 4 residents (Resident 1) reviewed for care planning. This failure placed residents at risk for unmet care needs, decline in function, and a diminished quality of life. Findings included . The facility policy titled, Care Planning Process, revised on 05/19/2023, documented the care plan should describe services and interventions to allow the resident to maintain their highest practicable physical, mental, and psychosocial wellbeing, should re-evaluate the resident's status and when significant changes in status occurs, should then modify the care plan as appropriate and necessary. Resident 1 was admitted to the facility on [DATE] with multiple diagnosis including Rheumatoid arthritis (a chronic inflammatory disorder that can affect the joints, resulting in bone erosion and joint deformity) (RA). The Quarterly Minimum Data Set (MDS), an assessment tool, dated…

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 an ongoing program of exercise to prevent a decline in range of motion for 1 of 4 residents (Residents 1) reviewed for restorative services. Failure to provide consistent services placed residents at risk of deconditioning, loss of range of motion, inability to complete activities of daily living (ADL), and a diminished quality of life. Findings included . The facility policy titled, Restorative Nursing, revised on 12/2022, documented the restorative program functions to enable residents to maintain their highest practicable level of physical, mental, and psychosocial functioning and promotes a positive quality of life for residents and prevention of functional decline. Resident 1 admitted to the facility on [DATE] with multiple diagnosis including Rheumatoid arthritis (a chronic inflammatory disorder that can affect the joints, resulting in bone erosion and joint deformity) (RA). The Quarterly Minimum Data Set (MDS), an assessment tool,…

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 interviews and record review, the facility failed to ensure activities of daily living (ADLs), including showering/bathing were provided for dependent residents for 3 of 3 sampled residents (Resident 1, 2 & 3) reviewed for ADL care. This failure placed residents at risk of not receiving the care and services needed for which they were unable to perform themselves and a diminished quality of life. Findings included . Review of facility policy titled, Personal Needs, revised on 12/20/2022, documented resident care plans would address the individual care needs and preferences of the resident and personal care and ADL support would be provided according to the residents' care plan. 1) Resident 1 was admitted to the facility on [DATE]. The quarterly minimum Data Set (MDS), an assessment tool, dated 10/20/2023, documented the resident had severe cognitive impairment, and displayed no behaviors that interfered with care. The care plan intervention for bathing, initiated on 04/11/2018 and revised on…

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

Based on interview and record review, the facility failed to provide at least eight hours of Registered Nurse (RN) supervision for 3 of 30 sampled days (07/15/2023, 07/16/2023 and 07/22/2023) reviewed for RN coverage. This failure placed residents at risk for not receiving needed care and supervision of care being provided. Findings included . The Aging and Long-Term Support Administration (ALTSA) Staffing Pattern, and the facility's Daily Nurse Staffing Forms for the 30 day look back period, showed the facility did not have any RNs on duty on 07/15/2023, 07/16/2023 and 07/22/2023. On 07/27/2023 at 1:58 PM, Staff S, Staffing Coordinator, said they did not normally have an RN working on the weekends. Reference WAC 388-97-1080 (3) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to ensure care was provided in a dignified manner for 4 of 4 sampled residents (17, 54, 5 & 4) reviewed for resident rights. This failure placed residents at risk for not being groomed in their normal manner, not having privacy during personal care and a diminished quality of life. Findings included . 1) Resident 17 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease. The quarterly Minimum Data Set (MDS), an assessment tool, dated 07/16/2023, showed Resident 17 required extensive assistance for activities of daily living (ADLs). On 07/23/2023 at 3:07 PM, Resident 17's wheel chair was observed to be covered with debris. Food was over every surface and extensively over all parts visible on the wheel chair. On 07/25/2023 at 9:41 AM, Resident 17 was observed to have brown dried material on his face and bridge of nose. Resident 17 was out in the hallways and lobby. At 12:34 PM, Staff H, Certified 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 observation and interview, the facility failed to ensure the environment had acceptable levels of noise and prevent excessive odors for 2 of 4 halls (North side halls & 200 and 300 halls) and 1 of 1 sampled residents (54) reviewed for homelike environment. This failure placed residents at risk of stress, unpleasant odors and a decreased quality of life. Findings included . Resident 54 was admitted on [DATE] with diagnoses including dementia. The annual Minimum Data Set, an assessment tool, dated 07/04/2023, documented resident was severely cognitively impaired and required extensive assistance with transferring, toileting and personal hygiene. <Noise Levels> On 07/23/2023 at 11:00 AM, the call bell alarm at the North Nurses' Station was observed alarming for approximately 30 minutes. The alarm indicated room [ROOM NUMBER] lamp fault. At 11:02 AM, Resident 54 was observed in the TV room in the 300 hall and could be heard repeatedly yelling Help, Help Me at the North Nurses' Station and down both 200…

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 all drugs and biologicals used in the facility were stored in accordance with professional standards for 1 of 2 medication storage areas (South) reviewed for medication storage. This failure placed residents at risk of receiving wrong or ineffective medications and treatments. Findings included . On 07/23/2023 at 3:00 PM, the South medication storage room was observed and showed refrigerator temperatures were not regularly recorded on the refrigerator temperature log. The refrigerator temperature log, dated 06/01/2023 to 06/30/2023, showed 16 missing recordings (18 of 60 opportunities) of the refrigerator temperature. The refrigerator temperature log, dated 07/01/2023 to 07/23/2023, showed 25 missing recordings (25 of 46 opportunities) of the refrigerator temperature. On 07/28/2023 at 11:40 AM, Staff B, Director of Nursing Services and Registered Nurse, said the nurse on shift was responsible for recording the temperature twice per day. Reference WAC 388-97-1300 (2) .

Based on interview and record review, the facility failed to ensure facility staff received dementia training for 3 of 5 sampled staff (C, D & E) reviewed for staff in-service trainings. This failure placed residents at risk of receiving care from unskilled staff. Findings included . 1) Staff C, Nursing Assistant, was hired on 11/29/2022. The Relias (electronic learning center for staff training) transcript and the Training Log/Sign In Sheet for Staff C did not show documentation of dementia training since date of hire. 2) Staff D, Floor Tech, was hired on 02/03/2023. The Relias transcript and the Training Log/Sign In Sheet for Staff H did not show documentation of abuse/neglect and dementia training since date of hire. 3) Staff E, Licensed Practical Nurse, was hired on 12/28/2022. The Relias transcript and the Training Log/Sign In Sheet for Staff E did not show documentation of dementia training since date of hire. On 07/27/2023 at 8:58 AM, Staff A, Administrator, said they did not do dementia trainings. Reference WAC 388-97-1680 (2)(b) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure procedures were in place to assist residents with completing advance directives (AD), and obtaining and maintaining Durable Power of Attorney documentation for 2 of 2 sampled residents (Residents 22 & 31) reviewed for AD. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . 1) Resident 22 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 05/16/2023, documented the resident was cognitively intact. Resident 22's electronic health record (EHR) did not show an AD or documentation of a discussion or education regarding ADs. 2) Resident 31 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident was cognitively intact. Resident 31's EHR did not show an AD or documentation of a discussion or education regarding ADs. On 07/25/2023 at 2:35 PM, Staff Z, Social Services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure medications and treatments were being administered per provider orders for 1 of 5 sampled residents (Resident 53) reviewed for services meet professional standards. This failure placed residents at risk for medical complications, substandard quality of care and unmet care needs. Findings included . Resident 53 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 06/19/2023, showed Resident 53 was moderately cognitively impaired and was able to answer yes/no questions. Record review of Resident 53's April 2023, May 2023, June 2023 and July 2023 Medication Administration Records (MAR) and Treatment Administration Records (TAR) showed the following instances of medications and/or treatments were not documented as administered over a four month period, 04/01/2023 to 07/27/2023: --Weight weekly every day shift, every Monday was not administered 5 times, on 05/29/2023, 06/05/2023, 06/19/2023, 07/03/2023…

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 ensure resident communication devices were available for 1 of 1 sample resident (Resident 53) reviewed for activities of daily living. This failure placed residents at risk of not being able to adequately express themselves and a diminished quality of life. Findings included . Resident 53 was admitted to the facility on [DATE] with diagnoses including a stroke with difficult verbal expression/communication. The quarterly Minimum Data Set, an assessment tool, dated 06/19/2022, showed Resident 53 was moderately cognitively impaired and was able to answer yes/no questions. The Care Plan, dated 01/17/2022, showed an alteration in sensory/communication related to speech disturbance due to expressive aphasia (difficulty expressing self). The care plan, revised 06/08/2022, showed Resident 53 needs communication devices in order to more adequately express himself and needs to be able to express himself and make his needs known. The care plan,…

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 dependent residents eating assistance for 1 of 1 sampled resident (Resident 5) reviewed for activities of daily living (ADLs) for dependent residents. This failure placed residents at risk of choking, weight loss and a decreased quality of life. Findings included . Resident 5 was admitted to the facility on [DATE] with diagnoses including dementia. The quarterly Minimum Data Set, an assessment tool, dated 06/12/2023, showed Resident 5 required extensive assistance with ADLs and supervision for dining including queuing and redirection. The [NAME] (care instructions for staff), undated, showed Resident 5 required assistance of one staff person to eat, and documented, Resident to go to DR [dining room] for all meals for supervision and assistance; Encourage to go to dining room for all meals; Monitor and record food intake at each meal; Needs time to adjust to changes in diet and circumstances. Encourage to eat; Praise progress or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure there was an activity program to meet individual resident needs for 1 of 4 sampled residents (53) reviewed for activities. This failure placed residents at risk for becoming bored and depressed when not provided meaningful engagement throughout the day, and a diminished quality of life. Findings included . Resident 53 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 06/19/2023, showed Resident 53 was moderately cognitively impaired and was able to answer yes/no questions. Resident 53's care plan, dated 06/06/2023, showed Resident 53 was dependent on staff for activities, cognitive stimulation, social interaction and Resident 53 would attend one sensory group per week, . [and] participate in one 1:1 per week-going outside, listening to music, and watching movies/television. The care plan showed Resident 53 preferred activities including going outside, watching movies, listening to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure neurological assessments (neuros, assesses the nervous system and identified any abnormalities affecting function and activities of daily living) were performed after an unwitnessed fall and failed to ensure residents received necessary care and services with positioning based on comprehensive person-centered care plan for 2 of 5 sampled residents (40 & 16) reviewed for quality of care related to accidents and positioning. This failure placed residents at risk for unidentified injuries, health complications, worsening conditions, a delay in treatment, and a diminished quality of life. Findings included . <Neuros> Resident 40 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), dated [DATE], showed the resident was moderately cognitively impaired. The incident investigation report, dated 04/20/2023 at 7:45 PM, documented, resident was noted to be on floor by CNA [Certified Nursing Assistant]. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure pressure injury (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) development was prevented and promoted wound healing by implementing and following care interventions and physician orders for 1 of 3 sampled residents (Resident 4) reviewed for pressure injuries. This failure placed residents at risk for wound complications, infection, delayed healing, increased pain and a decreased quality of life. Findings included . Resident 4 was admitted to the facility on [DATE] with diagnoses including diabetes (a disease that causes high sugar in the body) and a right side below the knee amputation. The quarterly Minimum Data Set, an assessment tool, dated 06/22/2023, documented the resident was cognitively intact, required extensive assistance from 1-2 staff members for activities of daily living (toileting, transfers, mobility, dressing, etc.) and was at risk for development of pressure injuries.…

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 identified weight loss acted upon and interventions developed for 1 of 1 sampled resident (Resident 53) reviewed for nutrition. This caused harm to Resident 53 when the resident experienced a significant weight loss of greater than 5% body weight within a 30-day period and the identified weight loss was not addressed. This failure placed residents at risk for weight loss, inadequate nutrition and a diminished quality of life. Findings included . Resident 53 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 06/19/2023, showed Resident 53 was severely cognitively impaired. Resident 53's Self-Care care plan, revised 09/20/2021 and 06/20/2023, showed Resident 53 had left sided hemiparesis (muscle weakness or paralysis to one side of the body) and the resident's needs would be anticipated by staff 100% of the time. The care plan documented the resident required nutrition through a feeding…

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.