Spokane Valley Health And Rehabilitation Of Cascad

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a complete and thorough investigation of an allegation of abuse for 1 of 3 sampled residents (Resident 3) whose records were reviewed for accident hazards. This failure placed the residents at risk for continued abuse or neglect.Findings included.Review of the October 2015 Nursing Home GUIDELINES or the Purple Book showed that the thoroughness of the investigation was a critical component of any investigation. The guidelines showed that for the facility to provide evidence of the thoroughness of the investigation, the information must be recorded. Each phase of a thorough investigation included two steps, data collection (which answered Who? What? and When? of the event) and data analysis (which summarized and analyzed the facts gathered to either establish reasonable cause for the incident or establish the need for further investigation). Within the first 24 hours of the allegation, part of the initial investigation included interviewing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement interventions to prevent falls and associated injuries and injury during transfers or bed mobility for 3 of 3 sampled residents (Residents 1, 2 and 3) whose records were reviewed for accident hazards. This failure placed the residents at risk for falls, physical injury, and pain. Findings included.<Resident 1>Review of a 10/03/2025 annual assessment showed Resident 1 admitted to the facility on [DATE] with medically complex conditions including dementia with anxiety, a stroke, and pain in the right knee. The assessment showed the staff assessed the resident to be cognitively intact, did not reject care, used a wheelchair, and was dependent on the staff for toileting hygiene, bed mobility, transfers and dressing. The assessment showed the staff identified the resident was frequently incontinent of both bowel and bladder and not on a toileting program and had one fall since the prior assessment.In an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure adequate staffing was maintained to provide consistent and required assistance during bed mobility and use of a mechanical lift (a device that uses mechanical means, like gears, chains, or cables driven by a motor, to raise and lower persons and moving individuals with limited mobility safely) for 1 of 3 sampled residents (Resident 3) reviewed for accident. In addition, the facility failed to ensure the Director of Nursing maintained a license that authorized them to work as a Registered Nurse (RN) in the State of [NAME]. These failures placed the resident at risk for unmet care needs.Findings included.<Insufficient Staffing> Review of a [DATE] admission assessment showed Resident 3 admitted to the facility on [DATE] with medically complex conditions, including muscle weakness, difficulty walking and right foot drop (a condition where the muscles that lift the front part of the foot are weakened or paralyzed resulting in an inability to raise…

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 1 of 3 sampled residents (Resident 6), reviewed for medication administration, received medication as ordered by the physician. This failure resulted in a pattern of significant medication errors which placed the resident at risk for medical complications, unintended health consequences and diminished quality of life. Findings included . Review of the hospital discharge summary and orders dated 10/10/2024 showed Resident 6 was to receive fluconazole (oral antifungal medication) 600mg (milligrams; a unit of measurement) daily until 10/28/2024. The resident was to be closely monitored by nephrology (medical specialty that focuses on the kidneys) due to their advanced kidney disease. Per the October 2024 Medication Administration Record, Resident 6 received fluconazole 600mg twice daily on 10/11/2024, 10/12/2024, 10/13/2024, 10/14/2024, and 10/15/2024 (double the amount ordered). The resident's record showed they discharged from the facility on 10/15/2024. Review of the October 2024 progress notes showed no entries…

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

Based on interview and record review, the facility failed to notify the resident representative of an incident requiring transfer to the hospital experienced by 1 of 4 sampled residents (Resident 1), reviewed for accident hazards. This failure placed the resident at risk for delayed decisions for treatment by the legal representative. Findings included . Review of the 11/20/2024 annual assessment showed Resident 1 had significant cognitive impairments and was dependent upon staff for assistance with activities of daily living (ADLs). Per the 11/21/2024 care plan, Resident 1 had a surrogate decision-maker who was to be involved in all medical and financial decision making. Review of the December 2024 progress notes for Resident 1 showed on 12/05/2024 Staff B, Registered Nurse was notified by staff at the front desk that Resident 1 had a fall during an external appointment that day which resulted in low back pain and required a transfer to the hospital for evaluation. The note showed the resident was transferred back to the facility with no new physician orders. There was 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 ensure 1 of 4 sampled residents (Resident 1), reviewed for accident hazards, received adequate supervision while at an appointment with an external provider. This failure placed the resident at risk of injury and unmet needs. Findings included . Review of the 11/20/2024 annual assessment showed Resident 1 had significant cognitive impairments and was dependent upon staff for assistance with activities of daily living (ADLs). Per the 11/21/2024 care plan, Resident 1 was at a high risk to fall, had a history of seizures (sudden uncontrolled electrical disturbance in the brain) and involuntary movements, and was confused. The care plan showed staff were to provide close monitoring of the resident, a specialty wheelchair that tilted back (to prevent falls from leaning forward), and required the assistance of two staff and a mechanical lift for transfers. Review of the December 2024 progress notes for Resident 1 showed on 12/05/2024 Resident 1 had an external appointment that day. Further review of the progress…

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 8 sample residents (Resident 1) reviewed for abuse, was free from sexual abuse from another resident (Resident 2). This failure placed Resident 1 and other residents at risk for psychosocial harm and a diminished quality of life. Findings included . Review of the 09/09/2024 annual assessment showed Resident 2 was severely cognitively impaired, wandered one to three days of the assessment period, had delusions (false belief about external reality despite evidence to the contrary) and was able to walk with supervision. Review of the care plan initiated 09/06/2023 showed Resident 2 had poor physical boundaries with others and required staff to monitor their behavior. Per the 09/04/2024 quarterly assessment Resident 1 was severely cognitively impaired and independent with walking. Review of a 09/17/2024 facility investigation showed Staff D, Nursing Assistant, was walking down the hallway at approximately 2:45 PM that day and found Resident 2 in Resident 1's room. Per the report, Resident 1 was lying…

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

Based on interview and record review, the facility failed to ensure that direct care staffing information was accurate upon submission to the Centers for Medicare and Medicaid Services (CMS) for Quarter 1 of 2024 (January 1, 2024 through March 31, 2024) reviewed for Payroll Based Journal (PBJ - mandatory reporting of staffing information based on payroll data) submission. This failure caused CMS to have inaccurate data related to facility staffing levels and had the potential to impact resident care and services. Findings included . Review of the Certification and Survey Provider Enhanced Reports (CASPER) PBJ Staffing Data Report showed the facility reported data for Quarter 1, 2024 at a level lower than required by mandated staffing levels. In an interview on 10/16/2024 at 3:15 PM Staff B, Director of Nursing, stated the facility was having a lot of change during Quarter 1, 2024 and they did not think hours were being reported correctly. On 11/14/2024 at 8:10 PM Staff A, Operations Director, documented the facility had additional staffing data from Quarter 1, 2024 that was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appetizing and palatable food for 6 of 7 sampled residents (48, 59, 8, 41, 1, 43) reviewed for food. This failure placed the residents at risk for decreased nutritional intake, and a diminished quality of life. Findings included . According to [NAME] Administrative Code [PHONE NUMBER]0, Time/temperature control for safety food, hot and cold holding (FDA Food Code 3-501.16). Food must be maintained: At 135°F (57°C) or above, or at 41°F (5°C) or less. Resident Observations and Interviews <Resident 48> On 08/01/2024 at 2:41 PM, Resident 48 was observed sitting in a wheelchair in their room using their computer. When asked about the food, the resident stated the food was horrible, did not have much taste, and was not something they would eat if they had a choice. On 08/06/2024 at 8:29 AM, Resident 48 stated breakfast was good, had eggs, toast, oatmeal, and coffee, but there was no meat. Resident 48 further stated the meals often…

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 enhanced barrier precautions (EBP, an infection control intervention to reduce transmission of multi-drug resistant organisms) were implemented when indicated for 4 of 4 sampled residents (69, 7, 73, 1) reviewed, and that hand hygiene was completed when indicated during 1 medication pass observed and 2 wound treatments observed. Additionally, the water management plan was not developed and implemented as required, Infection Prevention Program policies and procedures were not reviewed annually, and appropriate follow-up measures were not completed timely when one resident screened for Tuberculosis exposure (TB, a bacterical infection that mainly affected the lungs) had a positive skin test. These failures placed residents at risk for cross contamination of infectious material, and possible exposure or illness from debilitating bacterial and viral illnesses. The article, Implementation of Personal Protective Equipment (PPE) use 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 record review and interview, the facility failed to ensure residents were provided education regarding the risks and benefits of influenza and pneumococcal immunizations, and received the immunizations or did not receive them due to contraindications or refusals for 4 of 5 sampled residents (36, 48, 66, 69) reviewed. This failure put residents at risk of being unable to participate in aspects of their care, and at risk of acquiring viral and bacterial diseases. Findings included . The 03/04/2022 revised Influenza Program facility policy documented residents and family members received education regarding the benefits of the influenza immunization. Residents were offered and given the vaccine unless it was contraindicated, they had already received it during the current flu season, or the resident refused it. The 05/31/2023 revised Pneumococcal Program facility policy documented residents and family members received education regarding the benefits of pneumococcal immunization. Residents were offered 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 record review and interview, the facility failed to ensure resident records included evidence of the resident's vaccination status for COVID-19 (a viral illness that caused difficulty breathing, fever, or other severe symptoms that included possible death), that the residents had been offered education regarding the risks or potential side effects of the vaccine, had been offered the vaccine if available, refusals, contraindications, or administrations if given, for 4 of 5 sampled residents (36, 48, 66, 69) reviewed. This failure placed residents at risk of not being informed of their choices to receive immunizations, and at risk for acquiring serious viral illnesses. Findings included . The 07/03/2024 Centers for Disease Control (CDC) Staying Up to Date with COVID-19 Vaccines retrieved 08/14/2024 from cdc.gov/covid/vaccines/stay-up-to-date.html documented everyone aged 5 years and older should get 1 dose of an updated COVID-19 vaccine to protect against serious illness. People who are up to 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.

Based on observation, interview and record review, the facility failed to ensure residents were provided care in a dignified manner for 3 of 4 sampled residents (4, 58, 67) reviewed for resident rights. Specifically, Resident 4 was referred to as a feeder, and Residents 58 and 67 required use of urinary catheters (a tube inserted into the bladder that allowed urine to drain) and the urine collection bags were not covered and were visible to the public. This failure put the residents at risk for embarassment and decreased quality of life. Findings included . <Resident 4> A 06/04/2024 quarterly assessment documented Resident 4 had diagnoses including traumatic brain injury (TBI), and spastic hemiplegia (muscles on one side of the body are in a constant state of contraction) affecting their left dominant side. Resident 4 was moderately cognitively impaired and was dependent on staff for most activities of daily living (ADLs). The comprehensive care plan documented Resident 4 was at nutritional risk and required adaptive equipment at meals. Staff were instructed to provide 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.

Based on interview and record review, the facility failed to investigate a fall for 1 of 3 sampled residents (285), reviewed for falls. This failure placed the resident at risk of further falls, injury, and a diminished quality of life. Findings included . Review of the 05/17/2021 facility policy titled, Fall Response and Management documented nursing staff was to complete a post fall investigation, notify the physician, and communicate the event and intervention changes to the staff. According to the 08/04/2024 admission assessment, Resident 285 required partial to moderate assistance with activities of daily living such as transferring and toileting and was able to make their needs known. In an interview on 08/06/2024 at 8:44 AM, Resident 285's family member stated the resident had fallen on 08/02/2024 when staff had assisted him to the toilet. The family member stated the resident was standing in the bathroom, fell back and hit their hip on the toilet and experienced a lot of pain and was not getting any better. During an interview on 08/08/2024 at 8:38 PM, Staff D, 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.

Based on interview and record review, the facility failed to ensure 1 of 5 sampled residents (23) reviewed for Pre-admission Screening and Resident Review (PASARR, an assessment completed to determine whether a resident with a diagnosis of a serious mental illness needed specialized mental health services) was completed accurately and prior to admission as required. In addition, the facility failed to ensure a new PASARR assessment was completed when Resident 23 had changes in their mental health diagnoses. These failures placed the resident at risk for unmet care needs. Findings included . <Resident 23> Resident 23's admission record documented the resident admitted to the facility with a mental health diagnosis of paranoid personality disorder, a mental health disorder characterized by irrational and persistent beliefs that people were trying to harm, deceive or exploit them. Review of Resident 23's record showed a PASARR was completed by Staff G, Social Worker, on 06/26/2023, four days after the resident was admitted to the facility. Section 1A of the assessment documented…

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

Based on observation, interview and record review, the facility failed to ensure care plan interventions were implemented for 3 of 19 sampled residents (1, 283, 4) reviewed for care planning. Failure to ensure nutritional interventions for Residents 1 and 4, and vascular ulcer interventions for 283 were followed placed the residents at risk for poor nutritional intake, potential skin breakdown, unmet care needs, and a diminished quality of life. Findings included . <Resident 1> The 07/08/2024 annual assessment documented Resident 1 was able to make their needs known to staff, had impaired range of motion to an upper extremity on one side of their body, and needed set up or clean up assistance from nursing staff to eat. On 08/01/2024 at 10:15 AM, Resident 1 was observed lying in their bed in their room talking with their representative. The representative stated Resident 1 was at risk for choking, would put too much food on the spoon when eating and the staff were supposed to supervise for safety, but it wasn't being done. In response to the comment, Resident 1 made a thumbs up…

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

Based on interview and record review, the facility failed to complete a discharge summary, including a recapitulation of the resident's stay as required, for 1 of 1 sampled residents (19), reviewed for discharge. This failure placed the resident at risk for having an incomplete medical record. Findings included . The 07/08/2024 quarterly assessment documented Resident 19 was cognitively intact to make decisions regarding care and needed set up assistance from staff to complete activities of daily living. A record review documented Resident 19 was admitted to the facility for physical and occupational therapy, following a urinary tract infection and sepsis (a life-threatening complication of an infection). A review of the progress note on 07/30/2024 documented Resident 19 was discharged to another facility. The 07/30/2024 discharge summary completed by Staff F, Physician Assistant, documented the resident discharged but did not state where to, nor did the summary provide a recapitulation of the care and services the resident received while at the facility. In an interview on…

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

Based on observation, interview, and record review, the facility failed to consistently provide bathing and/or grooming for 3 of 3 sampled residents (1, 43, 5), reviewed for activities of daily living (ADLS). This failure placed the residents at risk for poor personal hygiene, unmet care needs and a diminished quality of life. Findings included . <Resident 1> The 07/08/2024 annual assessment documented Resident 1 had diagnoses which included paraplegia, a condition that caused the loss of muscle function in the lower half of the body. In addition, the assessment documented the resident was dependent on nursing staff to complete activities of daily living for bathing and personal hygiene such as shaving. On 08/01/2024 from 9:37 AM to 9:50 AM, Resident 1 was observed lying in bed in their room. The resident's hair was greasy in appearance and there was long facial stubble present. When asked if they were being bathed, and assisted to shave, the resident stated no, and made a thumbs down gesture. Resident 1's representative was present at the time and stated it had been about three…

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 1 sampled residents (25) reviewed for activities, received an ongoing program of activities that met their interests. This failure placed the resident at risk for boredom and diminished quality of life. Findings included Per the 06/24/2024 quarterly assessment, Resident 25 was moderately cognitively impaired, was able to make some needs known, and had diagnoses which included dementia and depression. The assessment documented it was very important to the resident to be involved in activities that included: books, music, animals, religion, spending time outdoors, doing things with groups of people and participating in their favorite activities. Per the 03/22/2023 care plan, Resident 25 was at risk for activity deficits related to cognitive and physical deficits, difficulty with balance and memory, required encouragement to participate due to difficulty initiating stimulation and socialization. The goal for the resident was to participate in varied group and individual activities such as church…

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 pressure relieving interventions were implemented for 1 of 4 sampled residents (4) reviewed. Specifically, Resident 4 did not have their pressure relieving foam boot applied consistently when in bed and an area where the resident had a history of pressure on their left heel reopened. This failure placed the resident at risk of further deterioration of their heel, pain, infection, and decreased quality of life. Findings included . <Resident 4> A review of the record showed Resident 4 had diagnoses including traumatic brain injury (TBI), hemiplegia (paralysis) affecting the left dominant side of the body, and Stage 3 pressure ulcer of the left heel, (full thickness loss of skin without exposure of muscle, tendon, or bone). The 06/04/2024 quarterly assessment documented Resident 4 was moderately cognitively impaired and was dependent on staff for most activities of daily living (ADLs) including rolling from side to side, personal hygiene and toileting. The resident was at risk for pressure ulcers, had 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 consistent, ongoing communication and collaboration with the dialysis facility for 1 of 1 sampled resident (65), reviewed for dialysis. These failures placed the residents at risk for unmet care needs and medical complications. Findings included . The 06/27/2024 admission assessment documented Resident 65 was able to make decisions regarding their cares, and had diagnoses which included kidney disease, and diabetes (a disease caused by the inability of the body to convert the food we eat into sugar needed for the cells to use as energy). In addition, the assessment documented the resident received dialysis (a procedure that removes waste products and excess fluid from the blood when the kidneys stopped working properly). Review of the 01/25/2024 agreement between the facility and the dialysis center documented care of residents receiving dialysis was to be coordinated between the facility and the dialysis center, to ensure continuity of care and the resident's well-being. Per the 06/28/2024 dialysis…

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

Based on interview and record review, the facility failed to ensure residents were seen by the physician within the required timeframes for 2 of 8 sampled residents (5, 59) reviewed. This failure placed residents at risk for unmet medical needs and decreased quality of care. Findings included . <Resident 59> The 07/12/2024 annual assessment documented Resident 59 was able to make decisions regarding their care and had diagnoses which included kidney disease. On 08/01/2024 at 12:23 PM, Resident 59 was observed sitting upright in bed. When asked if they had any concerns about their care, Resident 59 stated there was a new team of doctors at the facility and they had asked to see one, but it hadn't happened. Resident 59 further stated they had chronic urinary tract infections, had just finished antibiotics, and would like to speak to the doctor. Review of Resident 59's record found documentation that showed Staff R, Physician's Assistant, visited the resident on 06/18/2024, 07/03/2024, 07/09/2024, 07/15/2024, 07/25/2024, and 08/06/2024. A provider progress note on 06/12/2024 by 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 complete a yearly performance review on 3 of 3 sampled nursing assistants (AA, BB, CC) as required. This failure placed residents at risk of receiving care from inadequately trained staff. Findings included . Review of the following Nursing Assistant (NA) personnel files found the following: - Staff AA was hired on 05/03/2022. No documentation was found to show an annual performance evaluation had been completed as required. - Staff BB was hired on 07/01/2023. No documentation was found to show an annual performance evaluation had been completed as required. - Staff CC was hired 07/13/2023. No documentation was found to show an annual performance evaluation had been completed as required. In an email correspondence on 08/12/2024 at 6:34 AM, a request for the annual performance reviews for the above nursing assistants was sent to Staff B, Director of Nursing. On 08/13/2024 at 8:18 AM, Staff B replied that no annual performance reviews had been completed. Reference (WAC): 388-97-1680(2)(b)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure behavioral health services were provided for 2 of 2 sampled residents (7, 36) reviewed. This failure placed the residents at risk of declining mental health, escalation of their chronic mental health conditions and decreased quality of life. Findings included . <Resident 7> A review of the record showed Resident 7 was admitted on [DATE] and had diagnoses including psychosis (disconnection from reality), schizoaffective bipolar disorder (a complex mental health condition that has symptoms of both Schizophrenia and mood disturbances) and catatonic disorder (inability to move normally). The [DATE] quarterly assessment documented Resident 7 was severely cognitively impaired, had hallucinations and physical behavioral symptoms such as hitting and kicking, and also rejected care. Resident 7 was dependent on staff for most activities of daily living (ADLs), took antipsychotic medication daily, and had not had a gradual dose reduction…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. Five medication errors were identified for 1 of 8 sampled residents (Resident 73) observed during 40 medication opportunities, which resulted in an error rate of 12.5 percent. The failure to administer medications correctly placed the residents at risk for receiving subtherapeutic effects of their medications and possible adverse side effects. Findings included: During an observation on 08/12/2024 at 7:40 AM Staff E, Licsensed Practical Nurse prepared and administered multiple medications to Resident 73 which included one tablet of Mesalamine (a medication for Ulcerative Colitis, a bowel disease that causes swelling and sores in the colon and rectum), and two sprays of Azelastine (a medication for allergies) nasal spray in each nostril, but did not include Acetylcysteine (a medication for anxiety), Spiriva Respimat (a medication to improve breathing), and Ipratropium-Albuterol (a medication to improve breathing). Per review of the current physician…

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 expired medications were disposed of and multi-dose vials were dated when opened in 1 of 2 medication rooms inspected, and that insulin needles were securely stored on a unit that was closed. This failure placed residents at risk of receiving expired medications and potential needlestick injuries. Findings Included . On 08/01/2024 at 8:30 AM, a team of surveyors entered the facility to conduct a recertification survey. The team was provided a workspace in a dining area on a rehabilitation unit that was no longer in use. Across the hall from the dining area, a nursing station no longer in use was located, and contained a small dorm-style refrigerator, a sink area, and multiple unlocked cabinets, and drawers. At 11:01 AM, the nursing station was inspected. Inside a middle unlocked long cabinet on an upper shelf, there were 2 boxes of insulin needles, each 2/3 full. One box of needles expired on 07/31/2024. The second box of needles had an expiration date of 01/31/2025. In an adjacent cabinet on the middle shelf, there…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dietary staff had the required qualifications (current Food Worker Cards) for one of twelve dietary staff reviewed (EE). This failed practice had the potential risk for unsafe food handling practices and placed all residents at risk for developing foodborne illness. Findings included . A review of the dietary cards showed no Washington State Food Workers card for Staff EE (hire date 6/21/2024). Staff EE did have a certificate dated 7/4/2024 from Food Handler Solutions for completing the food handler's course. Review of Food Handler Solutions website, foodhandlersolutions.com/[NAME]-food-handler-card/ showed, the Food Handler Solutions Program is currently not approved in the state of [NAME]. This program is only intended to be used for personal development and preparation for the state provided training. A review of the staffing schedules documented Staff EE had worked in the kitchen August 1st-4th 6:00AM-2:30PM, and August 7th-11th…

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 hand hygiene was completed when indicated during 1 of 4 meals observed during dining. This failure resulted in potential risk of food borne illness and a decreased quality of life for all residents. Findings included . On 08/01/2024 at 11:59 AM, Staff JJ, Nursing Assistant was observed pushing a resident in a wheelchair into the Dayspring dining room. Staff JJ then proceeded, without performing hand hygiene, to deliver a meal tray to a second resident, cut the resident's sandwich, and refill the coffee cup. Staff JJ continued, without performing hand hygiene, to take a meal tray for a third resident and unwrap the food items, pour water into a cup, place the eating utensils on the tray, and deliver the meal tray to the resident in the dining room. Then again, without performing hand hygiene, Staff JJ prepared a meal tray for a fourth resident by cutting up the food, opening items, opening straws and putting them in the drinks, then delivered the meal to the resident in the dining room. During an observation 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 observation, interview, and record review the facility failed to ensure pharmacy services were provided to meet the needs of 3 of 3 sampled residents (Resident 1, 2, and 3) reviewed for medication management. The failure to ensure medications were acquired and administered as ordered, and follow facility processes for medications not available, placed residents at risk for adverse events related to missed medications. Findings included . <Resident 1> Review of the 07/01/2024 admission assessment showed Resident 1 had a diagnosis of anemia (deficiency of healthy red blood cells that can cause fatigue and unexplained weakness) and required staff assistance with activities of daily living (ADLs). Review of a provider progress note dated 07/09/2024 showed Resident 1's representative reported the resident's nephrologist (doctor who specializes in kidney care) recommended continuing an anemia treatment the resident had been receiving prior to admission to the facility; Procrit injections. The note documented the resident's family would provide the medication given the cost. In a…

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

Based on interview and record review, the facility failed to ensure professional standards of practice were followed when discontinuing medications for 1 of 3 sampled residents (Resident 3) reviewed for medication management. This failure placed the resident at risk of not receiving correct medications, adverse health effects, and diminished quality of life. Findings included . Per the Washington State Board of Nursing (https://nursing.wa.gov/faq/can-registered-nurse-be-delegated-enter-medication-prescriptions-electronic-health-system-or-call; retrieved 07/31/2024) a registered nurse may enter medication prescriptions into an electronic health system under the direction of an authorized health care practitioner. Review of the 07/03/2024 hospital transfer orders for Resident 3 showed a medical provider at the hospital ordered the medication tizanidine (a muscle relaxant) daily at night and L-Lysine (an over-the-counter supplement) daily. Review of Resident 3's July 2024 MAR showed the tizanidine was not provided to the resident from 07/03/2024 through 07/07/2024. Per the MAR the…

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

Based on interview and record review, the facility failed to ensure a system was in place in which residents' records were complete and accurate for 1 of 3 sampled residents (Resident 1) reviewed for accurate and complete medical records. The facility failed to ensure the medical record included consultant provider notes and medications administered during external provider visits. This failure to not maintain complete and accurate medical records placed residents at risk for medical complications, unmet care needs, and diminished quality of life. Findings included . Review of Resident 1's Medication Administration Record (MAR) for July 2024 showed an order for Procrit (injectable medication that stimulates red blood cell production for anemia treatment) once daily every 14 days, beginning on 07/11/2024. Per the MAR, the resident was not receiving the medication. (See F-755 Pharmacy Services for additional information.) Review of the July 2024 progress notes showed a 07/09/2024 provider progress note documenting that Resident 1's family would provide the Procrit. There were 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1), reviewed for food and nutrition services, was served the appropriate diet texture to prevent choking hazards. This failed practice placed the resident at risk for decreased nutritional intake, serious injury, and dimished quality of life. Findings included . Review of the annual assessment dated [DATE] showed Resident had diagnoses of dementia, stroke, aspiration (inhalation of foreign material into the respiratory tract), and received a mechanically altered diet (modification to the texture of food secondary to a physician order). Review of a 06/07/2024 facility investigation showed Resident 1 was coughing/gagging on their meal and required staff to provide suctioning to clear their airway. Per the investigation report, the resident was served a fish sandwich, tater tots and coleslaw, but had only consumed the tater tots at the time of the incident. Review of the electronic physician orders…

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 staff provided CPR (cardiopulmonary resuscitation) in accordance with national standards for effective CPR to one of two sampled residents (Resident 2), reviewed for death. Additionally, the facility failed to ensure two of three sampled facility staff (Staff B and D), reviewed for CPR certification, had current CPR certification credentials. These failures placed residents at risk for not receiving effective care in accordance with their decision-making if their heart stopped beating or their breathing stopped. Findings included . <Resident 2> Review of the facility policy titled, Cardiopulmonary Resuscitation, updated [DATE], showed residents with a designated CPR status of Full Code would receive CPR and all basic life support therapies in accordance with the American Heart Association (AHA) guidelines. Facility staff would call emergency medical services (EMS) and obtain the emergency cart. Per the policy, the facility would set…

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, record review, and interview, the facility failed to ensure a medication error rate of less than five percent. During observation of medication pass, there were two errors observed out of 25 opportunities, resulting in an 8% error rate. This had the potential to place two sample residents (12, 42) at risk of not receiving the full benefit of their medication therapy. Findings included . Review of facility policy titled, Medication: Administration Including Scheduling and Medication Aides, revised 07/01/2022, read in pertinent part, Medications are administered to the resident according to the Six Right. All employees passing medications are familiar with the action and adverse reactions of medications. Procedure: .Review the Medication Administration Record (MAR) for medications due, follow the Six Right: right medication, right dose, right resident, right route, right time, and right documentation, and perform three checks: read the label on the medication container and compare with the MAR when removing the container from the supply drawer, when placing 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 properly label a medication box for one of four sampled residents (42), observed during a medication pass. This failure placed the resident at risk of receiving an inaccurate dosage of medication. In addition, the facility failed to ensure that there were no expired medications in one of the two medication rooms. Findings included . Review of facility policy titled, Medication: Disposition, revised 07/01/2022, read in pertinent part, To ensure accurate disposal of medications. Connect with your pharmacy consultant to be certain of state-specific regulations for approved methods of destruction. Disposal of any medication will be carried out under local, state and federal guidelines or in consultation of the pharmacist in the appropriate disposal procedure. Review of Resident 42's Order Summary Report dated 04/06/2023 showed Voltaren External Gel 1%, apply to bilateral knees topically two times a day (BID) for pain related to pain in right and left knees, apply four grams per knee before lidocaine patch [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 serve food that was at a safe and appetizing temperature for 3 of 5 sampled residents (22, 29, 42), reviewed for food palatability. This failure placed residents at risk for decreased food consumption and decreased enjoyment of their meals. Findings included . The 04/03/2023 Food Preparation-Food and Nutrition facility policy showed that food preparation was timed to ensure that cold foods were served below 41 degrees Fahrenheit (F) and hot foods were served above 135 degrees F. On 04/04/2023, the lunch meal service was observed on Morningside Unit with the following times: -At 11:52 AM, the cart of trays arrived on the unit. Three staff were observed preparing trays and drinks. -At 11:57 AM, the first meal tray was delivered to a resident. -At 12:23 PM, five trays were still in the cart waiting to be delivered. One staff member was standing at a separate small cart sorting meal preference place cards. The doors to the main food cart remained open the duration of the service. -At 12:32 PM, the last tray on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to consistently provide bathing/showers for two of four sampled residents (52, 25) in a total sample of 18, who required extensive assistance from two staff to complete their activities of daily living (ADLs). This failure placed the residents at risk for a diminished quality of life and unmet care needs. Findings included . Review of the 11/29/2022 facility policy titled, Activities of Daily Living, showed, .Any resident who is unable to carry out activities of daily living will receive necessary services to maintain good nutrition, grooming and personal and oral hygiene . Resident 52 Review of Resident 52's electronic admission Record showed they were admitted to the facility on [DATE] with diagnoses that included stroke, dementia, and respiratory failure. Review of the 01/10/2023 admission Minimum Data Set (MDS) - a mandatory standardized, comprehensive assessment of each individual resident - showed Resident 52 had a Brief Interview 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 a program of meaningful activities in accordance with the resident's preferences and current cognitive ability, as identified in the resident assessment, for one of two sampled residents (52), reviewed for activities, in a total sample of 18. This failure placed the resident at risk for a diminished quality of life. Findings included . Review of a facility policy titled, Guidelines Using Activities As Behaviors Interventions, Special Care Unit-Rehab/Skilled, dated 01/09/2023 showed, .Individualized, non-pharmacological approaches to care that are provided as part of a supportive physical and psychosocial environment, directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities, as well as maintaining or improving a resident's mental, physical, or psychosocial well-being . Review of the electronic admission Record showed Resident 52 was 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 observation, interview, and record review, the facility failed to follow the physician orders for parameters set before administering medication for 2 of 5 sampled residents (17, 49), reviewed for medications. These failures placed the residents at risk for adverse side effects and unmet care needs. Findings included . Resident 17 Review of facility policy titled, Medication: Administration Including Scheduling and Medication Aides, revised 07/01/2022, read (in part), Medications are administered to the resident according to the Six Rights. All employees passing medications are familiar with the action and adverse reactions of medications. Procedure: .Review the Medication Administration Record (MAR) for medications due, follow the Six Rights: right medication, right dose, right resident, right route, right time, and right documentation, and perform three checks: read the label on the medication container and compare with the MAR when removing the container from the supply drawer, when placing 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 provide care and services to prevent weight loss and impaired nutritional needs for one of two sampled residents (22), reviewed for nutrition and weight loss in a total sample of 18. This deficient practice caused Resident 22 to have a 7.5% weight loss in a three-month time frame. The facility failed to add additional interventions, failed to notify the provider in a timely manner of the weight loss, and consistently provide fluids as directed on the care plan at meals. These failures placed Resident 22 at risk for additional weight loss and impaired nutrition. Findings included . Review of the facility policy titled, Impaired Nutritional Status and Nutritional Risk, dated 03/30/2023 showed the facility .Ensures that each resident maintains acceptable parameters of nutritional status such as body weight, fluid and electrolyte balance, and hydration status unless the resident's clinical condition demonstrates that this is not possible…

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 that orders for as needed (PRN) antipsychotic medications (a type of medication used to treat symptoms of psychosis) were limited to 14 days for 2 of 4 sampled residents (11, 20), reviewed for Hospice (care for a terminal illness) services. In addition, the prescribing practioner had not re-evaluated Resident 11 for the appropriateness of the PRN antipsychotic medication, as required. These failures placed the residents at risk for unintended medication side effects and a decreased quality of life. Findings included . Resident 11 A review of records showed Resident 11 had diagnoses including adult failure to thrive, fusion of the cervical spine (backbone), and a benign meningioma (non-cancerous tumor in the brain). A significant change assessment completed on 02/07/2023 showed the resident had severe cognitive impairment, hallucinations (perceiving things that aren't really there), and delusions (a false belief that persists in spite of evidence to the contrary). The assessment also showed the resident…

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