Avalon Healthcare - Tacoma

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use, and decrease the development of adverse side effects and antibiotic resistance for 2 of 2 sampled residents (Residents 29 and 45) when reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics. Findings included . Review of the facility policy titled Antibiotic Stewardship dated 03/2019 showed the facility would follow national standards, including revised McGeers criteria, to guide treatment for infections. Review of the revised McGeers criteria dated 09/2023 showed a resident with a urinary catheter must have at least one of the following signs or symptoms:1. Fever,2. Acute change in mental status with no alternate diagnosis and leukocytosis (increased white blood cells)3. New-onset…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer, educate, and obtain consent for pneumococcal vaccines for 2 of 5 sampled residents (Residents 31 and 45) when reviewed for immunizations. These failures denied residents the opportunity to make an informed decision regarding receiving immunizations and placed the residents at risk for communicable diseases. Findings included .Resident 31Review of the electronic health record (EHR) showed Resident 31 admitted to the facility on [DATE] with diagnoses of stroke (when blood flow is cut off from parts of the brain) and weakness. The resident was not able to make needs known. Review of the EHR showed no documentation Resident 31 was assessed for the need for pneumococcal vaccine and no documentation the resident or their representative was educated or offered the vaccine. Resident 45Review of the EHR showed Resident 45 admitted to the facility on [DATE] with diagnoses of congestive heart failure and Alzheimer's disease. The resident was able to make…

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 psychotropic medications (any drug that affects the brain activities associated with mental process and behavior) were regularly monitored and had documented adverse side effects and effectiveness for 1 of the 5 sampled residents (Resident 49) when reviewed for unnecessary medication use. This failure placed the residents at risk of unnecessary medication use, side effects without interventions, and diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 49 was admitted to the facility on [DATE] with diagnoses of major depression, anxiety, diabetes (high blood sugar) and insomnia. The Quarterly Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 49 was cognitively intact. Observation on 07/25/2025 at 10:41 AM showed Resident 49 was in their room with a staff member providing one on one supervision. Review of the EHR showed Resident 49 was taking scheduled psychotropic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide bed hold notices in writing at the time of transfer to the hospital or within 24 hours of transfer to the hospital for 2 of 2 sampled residents (Residents 37 and 29) when reviewed for hospitalization. This failed practice placed the residents at risk for lack of knowledge regarding the right to hold their bed while they were at the hospital.Findings included… Resident 37 Review of the electronic health record (EHR) showed Resident 37 initially admitted to the facility on [DATE] with diagnoses of dementia, adult failure to thrive, and alcoholic cirrhosis of the liver (liver damage leading to scarring and liver failure). Resident 37 was able to make needs known. Review of the EHR showed Resident 37 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. There was no documentation to show Resident 37 was offered a bed hold for their transfer/discharge to the hospital. During an interview on 07/29/2025 at 1:32 PM, Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify a significant change of condition for 1 of 3 sampled residents (Resident 58) reviewed for significant change. Failure to identify the need for significant change of condition assessment minimum data set (MDS, a required assessment tool) placed the residents at risk for unidentified/unmet care needs, and diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 58 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (progressive disease that destroys memory and other important brain functions), diabetes (high blood sugar) and depression. Review of the EHR showed Resident 58 started hospice (end of life care) services on 02/20/2025. Review of the MDS schedule showed an annual MDS on 12/31/2024 and a quarterly MDS on 04/02/2025 that did not address hospice services. During an interview on 07/28/2025 at 9:44 AM, Staff B, Director of Nursing Services, stated…

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 an accurate assessment for 2 of 19 sampled residents (Residents 37 and 29) when reviewed for accuracy of assessments. These failures placed the residents at risk of unmet care needs, inaccurate information in the resident's medical record, and a diminished quality of life. Findings included .Resident 37 Review of the electronic health record (EHR) showed Resident 37 readmitted to the facility on [DATE] with diagnoses of dementia (a decline in mental abilities, severe enough to interfere with daily life), adult failure to thrive, and alcoholic cirrhosis of the liver (liver damage leading to scarring and liver failure). Resident 37 was able to make needs known. Review of Resident 37's EHR showed a “Hospice Certification and Plan of Care,” order dated 04/11/2025. It showed that hospice care services were being provided and documented per the provider's order. Review of the quarterly minimum data set assessment (MDS) dated [DATE] showed Resident 37…

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 care plans were timely revised on a change in resident status for 2 of 19 sampled residents (Residents 48 and 37) when reviewed for revision of care plan. This failure placed residents at risk for unmet care needs, inaccurate care plans, and a diminished quality of life. Findings included .Resident 48 Review of the electronic health record (EHR) showed Resident 48 was admitted to the facility on [DATE] with diagnoses to include respiratory failure, diabetes (high blood sugar), heart failure and end stage renal disease with dialysis (treatment that removes waste products and excess fluids from the blood when the kidneys are unable to complete these functions). Resident 48 was able to communicate their needs. During an interview on 07/23/2025 at 9:41 AM, Resident 48 stated they were on a fluid restriction of 40 ounces a day. Review of the care plan focus area of oral intake, initiated 09/20/2023, showed Resident 48 was on a 1000 milliliters (mls)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were provided an activity program for 1 of 3 sampled residents (Resident 55) when reviewed for activities. This failure placed the resident at risk for boredom, feelings of worthlessness, and a diminished quality of life. Findings included.Resident 55Review of the electronic health care record (EHR) showed Resident 55 admitted to the facility on [DATE] with diagnoses to include dementia (a progressive decline in memory, thinking, reasoning, and judgment, that interfere with daily functioning and social relationships), muscle weakness, and adult failure to thrive. Resident 55 was unable to make needs known. Observation on 07/23/2025 at 10:23 AM showed Resident 55 laid in bed eyes open with their television (TV) off and angled away from the bed. Resident 55 pointed at the TV and stated, Look. Observations on 07/24/2025 at 9:56 AM and 2:27 PM and 07/25/2025 at 11:14 AM showed Resident 55 laid in bed eyes open with their TV…

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 timely develop a collaborative comprehensive care plan involving hospice care (end of life care and services) for 2 of the 2 sampled residents (Resident 37 and 55) when reviewed for hospice. This failure placed residents at potential risk for unmet needs and a diminished quality of life.Findings included . Review of the facility's policy titled, Administration hospice, dated July 2018, showed, The facility and the hospice will establish a coordinated plan of care which identifies the specific services/functions each provider is responsible for performing.” Resident 37 Review of the electronic health record (EHR) showed Resident 37 readmitted to the facility on [DATE] with diagnoses of dementia (a decline in mental abilities, severe enough to interfere with daily life), adult failure to thrive, and alcoholic cirrhosis of the liver (liver damage leading to scarring and liver failure). Resident 37 received hospice care services and was able to make needs…

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 interventions to prevent/heal pressure injuries were provided for 1 of 2 sampled residents (Resident 2) when reviewed for pressure injury. This failure placed the resident at risk of inability to heal pressure injury, worsening pressure injury, and a diminished quality of life. Findings included .Resident 2Review of the electronic health record showed Resident 2 admitted to the facility on [DATE] with diagnoses to include hemiplegia (paralysis or severe weakness on one side of the body), psychotic disorder with delusions, and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Resident 2 was unable to make needs known. Observation on 07/23/2025 at 11:54 AM showed Resident 2 in bed laying on their back with two inflatable boots on the nightstand. Observations on 07/23/2025 at 11:54 AM, 07/24/2025 at 9:30 AM and 2:24 PM, 07/29/2025 at 8:21 AM, and 07/30/2025 at 9:23 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents did not have access to weapons for 1 of 3 sampled residents (Resident 38) when reviewed for accident hazards. This failure placed residents at risk of being assaulted, avoidable injury, and a diminished quality of life. Findings included .Resident 38Review of the electronic health record showed Resident 38 admitted to the facility on [DATE] with diagnoses to include heart disease, dementia (a progressive decline in memory, thinking, reasoning, and judgment, that interfere with daily functioning and social relationships), unspecified psychosis (a mental health condition characterized by a loss of contact with reality), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Resident 38 was able to make needs known. Observation on 07/23/2025 at 9:46 AM showed a piece of rebar (a steel reinforcing rod in concrete) next to Resident 38's sink. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure accurate monitoring and documentation for fluid restrictions for 1 of 3 sampled residents (Resident 29) when reviewed for hydration. This failure placed residents at risk for medical complications related to hydration and a diminished quality of life.Review of the electronic health record showed Resident 29 admitted to the facility on [DATE] with diagnoses of type 2 diabetes (when there is too much sugar in the blood) and kidney failure and was receiving dialysis services (when the blood if filtered through a machine to remove waste). The resident was able to make needs known. Review of the provider orders showed an order dated 05/10/2025 for a fluid restriction of 2000 milliliters (ml) daily. There was no documentation of the amount of fluid received from nursing /dietary and the daily total was not calculated and documented in the EHR. During an interview on 07/28/2025 at 9:43 AM, Staff K, Registered Nurse/Resident Care Manager…

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 providers orders and professional standards of practice for 1 of 1 sampled resident (Resident 5) when reviewed for enteral nutrition. This failure placed the resident at risk for infection, malnutrition, and diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 5 was admitted to the facility on [DATE] with diagnoses that included gastrostomy status (the delivery of nutrients through a feeding tube directly into the stomach or small intestine), heart failure, convulsions (uncontrolled jerking, loss of consciousness) and anoxic brain damage (brain damage from lack of oxygen). Resident 5 was not able to communicate their needs. Review of Resident 5's quarterly minimum data set (MDS, a required assessment tool), dated 06/30/2025, showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide prompt follow up on provider's referral for dental care services for 1 of 4 sampled residents (Resident 44) reviewed for dental services. This failure placed Resident 44 at potential risk for continued dental problems, unmet needs, and a diminished quality of life.Findings included. Review of the facility's policy titled, Dental Services, dated November 2017 showed, Dental services are available to residents, including, but not limited to examination, oral prophylaxis [actions taken to prevent disease] and emergency dental care to relieve pain and infection. Review showed, If any resident is unable to pay for dental services, the facility should attempt to find alternative funding sources or delivery systems so that the resident may receive the services needed to meet their dental needs and maintain his/her highest practicable level of wellbeing. Review of the electronic health record (EHR) showed Resident 44 admitted to the…

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

Based on interview and record review, the facility failed to maintain an infection prevention and control program by completing and analyzing infection control data, identifying trends, and completing follow-up activities in response to those trends for 3 of 3 sampled months (April, May, June 2025) when reviewed for infection control. This failure placed the residents at risk for communicable diseases, poor clinical outcomes, and a decreased quality of life. Findings included.Review of the facility policy titled Infection Preventions and Control Program dated 08/2022 showed the surveillance log will include the pathogen and the infection preventionist will use the information to identify trends to minimize further spread and the information would be used to implement changes and/or education to address the trends. Review of the facility infection control line listing documentation for 04/2025, 05/2025 and 06/2025 showed no identified organisms were included in the data. No monthly summary was completed showing the data was analyzed or trends identified and 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 and interview, the facility failed to have an emergency call light system in place that allowed a resident to call for help from their bathroom for 1 of 4 hallways (300 hallway) when reviewed for call light system. This failure placed the resident at risk of not being able to call for assistance, delayed response to a fall, injury, and a diminished quality of life.Findings included . Observations on 07/24/2025 at 9:31 AM and 07/25/2025 at 10:43 AM showed the bathroom in room [ROOM NUMBER] had no emergency call light system. During an interview on 07/24/2025 at 9:31 AM, Resident 1, who resided in room [ROOM NUMBER], stated they used the bathroom and had not noticed that there was no call light in the bathroom. During an interview on 07/25/2025 at 10:49 AM, Staff B, Director of Nursing Services, stated there was not an emergency call light in room [ROOM NUMBER]'s bathroom and there should be. During an interview on 07/25/2025 at 10:49 AM, Staff A, Administrator, stated their expectation was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interviews and record review the facility failed to assess residents with a history of Substance Use Disorder (SUD) for associated risks, develop comprehensive individualized care plans and implement interventions to ensure the safety for 5 of 5 sampled residents (Residents 1, 2, 3, 4 & 5) reviewed for SUD related emergencies. Failure of the facility placed residents with a history of SUD at risk of delayed treatment for overdoses, reduced effectiveness of prevention strategies and placed other residents at risk of a diminished quality of life. Findings included . Review of the Quality of Care Accident Hazards/Supervision Policy and Procedures dated 07/2018 showed the facility recognized the high-risk nature of the facility population and setting, that efforts to minimize risk to residents included individualized, resident-centered interventions to reduce individual risks related to hazards in the environment. Specifically for Residents with Substance Use Disorder (SUD) the procedure guidelines…

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

Based on interview and record review, the facility failed to develop a personalized discharge plan based on each resident's identified needs, goals and preferences for 4 of 4 sampled residents (Residents 4, 1, 3 & 5) reviewed for discharge planning. This failure placed residents at risk for delayed discharge, and unmet care needs after discharge. Findings included . < Resident 4> Review of the 01/03/2025 admission Minimum Data Set (MDS - an assessment tool), showed the resident's goal was to discharge to the community. According to this MDS, active discharge planning was no occurring for the resident to return to the community. Resident 4's Comprehensive Care Plan (CCC) initiated on 12/27/2024 showed no Discharge Care Plan. Review of the Social Services (SS) Psychosocial Evaluation, dated 01/03/2025, showed Resident 4 declined to respond to the questions related to their prior living arrangements and discharge goals. Review of a Social Services note, dated 12/30/2025, showed the Social Services Assistant (SSA) spoke with resident's stepdaughter in Hawaii about possible discharge to…

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

Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided drinks, including water and other liquids consistent with residents needs and preferences and sufficient to maintain resident hydration for 11 of 13 sampled residents (Residents 5, 4, 6, 7, 9, 10, 11, 15, 12, 13, & 14). Failure of the facility to ensure water pitchers at bedside, placed residents at risk of thirst and insufficient fluid intake. Findings included . The following Resident rooms were observed on 03/11/2025 at 12:25 PM without a water pitcher at bedside: 105 A, 105 B, 106 A, 107 A, 107 B, 204 B, 206 A, 206 B, 207 B, 302 B, 304 B, 401 B, 402 B, 403 A, 403 B, 404 B, 405 A, 407 B, 412 B, 413 A, 413 B. Rooms 309 A and 309 B were observed with empty pitchers at the bedsides. <Resident 5> On 03/11/2025 at 12:11 PM, Resident 5 was observed in bed without a water pitcher at bedside. Review of Resident 5's Care Plan showed a 02/24/2025 intervention to offer fluids at bedside and every meal to maintain hydration. <Resident 4> On 03/11/2025 at 12:16 PM,…

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 activities of daily living (ADLs) pertaining to bathing/showers were provided for dependent residents for 2 of 4 sample residents (Residents 1 & 5) 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 . On 03/11/2025 at 11:55 AM, Resident 1 and Resident 5 were observed in a room with a posted sign Resident Care Manager. Both the Resident's names were listed by the door. There was not a room number posted, as there was with other resident's rooms. Review of the census showed Resident 1 and Resident 5 resided in room [ROOM NUMBER]. <Resident 1> Review of the 02/26/2025 admission Minimum Data Set (MDS - an assessment tool), Resident 1 admitted to the facility on [DATE], were alert and oriented, felt it was very important to choose between a tub bath, shower, bed bath, or sponge bath, and…

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

Based on observation, interview and record review, the facility failed to provide food at appetizing temperatures when reviewed for kitchen services. This failure placed residents at risk of lowered nutritional intake, potential weight loss, and a diminished quality of life. Findings included . During an interview on 09/30/2024 at 11:49 AM, Resident 44 expressed dissatisfaction with the facility food temperatures stating they had received cold eggs. During an interview on 09/30/2024 at 9:57 AM, Resident 35 stated hot items were not hot enough a couple of times a week and foods that were supposed to be cold came at room temperature. Observation of the lunch tray preparation service on 10/07/2024 between 10:56 AM and 1:04 PM showed Staff U, Cook, taking the temperature of all prepared foods while on the steam table. All foods on the steam table were covered with foil, Staff U poked a hole through the foil of each entrée and side dish and documented the temperatures. Observation on 10/07/2024 at 11:34 AM showed Staff X, Dietary Aide, cutting and scooping watermelon into individual…

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

Based on interview and record review, the facility failed to follow-up on concerns of the resident council related to resident care for 1 of 2 resident council meeting minutes (September 2024) when reviewed for resident council. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the resident council minutes dated September 18, 2024, showed concerns voiced by members regarding missing items related to laundry, loud talking during sleep hours, long call light wait times and staff entering resident rooms and turning off the call light without assisting the resident. Review of the Grievance Log dated 03/2024 through 09/2024, showed no grievances that corresponded with the concerns verbalized at resident council meetings. During an interview on 03/13/2024 at 1:18 PM, Staff P, Recreation Assistant, stated when residents voiced a concern it was documented on a grievance form and given to the Administrator to follow-up. Staff P stated they did not know what happened after the grievance was given to the Administrator but…

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 residents with access to their funds on the weekends for 1 of 1 sampled resident (Resident 10) reviewed for personal funds. This failure placed the residents at risk for unmet financial needs and a diminished quality of life. Findings included . Resident 10 was admitted to the facility on [DATE]. Review of the electronic health record showed that the resident was rarely understood. During an interview on 09/30/2024 at 11:51 AM, Collateral Contact 1, stated the facility held Resident 10's money in a trust. During an interview on 10/07/2024 at 10:11 AM, Staff Q, Business Office Manager, confirmed Resident 10 had funds held by the facility and stated residents currently had access to funds between 8:00 AM and 4:30 PM Monday through Friday. Observation of general environment did not show information was posted informing residents that money was available after business hours. Reference WAC 388-97-0340 (1)(2)(3) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to ensure quarterly personal fund statements were provided to residents with personal fund accounts for 1 of 1 sampled resident (Residents 10) reviewed for personal funds. This failure placed residents at risk of not having an accurate accounting of their personal funds held in a trust account by the facility. Findings included . Resident 10 was admitted to the facility on [DATE]. Review of the electronic health record showed that the resident was rarely understood. During an interview on 09/30/2024 at 11:51 AM, Collateral Contact 1, stated the facility held Resident 10's money in a trust; however, they did not know how much money they had because they never received statements. During an interview on 10/07/2024 at 10:11 AM, Staff Q, Business Office Manager, stated they were supposed to provide residents with personal fund statements at the beginning of the month. Staff Q stated they could not recall when statements were last provided as they were new…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to maintain the plumbing system, provide a clean and sanitary environment and provide adequate housekeeping for 4 of 4 halls (100, 200, 300, and 400-hall) reviewed for physical environment. This failure allowed residents to live in unsanitary conditions and placed residents at risk of infection and an undignified existence. Findings included . <Bathrooms (BR)> Observation on 09/30/2024 at 9:51 AM, showed room [ROOM NUMBER]/409's BR's toilet had a ring of brown matter stained around the toilet bowl and an empty urine collection cup was on the floor. [NAME] matter was observed to be located on the edge of the toilet seat cover. At 12:54 PM, room [ROOM NUMBER]/409's BR was observed to be cleaned; however, there was broken tile to the right of the toilet where the handrail connected to the floor and there continued to be a urine collection cup on the floor. Observation on 09/30/2024 at 11:45 AM, showed room [ROOM NUMBER] had broken and missing…

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/or implement a comprehensive and person-centered care plans for 3 of 17 sampled residents (Residents 309, 20 and 39) reviewed for care plans. This failure placed residents at risk for unmet needs, inadequate care and a decreased quality of life. Findings included . Resident 309 Review of the electronic health record (EHR) showed Resident 309 admitted to the facility on [DATE] with diagnoses to include fracture of left femur (thigh bone), diabetes, and muscle weakness. Resident 309 required substantial/maximal assistance with lower body dressing. Review of the care plan, dated 09/12/2024, showed Resident 309 had potential for impairment to skin integrity related to fragile skin, impaired mobility, incontinence, and malnutrition. An intervention showed, Heel Protector Boots, the resident needs assistance to apply protective garments bunny boots. Observations throughout the day on 10/01/2024, 10/02/2024, 10/07/2024 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to revise and update the care plan for 2 of 17 sampled residents (Resident 1 and 30) reviewed for care plans and conduct a care conference for 1 of 3 sampled residents (Resident 209) reviewed for care planning. These failures placed the residents at risk for injury, medical complications, unmet care needs and diminished quality of life. Findings included . Resident 1 Review of the electronic health record (EHR) showed Resident 1 admitted to the facility on [DATE] with diagnoses to include vascular dementia (problems with reasoning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain) and absence of larynx (voice box). Resident 1 was able to make needs known. Review of Resident 1's care plan, initiated 07/23/2024, showed a goal The resident will not sustain injury from falls. Interventions included Review and update fall risk assessment quarterly, post any fall and as needed. Review of the September…

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 Resident 44 Review of the EHR showed Resident 44 admitted to the facility on [DATE] with diagnoses that included diabetes, depression, cocaine dependency and was able to make needs known. During an interview on 09/30/2024 at 11:32 AM, Resident 44 stated they were taking medications that caused constipation. Review of Resident 44's EHR showed no bowel movements documented for the dates: 09/15/2024, 09/16/2024, 09/17/2024, 09/21/2024, 09/22/2024, 09/23/2024, 09/24/2024, 09/29/2024, 09/30/2024, 10/01/2024, 10/02/2024, and 10/03/2024. Review of the medication administration record (MAR) showed no administration of as needed laxatives for the month of September 2024 until October 04, 2024. During an interview on 10/07/2024 at 9:20 AM, Staff F, Licensed Practical Nurse, stated when a resident did not have a bowel movement for three days, the system would notify the nurses to initiate bowel protocol for constipation. During an interview on 10/08/2024 at 10:30 AM, Staff B, Regional Nurse Consultant, stated 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 Resident 24 Review of the EHR showed Resident 24 admitted to the facility on [DATE] with diagnoses that included high blood pressure, intervertebral disc degeneration (a condition that occurs when the discs between the bones in the spine wear down) of the lumbar region (lower back), and was able to make needs known. Review of Resident 24's provider's orders showed an order dated 07/15/2024 for oxycodone (used to treat moderate to severe pain) give 10 milligrams (mg) every eight hours as needed for pain level of 7-10 (0 = no pain and 10 = worst pain felt). It further showed to provide non-pharmacological interventions prior to administration of the medication. Review of September 2024 MAR showed Resident 24 received oxycodone 10 mg for a pain level of 5 (outside of the ordered pain level parameters) on 09/16/2024 and 09/27/2024. It showed Resident 24 received oxycodone 10 mg for pain on 09/26/2024 and 09/27/2024; however, NA (not applicable) was documented for non-pharmacological interventions. Review of October…

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 prepare/provide the menu items included in regular or therapeutic diets for all facility residents provided meal service to meet the required nutriative value for each meal. This failure placed residents at risk for medical complications or nutritional deficits. Findings included . Review of lunch menu for 10/07/2024 showed the residents on Regular diets were to receive 3 ounces (oz) of glazed baked ham,1/2 cup of maple roasted sweet potatoes, 1/2 cup of spinach, 1 white roll and 1 slice of chocolate chess pie. The alternative lunch menu included a buffalo chicken sandwich, macaroni and cheese, green beans, a white roll and a slice of chocolate chess pie. Review of the lunch extension menu showed Controlled Carbohydrate diets and Soft and Bite Sized and Puree diets were to receive 4 oz of glazed baked ham, 1/2 cup of glazed baby carrots, 1/2 cup of spinach and 1 slice of chocolate chess pie. Observation on 10/07/2024 at 12:00 PM showed no white rolls or glazed baby carrots were prepared for meal service.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of adverse side effects and antibiotic resistance for 1 of 2 residents (Residents 20) and the facility failed to complete tracking and trending and report to the Quality Assurance and Performance Improvement program (QAPI) for 3 of 3 months (June, July, and August 2024) when reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics. Findings included . Review of the facility policy titled Infection Prevention and Control, Antibiotic Stewardship revised 03/2019 showed If antibiotic therapy is initiated prior to diagnostic testing, the prescriber will be notified when the result of the diagnostic testing is received. If needed, adjustments to the ordered antibiotic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to offer, educate, and obtain consent for influenza and/or pneumococcal vaccines for 2 of 5 sampled residents (Residents 18 and 50) reviewed for influenza and pneumococcal immunizations. These failures denied residents the opportunity to make an informed decision regarding receiving immunizations and/or placed the residents at risk for communicable diseases, complications of other medical conditions, and a decreased quality of life. Findings included . Resident 18 Review of the electronic health record showed Resident 18 admitted to the facility on [DATE] with diagnoses of heart failure, kidney disease and diabetes. The resident was able to make needs known. Review of the immunization record showed the resident refused the influenza and pneumococcal vaccinations. Further review showed no documentation that the resident was educated on the risks and benefits of the vaccines prior to offering them. Resident 50 Review of the EHR showed Resident 50 admitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to offer, educate, and obtain consent for Covid-19 vaccines for 2 of 5 sampled residents (Residents 18 and 50) reviewed for immunizations. This failure denied the residents the opportunity to make an informed decision regarding receiving immunizations and/or placed the residents at risk for communicable diseases, complications and a decreased quality of life. Findings included . Resident 18 Review of the electronic health record (EHR) showed Resident 18 admitted to the facility on [DATE] with diagnosis of heart failure, kidney disease and diabetes. The resident was able to make needs known. Review of the immunization record showed the resident refused the COVID vaccination. Further review showed no documentation that the resident was provided education on the risks and benefits of the vaccine prior to offering them. Resident 50 Review of the EHR showed Resident 50 admitted to the facility on [DATE] with diagnoses of acute kidney failure and morbid…

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 residents had a dignified dining experience by failing to provide non-disposable cups with meals for 4 or 4 sampled halls (100, 200, 300, and 400-halls) when reviewed for dining. This failure placed residents at risk for feelings of a worthlessness and a diminished quality of life. Findings included . Observation on 09/30/2024 at 12:35 PM showed staff on the 100-hall pouring juice and milk into plastic cups for all residents on the hall who received beverages. Observation on 10/08/2024 at 8:06 AM showed staff on the 400-hall pouring juice and milk into plastic cups for all residents on the hall who received beverages. Observation on 10/08/2024 8:08 AM showed staff on the 300-hall pouring juice and milk into plastic cups for all residents on the hall who received beverages. Observation on 10/08/2024 at 8:16 AM showed staff on the 200-hall pouring juice and milk into plastic cups for all residents on the hall who received beverages. During an interview on 10/08/2024 at 8:09 AM, Staff O, Certified Nursing Assistant…

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 honor a resident's right to choose the level of life saving interventions for 1 of 3 sampled residents (Resident 39) when reviewed for choices. This failure placed residents at risk for not being able to choose lifesaving treatment options, decreased autonomy, and death. Findings included . Review of the electronic health record (EHR) showed Resident 39 admitted to the facility on [DATE] with diagnoses of pulmonary emboli (blood clots in the lung), schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors) and anxiety. Review of a provider note, dated [DATE], showed Due to the fact that [the resident] is unable to make complex decisions for [themself] a discussion was had with a antiques community and given the lack of ability to make a decision about their care with regards to CPR and intubation and refusing treatment and recommendation was made to transition [them] to a DNR/DNI [do not resuscitate/do 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 interview and record review, the facility failed to initiate and resolve a grievance for 1 of 4 sampled residents (Resident 46) reviewed for personal property. This failure placed the resident at risk for feelings of frustration and a diminished quality of life. Findings included . Review of the electronic health record showed Resident 46 admitted to the facility on [DATE] with a diagnosis of osteomyelitis (a bone infection) and diabetes. Resident 46 was able to make needs known. During an interview on 10/01/2024 at 9:23 AM, Resident 46 stated their black pajama bottoms had been missing for approximately three weeks. Resident 46 stated they had informed Staff R, Housekeeping Manager, but had never received any follow-up. Review of the document titled Grievance Log dated 03/2024 through 09/2024 showed no grievance related to Resident 46's missing property. During an interview on 10/02/2024 at 11:11 AM, Staff R, Housekeeping Manager, stated they informed Resident 46 that the pajama bottoms may have been…

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 written notification of the reason for transfer to the hospital to a resident or responsible party for 1 of 4 sampled residents (Resident 17) reviewed for hospitalization. This failure placed the resident at risk for not knowing rights regarding transfer and discharge from the facility and diminished protection from been inappropriately discharged . Findings included . Review of the electronic health record (EHR) showed Resident 17 admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure) and chronic embolism (a condition in which a blood clot is over one to two months old and has scarred the vein effecting blood flow). Resident 17 was able to make needs known. Review of Resident 17's EHR showed a discharge with anticipated return on 08/16/2024, and readmission to the facility on [DATE]. There was no documentation showing the resident was provided a written notice for reason of transfer. During an…

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 a bed hold notice at the time of transfer to the hospital for 2 of 4 sampled residents (Residents 17 and 109) reviewed for hospitalization. This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life. Findings included . Resident 17 Review of the electronic health record (EHR) showed Resident 17 admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure) and chronic embolism (condition in which a blood clot is over one to two months old and has scarred the vein effecting blood flow. Resident 17 was able to make needs known. Review of Resident 17's EHR showed a hospitalization on 08/16/2024, and readmission to the facility on [DATE]. There was no documentation related to the resident being offered a bed hold. During an interview on 10/07/2024 at 10:29 AM, Staff C, Social Services Director, stated when a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to accurately assess 1 of 3 sampled residents (Residents 55) when reviewed for accidents. Failure to ensure an assessment accurately reflected Resident 55's smoking status placed the resident at risk for having inaccurate data in their medical records, unmet needs, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 55 admitted to the facility on [DATE] with diagnoses that included stroke, heart failure, respiratory failure, and was able to make needs known. The admission minimum data set assessment (MDS), dated [DATE], showed that Resident 55 received oxygen therapy and had no current tobacco use. During an interview on 09/30/2024 at 10:45 AM, Resident 55 stated they smoked outside in the smoking area at designated times while staff supervised. Observation on 10/02/2024 at 9:02 AM showed Resident 55 sat outside in the courtyard smoking while being supervised by a staff member.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to obtain an updated preadmission screening and resident review (PASRR, a mental health screening tool) when a new diagnosis of significant mental illness was identified for 1 of 2 residents (Resident 16) reviewed for PASRR. This failure placed the resident at risk for unmet care needs and a decreased quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 16 admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (a disease of the lungs that makes it difficult to breath). Review of the admission level one PASRR, dated 10/20/2022, showed no significant mental illness (SMI) and the resident did not require further assessment. Review of Resident 16's most recent PASRR, dated 10/18/2023, showed no SMI and the resident did not require further assessment. No other PASRR forms were in the medical record. Review of the EHR showed Resident 16 received a new diagnosis of major…

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 Resident 39 Review of the EHR showed Resident 39 admitted to the facility on [DATE] with diagnoses of schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors) and anxiety. Review of Resident 39's most recent PASRR showed it was not signed or dated. During an interview on 10/02/2024 at 9:20 AM, Staff C, SSD, stated Resident 39's PASRR should have been reviewed, signed and dated. Reference WAC 388-97-1915 (1)(2)(a-c) Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR, a mental health support screening tool) assessments were accurately completed for 2 of 5 sampled residents (Residents 46 and 39) reviewed for PASRRs. This failure placed the residents at risk for unidentified mental health care needs and diminished quality of life. Findings included . Resident 46 Review of the electronic health record (EHR) showed Resident 46 admitted to the facility on [DATE] with diagnoses of osteomyelitis (a bone…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to provide the necessary assistance for activities of daily living (ADL) for dependent residents related to dressing and nail care for 2 of 4 sampled residents (Residents 309 and 39) reviews for ADLs. This failure placed the residents at risk for poor hygiene, decreased self-esteem, and a diminished quality of life. Findings included . Review of the facility policy titled Activities of Daily Living (ADLs)/Maintain Abilities, dated 11/2017, showed A resident is given appropriate treatment and services to maintain or improve his/her ability to carry out the activities of daily living, including- Hygiene - bathing, grooming, dressing and oral care. It further showed The decision to refuse care and treatment is documented in the medical record. Documentation includes interventions identified on the care plan and in place to minimize or decrease functional loss that were refused by the resident or resident representative. Documentation includes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to implement individualized activities for 1 of 1 sampled resident (Residents 309) reviewed for activities. The failure to implement an activity plan of care that incorporated resident's stated interests, hobbies and preferences, placed the residents at risk for boredom, isolation, and a diminished quality of life. Findings included . Review of the electronic health record showed Resident 309 admitted to the facility on [DATE] with diagnoses to include fracture of left femur (thigh bone), diabetes and muscle weakness. Resident 309 was able to make needs known. During an interview on 09/30/2024 at 10:03 AM, Resident 309 stated, I want to get up and get dressed, but no one gets me out of bed, and I can't do it by myself and My TV doesn't work so I can't watch TV. Observations throughout the day on 10/01/2024, 10/02/2024, 10/07/2024 and 10/08/2024 showed Resident 309 laid in bed wearing a facility issued night gown. Resident 309 was looking 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to thoroughly assess, document, care plan necessary interventions, and monitor pressure ulcers for 1 of 1 sampled resident (Resident 209) reviewed for pressure ulcers. These failures placed the resident at risk for unmet needed treatment and services. Findings included . Review of the admission evaluation dated 09/24/2024 showed that Resident 209 admitted to the facility on [DATE] with diagnoses that included diabetes (a condition resulting in high blood sugar levels), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), pressure ulcer (PU, skin injury resulting from prolonged pressure on the skin) of the sacral region (portion of the spine between the lower back and tailbone), and pressure ulcer of the right and left buttock, and was able to make needs known. It showed skin observations included a deep tissue injury (DTI), dark blue-purple non-blanching, to the sacrum (lower back/tailbone…

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 and services were provided for 2 of 3 sampled residents (Resident 27 and 30) when reviewed for range of motion (ROM)/mobility. This failure placed the residents at risk for worsening mobility, developing of contractures (permanent tightening of muscle, tendons and skin, leading to deformity), and diminished quality of life. Findings included . Resident 27 Review of Resident 27's quarterly minimum data set assessment (MDS) dated [DATE], showed the resident admitted to the facility on [DATE] with diagnoses to include anxiety, depression, spinal cord injury with paralysis (the loss of the ability to move some or all the body) to all four extremities (legs/feet and arms/hands). Resident 27 was able to make needs known and was dependent on staff for mobility and care needs. During an interview on 10/09/2024 at 10:45 AM, Resident 27 stated they used to get some restorative passive range of motion (PROM, external force/moving a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to implement an identified intervention related to falls for 1 of 3 sampled residents (Resident 1) reviewed for accidents. This failure placed the resident at risk for major injury and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 1 admitted to the facility on [DATE] with diagnoses to include vascular dementia (problems with reasoning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain) and absence of larynx (voice box). Resident 1 was able to make needs known. Review of the care plan initiated 07/23/2024 showed a goal The resident will not sustain injury from falls with an intervention Review and update fall risk assessment quarterly, post any fall and as needed. Review of the September 2024 document titled Incident Log showed Resident 1 had a fall on 09/06/2024. Review of the incident report dated 09/03/2024 identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview, and record review, the facility failed to implement fluid restrictions (limits the amount of fluids a person can consume through food and drink), accurately monitor and document weights, and obtain ordered labs for 1 of 3 sampled residents (Resident 209) reviewed for nutrition. These failures placed the resident at risk for medical complications, unmet needs, and a diminished quality of life. Findings included . Review of the Electronic Heath Record (EHR) showed Resident 209 admitted to the facility on [DATE] with diagnoses to include diabetes (a condition resulting in high blood sugar levels), dysphagia (difficulty swallowing), hyperkalemia (a condition where there is too much potassium, a mineral/electrolyte that helps muscles and nerves function, in the blood), and chronic (persistent/long lasting) kidney disease. Resident 209 was able to make needs known. During an interview and observation on 09/30/2024 at 2:57 PM, Resident 209 stated they thought they were on a diabetic…

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 respiratory care consistent with professional standards of practice for 2 of 4 sampled residents (Residents 209 and 55) reviewed for respiratory care. Failure to obtain and/or follow provider's orders, accurately document oxygen (O2) therapy, and care plan for O2 therapy placed residents at risk for unmet needs and potential negative outcomes. Findings included . Review of the electronic health record (EHR) showed Resident 209 admitted to the facility on [DATE] with diagnoses to include acute (severe and sudden onset) respiratory failure with hypoxia (an absence of enough oxygen), chronic (persistent/long lasting) kidney disease, diabetes (a condition resulting in high blood sugar levels), and was able to make needs known. Observation on 09/30/2024 at 9:41 AM, showed Resident 209 was receiving O2 set to two liters (L) per minute via a nasal canula (devise to deliver O2 through a tube into the nose) that was connected to an O2…

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 act on the consultant pharmacist's medication regimen review (MRR) recommendations in a timely manner for 1 of 5 sampled residents (Resident 24) reviewed for unnecessary medication use. Failure to act timely on the pharmacist's recommendations placed the resident at risk for experiencing adverse side effects, medical complications, and a decreased quality of life. Findings included . Review of Resident 24's electronic health record (EHR) showed the resident admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (blocks airflow making it difficult to breathe), high blood pressure, intervertebral disc degeneration (a condition that occurs when the discs between the bones in the spine wear down) of the lumbar region (lower back), and was able to make needs known. Review of Resident 24's MRR dated 09/18/2024 showed that the following irregularity was noted on Resident 24's electronic medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to conduct abnormal involuntary movement scale (AIMS, an assessment with a rating scale to measure involuntary movements) related to antipsychotic medication for 1 of 5 sampled residents (Resident 17) reviewed for unnecessary medication. This failure placed the resident at risk for adverse side effects, medical complications, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 17 admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure) and chronic embolism (condition in which a blood clot is over one to two months old and has scarred the vein effecting blood flow). Resident 17 was able to make needs known. Review of the EHR showed an order for Seroquel (an antipsychotic) to be given 25 milligrams by mouth one time a day at bedtime. Review of the August 2024 and September 2024 medication administration record (MAR) showed Resident 17 received the…

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

Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in 1 of 2 medication carts (100 hall) when reviewed for medication storage. This failure placed residents at risk for receiving expired medications, ineffective treatment, and diminished quality of life. Findings included . Observation of 100-hall medication cart on 10/08/2024 at 9:56 AM with Staff K, Licensed Practical Nurse (LPN), showed artificial tears eye drops without expiration date, Vitamin D3 125 mcg expired on 9/2024, glargine insulin with open date of 08/29/2024 (expired), Lispro insulin without open date, and aspirin 81mg expired on 8/2024. During an interview on 10/08/2024 at 10:00 AM, Staff K, LPN, stated the medications should be dated when opened and should be monitored for expiration dates and discarded. During an interview on 10/08/2024 at 10:32 AM, Staff B, Regional Nurse Consultant, stated the medication storage in the 100-hall medication cart did not meet expectations. Reference WAC 388-97-1300(2) .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to assist with scheduling a dental appointment and address dental needs for 1 of 3 sampled residents (Resident 30) reviewed for dental services. This failure placed the resident at risk for continued dental problems, unmet needs, and diminished quality of life. Findings Included . Review of Resident 30's annual minimum data set assessment (MDS) dated [DATE] showed the resident readmitted to the facility on [DATE] with diagnoses to include anxiety, depression, and incomplete paraplegia (partial loss of function in lower body). Resident 30 was able to make needs known. During an interview on 09/30/2024 at 12:23 PM, Resident 30 stated they had requested to see a dentist because the filling fell out of their bottom right tooth, and they had to chew food on the left side of their mouth. Resident 30 stated that a nurse told them that they had put in for a doctor's referral to see a dentist. Review of Resident 30's electronic health record (EHR) showed no care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review the facility failed to provide necessary care and services to maintain the highest practicable mental and psychosocial well-being for one of three residents (Resident 1) reviewed for quality of care. This failure placed residents at risk of unmet needs and decreased quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with multiple diagnoses, including quadriplegia (paralysis that affects all limbs and body from the neck down) and depression. The Minimum Data Set assessment, dated 12/31/2023, documented Resident 1 was alert and oriented, directed their own care, and was dependent upon staff for bed mobility, transfers and activities of daily living. A 12/05/2023 2:01 PM nursing note by Staff B, a Registered Nurse and the previous Director of Nursing Services, documented a resident-to-resident incident where Resident 1 drove their power wheelchair toward another resident and hit their chair. The note documented Resident 1 was put on alert to…

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

Based on interview and record review, the facility failed to resolve grievances originating in the resident council for 3 of 3 months (July, August, and October 2023) when reviewed for Resident Council. This failure placed residents at risk of lacking the ability to have general facility grievances resolved, lack of input into facility operation, and a diminished quality of life. Findings included . During an interview on 11/08/2023 at 11:20 AM, the resident council stated that the facility did not resolve grievances aired in the resident council and nothing gets done month to month. The resident council further stated that the current unresolved grievances were shortened smoking times, lack of access to a vending machine, and the facility's front door automatic opener being broken. Review of the resident council's minutes from July 2023 showed no resolution of the previous resident council meeting's grievances. Further review showed grievances related to dietary services, social services, and activities. Review of the facility's grievance log for July 2023 showed no grievances for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain resident doors and bathrooms in a homelike manner for 3 of 4 halls (Halls 100, 200, and 300) when reviewed for Homelike Environment. This failure placed residents at risk of depressed mood, feelings of worthlessness, and a diminished quality of life. Findings included . During an interview on 11/06/2023 at 9:23 AM, Resident 16 stated that their bathroom had missing linoleum at the base of the toilet and the toilet was loose. Observation on 11/08/2023 showed the shared bathroom in room [ROOM NUMBER] with cracked linoleum at the base of the toilet revealing the bare floor beneath. Further observation showed that the toilet chamber lid was not the same size as the toilet chamber and rattled when the toilet was touched. Observation on 11/08/2023 showed the shared bathroom in room [ROOM NUMBER] with a single bolt attaching it to the floor and was able to be pushed over from one side. Further observation showed that the linoleum at the base of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident 50 Review of Resident 50's Electronic Health Record (EHR) showed they admitted to the facility on [DATE] with diagnoses including congestive heart failure, acute and chronic respiratory failure with hypoxia (low oxygen levels), and edema (buildup of fluid under skin), Review of Resident 50's admission MDS assessment dated [DATE] showed the facility identified the diagnosis of heart failure, respiratory failure, supplemental oxygen use, and localized edema. Review on 11/06/2023 at 3:55 PM of Resident 50's active care plan showed no plan of care for heart failure, respiratory failure, oxygen, or edema. During an interview on 11/07/2023 at 11:19 AM, Staff G, RCM, stated that Resident 50 did not have a plan of care for heart failure, respiratory failure, oxygen, or edema but should have. During an interview on 11/07/2023 at 1:26 PM, Staff B, DNS, stated that the comprehensive care plan should include the resident's diagnoses that were identified during the comprehensive assessment and this did not happen…

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 timely act on the consultant pharmacist's Medication Regimen Review (MRR) recommendations for 2 of 5 residents (Residents 2 and 10) reviewed for unnecessary medication use. Failure to act on the pharmacist's recommendations timely placed the residents at risk for experiencing adverse side effects, medical complications, and a decreased quality of life. Findings included . Review of a policy titled, Psychoactive Medication Management Guideline, dated 08/25/2020, showed that resident would have reviews as indicated by the interdisciplinary team (IDT) and pharmacist. Review of a document titled, Antipsychotic Medication Use, dated July 2022, showed that the physician would respond appropriately by changing or stopping problematic doses or medications or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. Resident 2 Review of Resident 2's MRR documentation showed that the consulting pharmacist had documented a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident 10 Review of Resident 10's EHR showed the resident admitted on [DATE] with orders for oxycodone to be given PRN every six hours. Further review showed the resident received a dose 15 times in the month of October 2023 and there was no documentation found in the resident's medical record that non-pharmacological interventions for pain were attempted prior to administering the pain medication. During an interview on 11/09/2023 at 8:50 AM, Staff B, DNS, stated that non-pharmacological interventions should have been attempted prior to administering pain medications for Resident 10 but were not. Reference WAC 388-97-1060 (3)(k)(i) Based on interview and record review, the facility failed to provide non-pharmacological (non-medication) interventions prior to the use of as needed pain medications for 2 of 6 residents (Residents 44 and 10) reviewed for unnecessary medications. This failure placed residents at risk of taking unnecessary medications, avoidable medication side effects, and a diminished quality 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 Resident 46 Observation on 11/06/2023, 11/07/2023, and 11/08/2023 showed Resident 46 laid in bed with the light off and bed covers over their head. Review of Resident 46's medication list on 11/08/2023 showed that they received antidepressants for major depressive disorder (MDD). Review of Resident 46's 07/25/2023 initiated care plan showed a focus area related to MDD to include behavior monitoring and non-pharmacological interventions. Review of Resident 46's EHR on 11/07/2023 showed that they did not have a behavior monitor or non-pharmacological interventions. During an interview on 11/08/2023 at 12:29 PM, Staff G, RCM, stated that the facility would track resident behaviors and provide non-pharmacological interventions through the EHR. Staff G further stated that Resident 46 did not have a BMR, they did not receive non-pharmacological interventions, and that this did not meet expectation. During an interview on 11/08/2023 at 12:47 PM, Staff B, DNS, stated that the facility tracked behaviors and provided…

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 maintain the medication refrigerator temperature log in 1 of 1 medication room reviewed for medication storage. This failure placed the residents at risk for receiving compromised or ineffective medications. Findings included . Review of the facility's policy titled Storage of Medication, revision dated 2007, showed that medications requiring refrigeration were kept in a refrigerator with a thermometer to allow temperature monitoring. It further showed that a temperature log or tracking mechanism was to be maintained to verify that temperatures remained within accepted limits and the temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily. Observation on 11/07/2023 at 4:34 PM with Staff B, Director of Nursing Services (DNS), of the medication room refrigerator containing various vaccines showed the November 2023 refrigerator temperature log with temperatures being logged once a day from 11/01/2023 through 11/07/2023. Review of the August, September, 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.

Resident 10 Review of Resident 10's EHR on 11/06/2023 at 8:51 PM showed an order with a start date of 03/09/2023 for trazadone (an antidepressant medication) at bedtime for a diagnosis of major depressive disorder. There was no documentation found of risks and benefits being reviewed or consent being obtained. During an interview on 11/09/2023 at 8:50 AM, Staff B, DNS, stated that the risks and benefits should have been reviewed, and consents obtained prior to administering trazadone to Resident 10. Reference WAC 388-97-0300(3)(a), -0260, -1020(4)(a-b) Based on interview and record review, the facility failed to have psychotropic (medications that affect a person's mental state) medication consents signed and in place prior to residents receiving medications for 2 of 6 residents (Residents 2 and 10) reviewed for psychotropic medications. This failure placed the residents at risk for adverse side effects and diminished quality of life. Findings included . Review of a document titled, Antipsychotic Medication Use dated July 2022 showed that residents (and/or resident representatives)…

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 a baseline care plan with goals and interventions for care within 48 hours of admission for 2 of 22 residents (Residents 1 and 50) reviewed for baseline care plans. Failure to address Resident 1's level of assistance needed for activities of daily living (ADL) and tracheostomy (a surgically created hole in the front of the neck that provides an air passage to help breath) status/care needs and Resident 50's respiratory failure, oxygen therapy and edema (swelling) placed residents at risk for unmet needs, not receiving necessary care or services, and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Plans - Baseline, revision dated December 2016 showed, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. It further showed that the Interdisciplinary Team would review the healthcare practitioner's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident 50 Observation on 11/06/2023 at 1:00 PM showed Resident 50 sat in a wheelchair at the bedside with dressings to both lower legs secured with an elastic wrap. Both feet were visible and there was a dark brown scab to the top of the left foot and both legs were swollen. Review of Resident 50's EHR showed the resident admitted on [DATE] with a diagnosis of cellulitis with edema (swelling due to infection) with a physician's order to apply an absorbent pad, cover with kerlix (gauze wrap) and secure with an ace wrap (elastic wrap) daily to the left leg and foot. Further review showed a care plan entry for cellulitis of the left lower leg with edema. The right leg edema, wound and dressing were not included in the orders or the care plan. During an interview on 11/07/2023 at 10:52 AM, Resident 50 stated they had wounds on both legs that were draining since admission and the staff had been applying bandages to both. Observation and interview on 11/08/2023 at 12:29 PM showed Resident 50 sitting at their bedside…

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 wound care was consistently conducted for 1 of 2 residents (Residents 36) reviewed for pressure related wounds. This prevented the facility from developing and implementing a plan of care that included all interventions to promote wound healing and prevent decline. Findings included . Review of the Resident 36's quarterly Minimum Data Set (MDS, a required assessment tool) dated 09/30/2023 showed that they admitted on [DATE] with a diagnosis of a pressure ulcer to the sacrum (tailbone). Review of Resident 36's physician's order dated 10/29/2023 showed that licensed nurses (LNs) were to provide wound care to Resident 36's sacrum daily and when necessary. Review of the care plan dated 01/19/2023 showed that Resident 36 had a focus area for a wound to the sacrum with interventions included to follow facility protocols for treatment of wounds and to administer treatment per provider's order. Observation and interview on 11/09/2023 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 respiratory care and services were followed according to professional standards of practice for 2 of 3 residents (Residents 257 and 50) reviewed for respiratory care. The failure to follow physician's orders for respiratory care, routinely change oxygen tubing, and initiate/implement respiratory care plans placed the residents at risk of unmet care needs, respiratory infections, and related complications. Findings included . Resident 257 Observation and interview on 11/06/2023 at 11:52 AM showed Resident 257 sat on the side of their bed with a nasal canula (tubing inserted into nose) for oxygen. The resident stated that they had trouble swallowing and often inhaled food and fluid. Also, the resident stated that they had recently been having trouble breathing. They started receiving an antibiotic, but after five days felt worse and was sent to the emergency room. They returned from the hospital and were diagnosed with sepsis (blood…

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 consistently conduct and document pre and post dialysis (the process of removing waste, salt, and extra water from the blood) assessments and ensure consistent ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 of 1 resident (Resident 21) reviewed for dialysis. This failure placed the resident at risk for unmet care needs and medical complications. Findings included . Review of a document titled, Dialysis Communication Report, undated, showed that the facility would utilize the report as a means for communicating for continuity of care between the facility and dialysis unit. Additionally, the form showed that the top portion was to be completed by the dialysis center staff and returned to the facility with the residents and any labs from the previous visit. The staff at the hemodialysis (HD) center was to document the time of the resident's arrival and departure, the residents' vital signs, and the residents' weight before and after dialysis. The document further…

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 post the actual nursing staffing hours daily. This failure prevented the residents, family members, and visitors from exercising their rights to know the actual numbers of available nursing staff in the facility. Findings included . Review of the nurse staff posting on 11/08/2023 at 9:31 AM showed that the posting for 11/07/2023 and 11/08/2023 did not include actual hours worked by nursing staff. Review of the nursing staff postings dated 10/07/2023 through 11/08/2023 showed that changes had not been made to the actual hours of nursing staff and resident census due to admissions. During an interview on 11/08/2023 at 9:36 AM, Staff C, Staffing Coordinator, stated that the expectation was that the actual hours nursing staff worked was posted. In addition, Staff C stated that they had not been posting actual hours because the facility did not have anybody to do this. During an interview on 11/08/2023 at 11:52 AM, Staff A, Administrator, stated that it was the expectation that the postings included not only 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 and interview, the facility failed to ensure all residents' beds had clean linens and mattresses were cleaned regularly for one of three residents (Resident 1) reviewed for clean, comfortable and homelike environment. This failure placed residents at risk for lack of dignity and decreased quality of life. Findings included Resident 1 Resident 1 was admitted to the facility on [DATE] with multiple diagnoses. Resident 1 was awake and alert and able to make needs known. On 11/03/2023 at 2:12 PM, when asked, Staff C, a nursing assistant, said resident's bed linens were changed and the mattresses wiped down on shower days and as needed. On 11/03/2023 at 2:24 PM, Resident 1 said sheets are not changed weekly. Resident 1 pulled back the bottom sheet on the mattress to display visible gray dusty material on the mattress surface. Resident 1 ran their hand over dusty area and dust came off onto the resident's hand. Resident 1 indicated it had been at least two weeks since the sheets had been changed…

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 impliment outbreak protocols to prevent the transmission of a communicable disease by ensuring accurate tracking of Covid-19 infections for 1 of 1 Covid-19 outbreaks, the proper application of transmission-based precautions for 4 of 7 residents (Residents 1, 3, 4, and 5 ) and to ensure the proper use and fit of personal protective equipment (PPE) by staff when reviewed for infection control. The facility also failed to notify the state licensor of a communicable disease outbreak when reviewed for infection control. These failures placed residents, visitors, and staff at risk for continued transmission/infections, related complications, and a decreased quality of life. Findings included . Review of the facility policy titled COVID-19 infection Control Manual, outbreak management checklist for Covid-19, Dated 06/01/2023, showed the facility would implement special Droplet/Contact precautions for all Covid-19 suspected/positive residents,…

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.