Avalon Healthcare - Tacoma

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were secured for one of three residents (Resident #1) observed with medications left unattended on the table in the resident's room. This failure placed the resident at risk for medication error and lost, compromised or ineffective medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a newly-admitted resident received care and treatment in accordance with professional standards of practice including assessment, basic care tasks, and pain management, for 1 of 3 residents (Resident 1) reviewed for quality of care and services. This failure resulted in the resident not having basic care needs assessed, addressed or documented upon their admission and placed the resident at risk for pain and discomfort, unmet needs, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served at a palatable temperature when reviewed for kitchen. This failure placed residents at risk of reduced nutritional intake, unintended weight loss, feelings of worthlessness, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to issue Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNF ABN: a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare. Beneficiaries may choose to continue the services but may be financially liable) and/or a Notification of Medicare (federal health insurance program for people age [AGE] or older) Non-Coverage (NOMNC- a required form notifying the resident that their skilled services coverage was ending and would no longer be covered by their Medicare A benefits) at least two calendar days before the Medicare coverage ended for 3 of 3 residents (Residents 64, 65, and 45) when reviewed for beneficiary notification. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure overbed light cords were functional or conformed with homelike standards for 4 of 4 halls (100, 200, 300, and 400 Halls) when reviewed for environment. Failure to have functional or homelike pull cords on overbed lights placed residents at risk of falling, inability to perform activities of daily living, decreased mood, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure beds against wall and low beds were not a physical restraint for 2 of 2 sampled residents (Residents 55 and 5) when reviewed for physical restraints. This failure placed residents at risk of inability to move about the facility, feelings of worthlessness, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASARR, a mental health screening tool) assessments were accurately completed for 4 of 5 sampled residents (Residents 8, 37, 2 and 21) when reviewed for PASARRs and unnecessary medications. This failure placed the residents at risk for unidentified mental health care needs. Review of a document titled, Resident Assessment (PASARR) for mental disorder (MD) and intellectual disability (ID)”, dated 08/2018, showed the PASSAR screening will be completed for each resident prior to admission. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement individualized comprehensive care plans for 3 of 19 sampled residents (Residents 36, 37, and 2) whose care plans were reviewed. Failure to develop and implement care plans that were individualized and accurately reflected resident care needs related to dementia and behavioral health placed residents at risk of unmet care needs and potential negative outcomes. Review of a facility's policy titled, Comprehensive Care Plans, dated 11/2017, showed the facility interdisciplinary team (IDT) will develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, physical, mental and psychosocial needs that are identified in the comprehensive assessment. [...]

Inspectors wroteBased on interview and record review, the facility failed to consistently provide non-pharmacological interventions for 2 of 5 sampled residents (Residents 55 and 37) when reviewed for unnecessary medications. This failure placed the residents at risk of receiving unnecessary medications, avoidable medication side effects, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance and follow up on an appointment for dental care services for 2 of 4 sampled residents (Residents 21 and 41) reviewed for dental services. This failure placed the residents at potential risk for continued dental problems and decreased quality of life.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a hot food and beverage policy to protect 2 of 3 sample residents (Resident 1 & 2) reviewed for avoidable burns. Resident 1 experienced harm when they were served hot coffee without securing the lid/top of the coffee cup in a closed or locked position which spilled in their lap resulting in a second-degree burn (involves the first two layers of skin, may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin). Resident 2 experienced harm when they were served hot soup without being temperature checked which spilled in their lap resulting in second-degree burns to their thighs and groin. This failed practice placed residents at risk for accidents and injuries.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteResident 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. [...]

Inspectors wroteResident 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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 .

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteResident 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteResident 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. [...]

Inspectors wroteBased 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.

Inspectors wroteResident 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. [...]

Inspectors wroteResident 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. [...]

Inspectors wroteBased 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.

Inspectors wroteResident 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. [...]

Inspectors wroteBased 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.

Inspectors wroteResident 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold notice in writing at the time of transfer to the hospital or within 24 hours of transfer to the hospital for 3 of 3 residents (Residents 16, 22 and 257) 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.

Inspectors wroteBased on interview and record review, the facility failed to explain the arbitration agreement in a form and manner that residents understood for 3 of 3 residents (Residents 16, 48, and 207) reviewed for arbitration agreement. This failure placed residents at risk of lacking understanding of the legal document signed, forfeiture of the right to trial, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility's arbitration agreement failed to include a provision for the selection of a venue that was convenient to both parties. This failure placed residents at risk of not being able to conduct an arbitration, lack of legal rights, and a diminished quality of life.

Inspectors wroteBased 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.

Inspectors wroteBased 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.