Avamere at Pacific Ridge

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently maintain the medication refrigerator temperature logs in 2 of 2 medication rooms (The 100/200 hall and 300/400 hall medication rooms) reviewed for medication storage. This failure placed the residents at risk for receiving compromised or ineffective medications.

Inspectors wroteBased on interview and record review, the facility failed to consistently monitor potential adverse side effects (ASE) related to the use of psychoactive (affecting the mind) medications for 4 of 5 sampled residents (Residents 2, 11, 14, and 69) when reviewed for unnecessary medication use. Failure to have adequate indications or diagnosis for psychoactive medication use for Resident 2, consistent orthostatic blood pressure monitoring for Resident 11, and to conduct/obtain abnormal involuntary movement scale (AIMS) assessment for the use of an antipsychotic medication (a psychoactive medication that affects a person's mental status) for Residents 14 and 69, placed residents at risk of medical complications, unidentified presence and severity of AIM ASE, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure sharps containers (containers to safely store used sharp, medical equipment, e.g. used needles) were regularly emptied and sharps were inaccessible to residents for 2 of 4 sampled sharps containers (200 and 300 hall) reviewed for accident hazards. This failure placed residents at risk of access to used medical equipment, transmission of dangerous infections, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to consistently provide non-pharmacological interventions (NPI, health interventions/approaches used instead of medication) for 2 of 5 sampled residents (Residents 11 and 14) 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 interview and record review, the facility failed to offer and educate for influenza and pneumococcal vaccines for 2 of 5 sampled residents (Residents 21 and 10) 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, hospitalization, and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure Covid-19 (a highly infectious respiratory illness caused by a virus) vaccinations had documented evidence in the medical record that education was provided regarding the benefits and potential side effects of the COVID-19 vaccine for 2 of 5 sampled residents (Residents 10 and 7) reviewed for Covid-19 vaccinations. There was no documented evidence that the resident/representative received education and accepted or refused the vaccine. These failures denied the resident/representative the right to make informed decisions and placed residents at risk for adverse health effects of a communicable disease.

Inspectors wroteBased on interview and record review, the facility failed to inform residents of their right to formulate an advanced directive and failed to periodically review residents' decision to formulate an advanced directive for 2 of 3 sampled residents (Residents 57 and 63) reviewed for advanced directives. This failure placed residents at risk of lacking the ability to appoint someone to make decisions for them when incapacitated and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, homelike environment for 2 of 17 sampled residents (Residents 10 and 48) reviewed for safe/homelike environment. The facility's failure to ensure Resident 10's damaged wall was repaired and Resident 48's room contained cleanable surfaces placed residents at risk of decreased mood, infection, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to initiate, investigate, and resolve a grievance for 1 of 3 sampled residents (Resident 50) reviewed for personal property and grievances. This failure placed the residents at risk for emotional distress and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure injuries of unknown sources were reported to the State Hotline for 1 of 2 sampled residents (Resident 42) when reviewed for abuse. This failure placed residents at risk for potential abuse/neglect and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate the potential for abuse and/or neglect for 1 of 2 sampled residents (Resident 42) reviewed for abuse and neglect. This failure placed Resident 9 at risk for psychosocial harm and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received a transfer/discharge notice and/or offered a bed hold for 2 of 3 sampled residents (Residents 6 and 12) reviewed for discharge/hospitalization. This failure placed residents at risk of not understanding their reason for transfer, inability to return to their room, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive assessment was accurate for dental conditions or skin conditions for 2 of 17 sampled residents (Residents 35 and 3) reviewed for accuracy of the comprehensive assessment. These failures placed residents at risk of unidentified needs, risk of inadequate plan of care, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident care plans were comprehensively completed to include resident participation for 2 of 17 sampled residents (Residents 12 and 50) when reviewed for care plans. This failure placed residents at risk of not having their input considered in their plan of care, lack of treatments, a decline in clinical condition, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were assessed for hearing needs, obtained needed hearing devices, and hearing devices used were included in plans of care for 1 of 2 sampled residents (Resident 35) reviewed for communication/sensory. This failure placed the residents at risk of inability to hear, reduced ability to participate in activities, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide complete nail care to 1 of 3 sampled residents (Resident 1) reviewed for activities of daily living (ADL). This failure placed dependent residents at risk for unmet care needs, poor hygiene and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement an individualized activity plan for 1 of 3 sampled residents (Residents 61) reviewed for activities. The failure to develop and implement an activity plan of care, that incorporated residents 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 ensure residents on a fluid restriction were not provided too much fluid for 1 of 4 sampled residents (Resident 78) reviewed for nutrition. This failure placed residents at risk of fluid overload, a decreased clinical status, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure recommendations from mental health consultations were followed up on for 1 of 5 sampled residents (Resident 11) reviewed for unnecessary antipsychotic (mind altering) medications. This failure placed the residents at risk for increased side effects, increased behaviors and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were completed to address all aspects of care for 1 of 5 sampled residents (Resident 9) reviewed for dementia care. Failure to develop and implement care plans to address residents' dementia diagnoses and behaviors, placed the residents at risk for unmet care needs, avoidable decline, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had dental devices to improve resident ability to eat for 1 of 2 sampled residents (Resident 35) reviewed for dental. This failure placed the residents at risk of discomfort, reduced nutritional intake, unintended weight loss, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors when medications were not administered per physician orders for 1 of 3 residents (Resident 1) reviewed for medication management. Resident 1, who was newly placed on an anticoagulant (blood thinning) medication to treat multiple blood clots, experienced harm when the facility failed to administer the medication resulting in pain, increased swelling, and required inpatient treatment at the hospital. This failure placed residents at risk for medical complications, unintended health consequences, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a wound was fully assessed on admission and weekly as ordered, was monitored, and changes reported as needed for 1 of 3 sampled residents (Resident 1) reviewed for wound care. This failure placed the resident at risk for pain, deterioration in condition, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a discharge plan that addressed all of the needs for a resident being discharged for 1 of 3 sample residents (Resident 1) reviewed for discharge process. This failure allowed a discharge plan to be implemented that did not address Resident 1's need for a CPAP (Continuous Positive Air Pressure device, a breathing therapy device that delivers air to a mask to ensure consistent breathing), and a shower chair and placed residents at risk of unsafe discharges.

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 5, 28, 66 and 38) when reviewed for PASARRs and unnecessary medications. This failure placed the residents at risk for unidentified mental health care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food in an individualized manner when the therapeutic diet was not followed for 1 of 3 sampled residents (Resident 23) when reviewed for nutrition. This failure placed residents at risk of choking and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to maintain sanitary food storage and preparation areas when reviewed for kitchen. This failure placed residents at risk of foodborne illness, avoidable discomfort, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to make needed repairs to maintain a homelike environment on 2 of 4 halls (Halls 100 and 400) and failed to use reusable utensils to maintain a homelike dining experience on 1 of 4 halls (Hall 300) when reviewed for environment. These failures place residents at risk for diminished mood, feelings of worthlessness, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide a written bed-hold notice, at the time of transfer to the hospital, for 2 of 2 sampled residents (Residents 64 and 10) when reviewed for hospitalization. This failure placed the residents at risk for a lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteResident 421 Resident 421 admitted to the facility on [DATE] with diagnoses that included adult failure to thrive (a decline in physical and functional abilities) and need for assistance with personal care. The admission minimum data set (MDS, an assessment tool), dated 03/25/2025, showed Resident 421 was usually able to make their needs known and understand others. Observation on 03/24/2025 showed Resident 421 laid in bed with their coat on with a strong smell of urine noted. Observation on 03/25/2025 at 2:29 PM showed Resident 421 stood in the doorway to their room with disheveled hair. The heels of their feet were not in their sneakers and the sneakers were not tied. Two different staff walked by Resident 421 without stopping to assist the resident. Observation on 3/27/2025 at 8:40 AM showed Resident 421 sat on the side of their bed eating breakfast. [...]

Inspectors wroteResident 4 Review of the EHR showed Resident 4 admitted to the facility on [DATE] with diagnoses to include dementia (a loss of memory, language, problem-solving and other thinking abilities), depression, and psychosis (trouble telling what's real from what is not). Resident 4 was able to make needs known. Review of the EHR showed an MRR, dated 12/02/2024, with a recommendation to decrease some medications. Review showed the provider declined the recommendation on 01/17/2025. Review of the pharmacist medication review report for January 2025 showed Resident 4 had a recommendation for January. During an interview on 03/27/2025 at 10:29 AM, Staff H, LPN/RCM, stated the pharmacist would conduct a MRR monthly. Staff H stated these should be reviewed by the provider within 72 hours, but the facility had been struggling to do this. [...]

Inspectors wroteResident 19 Review of the EHR showed Resident 19 admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (paralysis or weakness) of left side, dementia and atrial fibrillation (an irregular and often very rapid heart rhythm). Resident 19 was able to make needs known. Review of the provider's order dated 04/03/2024 showed Resident 19 was prescribed Seroquel 60 milligram (mg) for behaviors related to dementia. Review of Resident 19's March 2025 MAR showed the Seroquel had been administered daily. Review of the MAR showed there was no side effect monitoring. During an interview on 03/27/2025 at 10:38 AM, Staff H, LPN/RCM, stated side effect monitoring for the antipsychotic medication should have been documented on the MAR upon the first administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in 2 of 4 medication carts (100 and 300 medication carts) and 1 of 2 medication rooms (100/200 medication room) 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 observation, interview, and record review, the facility failed to ensure proper fit and use of personal protective equipment (PPE, equipment worn to minimize exposure to infectious diseases/illnesses) as required for transmission-based precautions (TBP, precautions/PPE used with known or suspected infectious diseases/illnesses) for 3 nursing staff (Staff N, O, and P) in 3 of 4 halls (100, 200, and 300 halls) when reviewed for infection control. Also, the facility failed to complete the ongoing collection and analyzation of infection control data, which included the identification of organisms present in the facility for 3 of 3 months (December 2024, January 2025, and February 2025) when reviewed for infection control. These failures placed residents, visitors, and staff at risk for communicable diseases, infections and related complications.

Inspectors wroteBased on interview and record review, the facility failed to offer and provide influenza and/or pneumococcal vaccines for 3 of 5 sampled residents (Residents 56, 37, and 48) when reviewed for vaccinations. This failure placed the residents at a higher risk for contracting influenza and pneumococcal infections, related complications, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to offer and provide Covid-19 vaccines for 2 of 5 sampled residents (Residents 28 and 37) when reviewed for vaccinations. This failure placed the residents at a higher risk for contracting Covid-19 infections, related complications, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure oversight of certified nurse assistants (CNA) received 12 hours of in-service training per year as required and were provided mandatory dementia management training when reviewed for nurse competencies or their performance evaluations reviews. Failure to ensure CNAs completed required hours of training and competencies and conduct annual performance evaluation reviews placed residents at risk for potential negative outcomes and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to have signed consent prior to administering mood altering medication for 1 of 5 sampled residents (Resident 66) when reviewed for unnecessary medications use. This failure placed the resident or their legal representatives at risk of receiving medication without knowledge to make informed decision regarding the use of the medication, adverse side effects, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain an advanced directive (AD, a legal document that establishes a representative to make medical decisions when you and unable to) and/or perform periodic reviews of AD for 1 of 3 sampled residents (Resident 24) when reviewed for AD. This failure placed the resident at risk of not having an established decisionmaker, lack of ability to direct care, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct an assessment and signed consent for the use of low bed, bed next to the wall and tilt in space wheelchair for 1 of 2 sampled residents (Resident 38) when reviewed for use of physical restraints. This failure placed the resident at risk for injury, unmet needs, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to transmit resident minimum data set (MDS, an assessment tool) to the Centers for Medicare & Medicaid Service (CMS) within the required timeframe for 1 of 19 sampled residents (Resident 53) when reviewed for MDS timeliness in transmission/submission. This failure to ensure MDS assessment and tracking records were completed and transmitted timely as required placed the resident at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the minimum data set (MDS, a required assessment tool) accurately reflected a weight loss of 10 percent or more in six months for 1 of 3 sampled residents (Resident 24) when reviewed for nutrition. This failure placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive care plans for 2 of 19 sampled residents (Residents 10 and 7) when reviewed for comprehensive care plans. Failure to care plan Resident 10's fall preventions and Resident 7's range of motion services placed residents at risk of avoidable injury, loss of movement, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's care plan was revised and accurately reflected the resident's care needs for 1 out of 19 sampled residents (Resident 24) when reviewed for care planning and revision of care plans. This failure placed the resident at risk for unmet care needs, medical complications, inaccurate care plan documentation, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards for 5 of 19 residents (Residents 5, 10, 24, 59, and 19) when reviewed for care and services. The facility failed to notify a provider (Resident 5), to follow provider parameters (Residents 10 and 19), to provide nonpharmacological interventions (Residents 10 and 24), to document alert charting (Resident 59), and to monitor for side effects (Resident 24). These failures placed residents at risk for unmet care needs, avoidable side effects, and a diminished quality of life.

Inspectors wroteResident 425 Resident 425 admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), hemiplegia and hemiparesis affecting right dominant side (weakness and paralysis of the right side of the body), and vascular dementia (a group of symptoms affecting memory and thinking). The end of Medicare Part A stay minimum data set (MDS, an assessment tool), dated 03/07/2025, showed Resident 425 was dependent on staff for all care. Review of the care plan dated 02/20/2025 showed Resident 425 was dependent on staff for activities, cognitive stimulation, and social interaction. Interventions included: Staff would provide social and one-on-one visits and activities to help meet Resident 425's activity goals. The care plan stated Resident 425's preferred activities were: Visits in room, music, television, movies, reading to them, and family visits. [...]

Inspectors wroteResident 425 Resident 425 admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), hemiplegia and hemiparesis affecting right dominant side, and vascular dementia (a group of symptoms affecting memory and thinking). The end of Medicare Part A stay minimum data set (MDS, an assessment tool), dated 03/07/2025, showed Resident 425 was dependent on staff for all care. Observation on 03/24/2025 showed Resident 425 was lying in bed on their back. Resident 425 was laying diagonally in their bed with head on the right side of the bed and feet at the left side of their bed. Review of EHR on 03/25/2025 showed Resident 425 required two staff physical assistance to turn and reposition in bed. Review of the care plan, dated 02/19/2025, showed Resident 425 had potential for impairment to skin integrity due to poor skin turgor (elasticity of the skin). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to increase range of motion or to prevent further decrease in range of motion for 1 of 3 sampled residents (Resident 7) when reviewed for contractures (a shortening of tissue which leads to rigidity of the joints) and mobility. This failure placed the resident at risk for worsening contractures, inability to complete activities of daily living, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a bathroom emergency call light (a system used to call for help) cord length was no higher than six inches from the floor in 1 of 4 hallways (400 hallway) when reviewed for accident hazards. This failure placed residents at risk for inability to reach the call light cord if they fell on the floor, delayed response in an emergency, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to monitor and consistently document weights per provider orders for 1 of 3 sampled residents (Resident 24) when reviewed for nutrition. This failure placed 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 prompt dental services for 2 of 3 sampled residents (Residents 28 and 10) when reviewed for dental. This failure placed the residents at risk for continued dental problems and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a tube feeding [TF] directly into the stomach or small intestine) was administered in accordance with physician's orders and professional standards of practice for 4 of 4 residents (Resident 1, 2, 3, & 4), reviewed for TF management. Resident 1 experienced harm when they were found positioned in bed at a 10 degree angle while actively receiving TF in respiratory distress and had tube feeding formula coming from their mouth requiring transfer to the hospital where they were diagnosed with aspiration pneumonia (a lung infection that occurs when you inhale liquid into your lungs). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the required care planned supervision to prevent accidents/falls for 3 of 5 sample residents (Resident 1, 2 & 3) reviewed for two person assists with transfers. Resident 1 experienced harm when they received care without two staff assistance which resulted in a fall, hospitalization and diagnosis of a traumatic brain injury (TBI). This failure placed residents at risk for falls, injury and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the required care planned supervision to prevent accidents/falls for 3 of 5 residents (Resident 1, 2 and 3) reviewed for two person assists with transfers. Resident 1 experienced harm when they received care while in bed without two staff assistance which resulted in a fall and shoulder fracture. This failure placed residents at risk for falls, injury and and diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment in resident areas for 3 of 4 halls (Halls 100, 200, and 400) when reviewed for environment. This failure placed residents at risk of decreased mood and a diminished quality of life.

Inspectors wroteBased on 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 provider's orders and professional standards of practice for 2 of 2 sampled residents (Residents 11 and 24) reviewed for enteral nutrition. The facility failed to have a system in place which ensured the amount of enteral formula (liquid food products) a resident received was reconciled with the amount they were ordered to receive. This failure placed the residents at risk for inadequate nutrition, hydration, and other adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assured timely acquiring, receiving, and administering of a prescribed medications) to meet the needs of 1 out of 4 sampled residents (Residents 55) reviewed for medication administration. The facility failed to consistently reconcile controlled medications in 3 of 3 medication carts (medication carts 200, 400, and 300) reviewed for medication storage. Failure to ensure timely receipt and administration of an ordered medication, placed Resident 55 at risk for medical complications and a poor quality of life, and failure to reconcile controlled medications placed residents at risk for misappropriation of their medications and the facility at risk for diversion of controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to consistently monitor residents' behaviors and/or medication side effects for 3 of 5 sampled residents (Residents 5, 33 and 184) when reviewed for unnecessary medications. This failure placed residents at risk of not receiving adequate mental health supports, increased behaviors, increased psychotropic use, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently maintain the medication refrigerator temperature logs in 2 of 2 medication rooms (medication rooms 100/200 hall and 300/400 hall) reviewed for medication storage and labeling. This failure placed the residents at risk for receiving compromised or ineffective medications.

Inspectors wroteBased on observation and interview, the facility failed to maintain a call light system that allowed residents to call for help from the floor of the bathroom for 2 of 4 hallways (Halls 200 and 400) when reviewed for call light system. This failure placed residents 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 observation, interview, and record review, the facility failed to have system and timely resolution of a grievance for 1 of 3 sampled residents (Resident 31) reviewed for grievances. Failure to ensure grievance/concerns were addressed and resolved timely had the potential to affect the resident's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 2 of 22 residents (Residents 72 and 5) when reviewed for accuracy of assessments. This failure placed the residents at risk of not receiving the care and services required to meet the residents' needs and inaccuracies in their care planning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff were following provider's orders for medication administration for 1 of 5 sampled residents (Resident 18) reviewed for unnecessary medications. In addition, the facility failed provide a psychiatry referral per provider's recommendation for 1 of 2 sampled resident (Resident 184) when reviewed for behavioral health care needs. This failure placed the residents at potential risk of having adverse side effects, medication errors and unmet care services.

Inspectors wroteBased on interview and record review, the facility failed to consistently monitor and document bowel movements (BM) and implement the bowel program when needed for 2 of 3 residents (Residents 61 and 40) reviewed for bowel protocol. This failure placed the residents at risk for worsening condition, discomfort, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a clear system in place to monitor and accurately document fluids consumed to ensure fluid restrictions (a diet which limits the amount of daily fluid intake) was implemented per provider's orders for 1 of 2 sampled residents (Residents 24) reviewed for fluid restrictions. These failures placed the resident at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure freedom from unnecessary pain medication for 1 of 5 sampled residents (Residents 33) reviewed for unnecessary medication use. Failure to provide non-pharmacological interventions (approaches, therapies, or treatments that do not involve drugs) prior to giving as needed pain medications placed the resident at risk for side-effects related to the medication, medical complications, 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/discharge to the resident or responsible party for 3 of 3 sampled residents (Residents 81, 24 and 33) reviewed for hospitalization. This failure placed the residents at risk for diminished protection from being inappropriately discharged .

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 2 of 3 sampled residents (Residents 81 and 33) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding the right to hold their bed while they were at the hospital and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and treatment of an ileostomy (an opening in the body for the discharge of body wastes into a collection bag) was consistent to prevent skin breakdown for 1 of 1 sampled residents (Resident 1) reviewed for colostomy/ileostomy care. This failure placed the resident at risk for unmet care needs and diminished quality of life.