Bainbridge Island Health & Rehab Center

Inspectors wroteBased on interview and record review, the facility failed to assess, implement interventions and notify the medical provider of inadequate fluid intake for 1 of 3 residents (Resident 1) reviewed for dehydration. This failure placed residents at risk for dehydration, thirst and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of physical abuse from other residents for 1 of 3 residents (Resident 1) reviewed. This failure placed residents at risk of physical injury, fear and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately identify and/or monitor target behaviors that psychotropic medications (medications that alter mood and behavior used to treat mental health conditions) were initiated to treat, and to evaluate and individualize behavior interventions for 2 of 5 residents (Residents 32 & 7) reviewed for unnecessary medications. These failures detracted from staff's ability to assess the effectiveness and need for ongoing use of psychotropic medications, and placed residents at risk of receiving unnecessary medication, experiencing associated adverse side effects, unwanted effects on mood and behavior and a diminished quality of life

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 2 of 14 sample residents (Residents 3 & 26) reviewed. Facility nurses' failure to follow and clarify Physician's orders when indicated, and to only sign for tasks that were completed, placed residents at risk for medication errors, skin breakdown and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide activity programming designed for and to support cognitively impaired residents in their preferred activities for 2 of 5 residents (Residents 26 & 53) reviewed for activities. This failure placed residents at risk of boredom, restlessness, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared in a manner that conserved nutritive value and palatability for 3 of 3 residents (Residents 53, 6, & 19) who required pureed meals. The failure to follow written recipes in th preparation of pureed food placed residents at risk of receiving food with decreased nutritive value and decreased satisfaction with meals.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were administered their prescribed medications for 1 of 3 (Resident 1) residents reviewed for medication administration. This failure placed residents at risk of clinical complications, experiencing side effects from unnecessary medications and delayed treatment for their disease.

Inspectors wroteBased on observation and interview, the facility failed to maintain a kitchen environment which allowed each resident to have nourishing, palatable and well-balanced meals without cross contamination for 1 of 1 kitchen reviewed for food safety. This failure put residents at risk for food-borne illness, unsanitary conditions, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to maintain residents' highest practicable level of well-being for 1 of 5 sampled residents (Resident 27) reviewed for bowel management. The failure to initiate bowel care in accordance with physicians' orders placed residents at risk for pain/discomfort, nausea, decreased appetite and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain, label/date, and properly store oxygen tubing/supplies and nasal cannula (NC, flexible tubing that sits inside the nose and delivers oxygen) for 1 of 1 sampled resident (Resident 9) reviewed for respiratory care. This failure placed the residents at risk for unmet care needs, respiratory infections, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to follow transmission-based precautions (TBP) when donning (taking on)/doffing (taking off) Personal Protective Equipment (PPE) for 1 of 2 sampled rooms (room [ROOM NUMBER]) reviewed for TBP. This failure placed the residents at an increased risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food products were dated when opened, discarded when beyond the use by date, kitchen equipment was clean and sanitary, food holding temperatures were accurately obtained and recorded, and that the low temperature dishwasher washer met the minimum wash and rinse cycle temperatures and the required minimum chemical concentration of sanitizer for proper cleaning and sanitization of resident dishes and utensils. Failure to ensure food was held at appropriate temperatures prior to serving, that meals were served on clean and sanitized disheware, and that outdated food products were not served to residents placed residents at risk for unpalatable food and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA), including Care Area Assessments (CAAs), were completed within 14 days for 1of 1 resident (Resident 17) reviewed for a decline in activities of daily living (ADLs). Failure to identify Resident 17's decline ADL function and to complete a SCSA placed the resident at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected residents' health status and/or care needs for 3 of 13 sample residents (Residents 27, 36, and 10) reviewed. The failure to assess resident cognitive patterns and to perform pain interviews as required, and to ensure assessments accurately reflected resident behaviors related to rejection of care, placed residents at risk for unidentified and unmet pain, cognitive and behavioral care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 1 of 13 residents (Residents 17) whose care plans were reviewed. These failures placed the resident at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with nail care for 1 of 13 residents (Resident 28) reviewed for activities of daily living (ADLs.) The failure to provide assistance with nail care placed the resident 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 provide assistance with nail care for 1 of 13 residents (Resident 2) reviewed for activities of daily living (ADLs.) The failure to provide assistance with nail care to a resident who was dependent on staff, placed the resident at risk for unmet care needs, poor hygiene, and diminished quality of life. Findings Included . Resident 2 Review of Resident 2's electronic health record (EHR) showed the resident was admitted to the facility on [DATE] with diagnosis of quadriplegia (a form of paralysis that affects all four limbs, plus the torso). During an observation on 09/25/2023 at 11:30 AM and 09/26/2023 at 08:48 AM, Resident 2 was noted to have long fingernails with discolored debris under their nail beds. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure monitoring of side effects of blood pressure medications for two of five residents (Resident 10 and 140) reviewed for unnecessary medication usage. The facility failed to follow blood pressure and pulse parameters as ordered by the physician which placed the resident at risk for adverse side effects, medical complications, and the unnecessary use of medication.

Inspectors wroteBased on observation and interview, the facility failed to consistently store medication safely in 2 of 4 areas reviewed (Pyxis machine and resident 12's room) for medication storage. This failure placed the residents at risk for unsafe medication consumption and diminish quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident medical records were complete, accurate and readily accessible for 2 of 13 residents (Residents 27, 10) whose records were reviewed. The facility failed to ensure Activities of Daily Living (ADL) documentation related to bathing was complete and accurately reflected care provided. These failures placed residents at risk for unidentified and/or unmet care needs.