Bremerton Trails Post Acute

Inspectors wroteBased on interview and record review, the facility failed to provide enter post hospital discharge wound care orders and provide consistent wound care treatments for pressure ulcers for 1 of 3 residents (Resident 1) reviewed for wounds. Resident 1 experienced harm when the sacral pressure ulcer (injury to the skin and underlying tissue over the tailbone), present on hospital discharge and readmission to the facility, worsened became infected and required surgical incision and drainage of the wound. The facility's failure placed residents at risk of worsening wounds, clinical complications and pain.

Inspectors wroteBased on observation, interview, and record review, during a COVID-19 (contagious viral respiratory illness) outbreak, the facility failed to evaluate residents and staff for their COVID-19 vaccination status, to have a system in place to evaluate residents for being removed off of isolation precautions that was consistent with local health jurisdiction recommendations, to provide/order COVID-19 vaccinations, to update resident representatives about the outbreak, and/or to follow personal protective equipment (PPE) recommendations which included: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of physical abuse from other residents for 2 of 4 residents (Resident 1 and 2) reviewed for abuse. This failure placed residents at risk of physical injury, fear and a decreased quality of life.

Inspectors wroteBased on observation and interviews, the facility failed to have a functioning call light system on 1 of 3 Resident Care Units (Cove unit). This failure placed residents at risk of delayed response to emergencies, care needs and fear for their well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide physician ordered pain medications for 2 of 3 residents (Resident 1 and 2) reviewed for medication administration. This failure placed residents at risk of increased pain, clinical complications, frustration and a decreased quality of life.

Inspectors wroteBased on observations, interviews and record reviews, the facility staff failed to follow droplet precautions (infection control measures used to prevent the spread of pathogens transmitted through respiratory droplets) for residents with influenza for 3 of 3 staff (Staff A, B and C) reviewed for infection control practices. This failure placed residents and staff at risk of influenza.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's guardian of clinical changes for 1 of 3 residents (Resident 1) reviewed. This failure placed residents at risk of lack of advocacy, support and assistance with medical decision making.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and provide resolution for a grievance for 1 of 3 residents (Resident 2) reviewed. This failure placed residents at risk of inadequate care, disrespect and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain emergency medical services timely for 1 of 3 residents (Resident 3) reviewed for quality of care. This failure placed residents at risk of medical complications, physical distress and a decline in condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide social service advocacy following an abuse allegation and assistance with representation for 1 of 3 residents (Resident 4) reviewed. This failure placed residents at risk for abuse, lack of a healthcare advocate and emotional wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents with positioning in bed, eating and toileting for 2 of 3 (Resident 1 and 2) residents reviewed for care. This failure placed residents at risk of malnutrition, dehydration, poor hygiene, pain and loss of dignity.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of misappropriation of a phone for 1 of 3 (Resident 1) residents reviewed. This failure placed residents at risk of loss of property, lack of communication with the community and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide physician ordered medications for 1 of 3 residents (Resident 3) reviewed for medication administration. This failure placed residents at risk of increased pain, frustration and a decreased quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to evaluate the effectiveness of current pressure offloading treatment plan, document weekly wound assessment and measurements, consistently re-position the resident as care planned every two to three hours and follow physician wound treatment interventions as ordered to prevent development or worsening of pressure ulcers (PU) for 1 of 1 sampled resident (Resident 2) reviewed for PU. Resident 2 experienced harm when their previously healed chronic PU re-developed and worsened from Stage II (a shallow, open sore that has broken through the top two layers of skin, the epidermis and dermis) to Stage III (a deep wound that has gone through the top two layers of skin and into the fatty tissue underneath), and caused an increase in pain level during wound care that required stronger pain medication management.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided in a dignified manner which maintained and enhanced quality of life for 3 of 5 sampled residents (Resident 65, 8 & 12) reviewed for dignity. This failure placed residents at risk for feelings of embarrassment, unmet care needs, decreased self-worth and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with personal funds/resident trust accounts had ready access to their accounts during evenings and weekends for 38 of 38 residents reviewed for person funds accounts. This failure placed residents at risk of not having access to their accounts during non-banking hours, a decreased sense of autonomy 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 38 of 38 residents reviewed for personal fund accounts. This failure placed residents at risk of not having an accurate accounting of their personal funds held in trust by the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the transfer of funds, from a resident personal fund account, was completed within 30 days following their discharge for 1 of 5 residents (Resident 111) reviewed for personal funds. This failure placed the residents and/or their representatives at risk for loss of funds and the interest accumulated.

Inspectors wroteBased on observation and interview the facility failed to ensure painted ceiling surfaces was maintained in a homelike environment for 1 of 22 sampled residents (Resident 1) reviewed for homelike environment and sound levels were homelike in 1 of 1 hallway (room [ROOM NUMBER]- 77 Hallway) reviewed for exit door. These failures placed residents at risk for an environment that was not homelike and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to have a system in place that ensured grievances were initiated, logged, addressed, and resolved in a timely manner to residents' complaints verbalized during Resident Council meeting for 3 of 3 months (July 2025, August 205 and September 2025) and for 3 of 3 sampled residents (Resident 33, 8 & 12) reviewed for grievances. The failure to initiate, log, investigate verbalized concerns, inform residents of their findings and actions taken, if any, prevented the facility from identifying care trends and determining if actions taken were effective in resolving the reported issues. These failures resulted in residents verbalizing the same complaints for multiple months without resolution, and placed residents at risk of feeling frustrated, unimportant, unheard, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medications (any drug that affects the brain activities associated with mental processes and behavior) were regularly monitored for side effects and target behaviors for 5 of 7 residents (Resident 105, 48, 1, 7, & 9) reviewed for unnecessary medication or behavioral/emotional. This failure placed residents at risk of unnecessary medication usage, increase in side effects without interventions, and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to accurately code the Minimum Data Sets (MDS, an assessment tool) for 3 of 3 sampled residents (Resident 4, 3 & 2) reviewed for the communication restorative program. The failure to ensure all required components of a communication restorative program were met and were accurately coded placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure baseline care plans were developed, implemented and given to the resident within 48 hours of admission for 3 of 3 sampled residents (Resident 107, 105 & 78) reviewed for new admission. This failure placed residents at risk for unidentified and/or unmet care needs, and other negative health outcomesFindings included .1) Resident 107 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool) documented still in progress. The electronic health record (EHR) showed no baseline care plan had been created or was given to the resident. On 09/24/2025 at 2:48 PM, Resident 107 said they never received a baseline care plan 48 hours after admission. 2) Resident 105 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident was moderately cognitively impaired. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care conferences (meetings with the interdisciplinary team and the resident and/or their representative to review and/or revise the care plan after each Minimum Data Set (MDS) assessments) occurred for 3 of 3 residents (Residents 4, 6, & 58) reviewed for care conferences, or to update resident care plans for 3 of 22 sampled residents (Residents 8, 12, & 1). This failure placed residents at risk of unidentified and unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to initiate bowel protocol interventions for 4 of 8 residents (Resident 10, 78, 100 & 8) reviewed for constipation, to ensure blood glucose levels were appropriately monitored and intervened upon for 1 of 2 resident (Resident 67) reviewed for insulin, to provide documentation of events leading to hospitalization for 1 of 3 residents (Resident 12) reviewed for hospitalization, and to provide overall quality care for 1 of 22 sampled residents (Resident 2). These failures placed residents at risk of unmet care needs, constipation, hospitalizations and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain acceptable parameters for weight loss by ensuring proper implementation of interventions for 1 of 4 sampled residents (Resident 55) reviewed for nutrition. Additionally, the facility failed to maintain and ensure adequate fluid hydration and fluid restrictions were implemented for 4 of 4 sampled residents (Residents 107, 17, 12 and 4) reviewed for hydration. These failures placed residents at risk for continued weight loss, dehydration, fluid overload and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with mental health diagnoses were given appropriate treatment and/or services, for 2 of 2 sampled residents (Residents 12 & 1) reviewed for behavior and emotion, or for Resident Council (a group of residents in the facility that meets regularly to discuss care, activities, or concerns). This failure placed residents at risk of increased symptoms, emotional distress, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were necessary by providing residents with non-pharmacological interventions (NPIs, non-medication interventions) for pain management, documenting side effect monitors, and/or to reassess the necessity of medication on admission for 5 of 7 residents (Resident 2, 105, 1, 7, & 8) reviewed for unnecessary medication and pain. This failure placed residents at risk of unmet care needs, unnecessary medication, increased pain, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appetizing and palatable food when reviewed for kitchen services. This failure placed the residents at risk for a diminished dining experience, dissatisfaction with food served, a potential for less than adequate nutritional intake and weight loss.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food items were labeled and dated when opened in 1 of 1 walk-in kitchen refrigerators. This failure placed residents at risk for food borne illness, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide Occupational Therapy (treatment that evaluates and treats people who have injuries, illnesses, or disabilities to help them live as self-sufficiently as possible by developing, recovering, or maintaining skills needed for everyday activities of life) for 2 of 3 (Resident 112 and 69) residents reviewed for therapy services. This failure placed residents at risk of decreased physical function, delay in returning home, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide accurate and complete access to all resident records for 1 of 1 annual recertification survey. These failures had the potential risk of causing a delay in the survey process, not addressing resident concerns and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices met professional standards regarding their Water Management Program, the laundry room, obtaining consent for vaccination for 4 of 5 residents (Residents 9, 1, 7, & 10) reviewed for vaccinations, and ensuring enhanced barrier precautions were followed for 1 of 3 observations (Resident 3) for transmission based precautions. These failures placed residents at risk of transmittable diseases, lack of informed consent, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure antibiotic stewardship practices met professional standards for 3 of 3 months (Months June 2025, July 2025, and August 2025) reviewed for antibiotic line list (an infection control surveillance list that tracks and reviews antibiotics). This failure placed residents at unnecessary antibiotic usage, risk of developing Multi-Drug Resistant Organisms, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen's walk-in freezer was in good working condition in 1 of 1 facility kitchen. This failure placed residents at risk of food-borne illness, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse within the required timeframe(s) for 2 of 5 residents (Residents 3 & 12) reviewed for abuse/neglect investigations. This failure placed residents at risk of abuse, fear and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure abuse or neglect investigations were thorough and complete for 2 of 2 residents (Residents 12 & 3) reviewed for abuse or neglect. This failure placed residents at risk of potential continuation of abuse or neglect, unidentified care needs, 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 by ensuring residents were provided scheduled medication, were updated promptly of medication unavailability, and/or were observed during medication administration, for 2 of 22 sampled residents (Residents 3 & 8) reviewed for professional standards, and to appropriately label multiuse medications for 1 of 3 medication carts (Olympic 2 cart) reviewed for medication storage observation. This failure placed residents at risk for medication complications, for receiving expired medication, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were assisted with activities of daily living (ADLs) including bathing and meal preparation assistance for 3 of 6 sampled residents (Resident 107, 12 & 55) reviewed for ADLs and choices. The failure to provide assistance with bathing and meal set up for residents who were dependent on staff for provision of such care, placed the residents at risk for poor hygiene, embarrassment, diminished self-image, weight loss and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide resident centered activities that incorporated the resident's preferences for 1 of 1 sample residents (Resident 78) reviewed for activities. This failure placed residents at risk for a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to comprehensively assess the use of bedrails/side rails for 1 of 1 residents (Resident 67) reviewed for side rails. This failure placed residents at risk of accident hazards, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to show evidence the Quality Assurance and Performance Improvement program plan (QAPI, a program that focused on the full range of care and services provided by the facility that included clinical care, quality of life and resident choice) was reviewed and updated with the current leadership. The facility failed to provide evidence that the committee staff and medical director participated in the QAPI program meetings. This failure placed residents at risk for adverse events and/or decreased quality of care and quality of life.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to provide competent and sufficient staff to complete resident showers and personal care according to their plan of care for 5 of 11 residents (Resident 1, 2, 3, 4 and 5) reviewed for sufficient staffing. This failure placed residents at risk of poor hygiene, loss of dignity, frustration and a decreased quality of life

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications per physician orders and guidelines for 4 of 5 residents (Resident 1, 2, 3 and 4) reviewed for medications. This failure placed residents at risk of clinical complications, unintended medication side effects, and infection.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure staff maintained infection control practices by cleaning blood glucose monitors (a device that measures the amount of glucose in your blood) between residents, performing hand hygiene before and after resident care, and maintaining separation between clean and dirty tasks for 1 of 3 (Staff A) staff observed. This failure placed residents at risk of contagious disease, infection and clinical complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure discharge planning included notification of necessary outside services for 1 of 3 sampled residents (Resident 8) reviewed for discharge planning. This failure placed residents at risk for unmet care needs, re-hospitalization, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents' mobility needs were addressed to access the community for 1 of 1 sampled resident (Resident 1) reviewed for accommodation of needs. This failure placed residents at risk of diminished independent functioning, socialization and mood disturbance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standard of practice when medications were discontinued without authorization from a medical provider, and physician's orders were not followed for 3 of 4 residents (Resident 1, 2, and 3). This failure placed residents at risk for medical complications, infection and discomfort.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure infection control standards were followed related to the use of required personal protective equipment with residents on enhanced barrier precautions (EBP, an infection control method that involves wearing gowns and gloves during high-contact interactions with residents in nursing homes) and hand hygiene during wound care for 1 of 3 residents (Resident 4) reviewed for wound care. This failure placed residents at risk of contracting and spreading infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 3 of 6 staff members (Staff A, B, and C) used personal protective equipment in accordance with the Centers for Disease Control (CDC) guidelines when caring for residents with known COVID 19 (an infectious virus causing respiratory illness that may cause difficulty breathing and could lead to severe impairment or death) infections. This failure placed residents and staff at risk for contracting and spreading the illness.

Inspectors wroteBased on interview and record review, the facility failed to consistently assess, monitor, provide timely wound care, and notify the provider of change in wound condition for 1 of 3 residents (Resident 1) reviewed for wound care. This failure resulted in physical harm for resident 1, who was severely cognitively impaired, when they had itching, stinging, and the physical appearance of pain and distress when they experienced a maggot (fly larvae) infestation and worsening of their scalp wound. This failed practice residents at risk for infection, psychological harm and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an effective pest control program was maintained to keep the facility free of flies on 4 of 4 resident care units (Cove, Bayshore, Mt. View and Olympic) and prevent flies from laying eggs on 1 of 3 residents (Resident 1) reviewed for pest control. This failure placed the residents at risk of infection, maggot infestation, distress and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient licensed nurses were available to administer medications timely for 3 of 4 residents (Resident 1, 2 and 3) reviewed for sufficient staffing. This failure placed residents at risk for clinical complications, frustration and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident rooms were clean and maintained for 5 of 5 sampled rooms (room [ROOM NUMBER], 13, 64, 16, and 21) reviewed for environment. This failure placed residents at risk for unsanitary living conditions, compromised dignity, and dissatisfaction with their living environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the survey results book included the results for 9 of 10 abbreviated (complaint) surveys that resulted in citations since the facility's previous recertification (annual) survey. These failures prevented residents, family members and visitors from exercising their right to review past survey results and the facility's plans of correction to evaluate the quality of care provided by the facility.

Inspectors wroteBased on interview and record review, the facility failed to report to State Agency (SA) and investigate allegations of abuse for 2 of 4 sampled residents (Residents 20 & 60) reviewed for abuse. This failure placed residents at risk for further abuse violations and lack of protection.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a discharge planning process that ensured required medical equipment was ordered, available at the time discharge, and documented in residents' discharge plans for 3 of 4 residents (Residents 144, 145 and 146) reviewed for discharge planning. These failures placed residents at risk for accidents, injuries, rehospitalization, and diminished quality of life.

Inspectors wrote<Edema Monitoring/Management> <Resident 87> Resident 87 admitted to the facility on [DATE]. Review of the 06/12/2024 admission MDS, showed the resident had diagnoses including heart failure and required diuretic (medication that draws fluid from the body through urine) therapy. An edema care plan (CP), initiated 07/10/2024, directed staff to monitor, document and report to the provider any signs and symptoms of skin problems related to edema: redness, edema, blistering, itching, burning, bruises, cuts, other skin lesions. Resident 87 had 06/05/2024 orders for: a) Furosemide (a diuretic) daily, with direction to hold medication for a systolic blood pressure of less than 100. b) A 07/03/2034 order to monitor edema to bilateral lower extremities (BLE) every morning using edema scale: 1+ / slight indent disappears rapidly. 2+ / indent disappears in 10-15 seconds. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure respiratory care and services were provided in accordance with Physician's orders and accepted professional standards of practice for 2 of 3 residents (Residents 37 and 48) reviewed for respiratory care. The facility failure to ensure residents receiving oxygen (O2) services had active orders for O2, an indication for use, O2 concentrator filters (used to protect the resident from inhaling dust and particulate matter) were routinely cleaned and maintained, and/or was administered by the ordered delivery method and documented on residents' administration records. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure drugs and biologicals were labeled and dated when opened in accordance with accepted professional standards of practice, and expired medications were discarded for 3 of 3 medication carts (Olympic, Cove 1 and Cove 2) that were observed. These failures placed residents at risk to receive expired medications and negative health outcomes.

Inspectors wroteBased on observation and interview, the facility failed to ensure food items were labeled and dated when opened, in 1 of 2 Nourishment Refrigerators/Freezers (Bayshore Dining Room). This failure placed residents at risk for cross-contamination, food borne illness, and a diminished quality of life.

Inspectors wroteBased on interviews, the facility failed to employ a qualified social worker (defined as an individual with a minimum of a bachelor's degree in social work or a bachelor's degree in a human services field and one year of supervised social work experience in a health care setting working directly with individuals) on a full-time basis. This failure placed residents at risk for unmet psychosocial needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain a Quality Assessment and Assurance (QA&A) committee that met at least quarterly and included the Medical Director or his/her designee, to conduct required Quality Assurance and Performance Improvement (QAPI) and QA&A activities. This failure detracted from the effectiveness of the QA&A committee and placed residents at risk for quality deficiencies, adverse events, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and/or their legal representative, in advance, of the risks and benefits associated with the use of antipsychotic medications (medications capable of affecting the mind, emotions, and behavior) and obtain informed consent prior to administering the medication(s) for 1 of 5 residents (Resident 87) reviewed for unnecessary medications. These failures precluded residents and/or legal representatives from making informed decisions regarding proposed psychotropic medication and prevented them from exercising their right to refuse/decline the proposed medication.

Inspectors wroteBased on interview and record review the facility failed to ensure grievances were initiated, logged, investigated, and or promptly resolved/responded to for 6 of 12 residents (Residents 10, 29, 33, 37, 46, and 54) reviewed for Resident Council and grievances. This failure placed residents at risk for feelings of frustration, powerlessness, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) Level II evaluations were referred and or completed timely for 2 of 6 residents (37, 9) reviewed for PASRRs. This failure placed residents at risk for inappropriate placement, and not receiving timely and necessary mental health services. Review of 42 CFR 483.106(b)(2)(ii) showed an individual who entered a nursing facility (NF) as an exception (an exempted hospital discharge), but later was found to require more than 30 days of NF care, the facility must refer the resident for a Level II PASRR evaluation, and the State mental health or intellectual disability authority must conduct the evaluation within 40 calendar days of admission.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident care plans were reviewed, revised, and accurately reflected resident care needs for 4 of 31 sampled residents (Residents 37, 87, 27 and 48) whose care plans were reviewed. These failures placed residents at risk for unidentified/ unmet care needs 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 4 of 31 sampled residents (Residents 87, 37, 13, and 27) reviewed for medication management. The failure to follow, obtain, and/or clarify incomplete physicians' orders when indicated, to sign for medication(s) that were administered, to document the reason and notify the provider when medications were held, placed residents at risk for medication errors, adverse side effects, delayed review of their medication regimen and unmet care needs.

Inspectors wroteBased on observation and interview facility failed to provide assistance with Activities of Daily Living (ADL), related to grooming for 1 of 4 sampled residents (Resident 20). This failure placed residents at risk for, matted hair, feeling unclean, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Podiatry (the treatment of feet and their ailments) care and services were provided for 1 of 1 resident (Resident 27) reviewed for foot care. This failure placed the resident at risk for further skin impairment, discomfort, and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to timely identify, assess, develop and implement nutritional interventions, and evaluate the effectiveness of the interventions for 1 of 4 residents with weightloss (Resident 87) reviewed for nutrition. Additionally, the facility failed to have a system in place that ensured fluid intake was accurately monitored, documented, and 24-hour intake totals were calculated and evaluated for 1 of 1 resident (Resident 37) reviewed with a fluid restriction. These failures placed residents at risk for continued weight loss, inadequate nutrition, fluid volume overload, fluid and electrolyte imbalances and other medical complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to comprehensively assess the use of bedrails/side rails and obtain accurate and complete informed consent from the resident for the use of side rails for 1 of 5 residents (Resident 27) reviewed for accidents. This failure placed the resident at risk for lack of informed care and decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to develop a dementia care plan that addressed the physical, mental and psychosocial needs of the resident, established personalized and achievable goals, and identified interventions to promote a person-centered environment for 1 of 2 residents (Resident 87) reviewed for dementia care. These failures placed residents at risk for unmet physical and psychosocial needs, increased behaviors and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 5 residents (Residents 87) reviewed for unnecessary medications, was free from unnecessary psychotropic drug use. The failure to have an adequate indication for use, approved diagnosis, and to identify individualized Target Behaviors (TBs) the medication was implemented to treat, placed residents at risk to receive unnecessary medications and/or experience adverse side effects

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were dependent on facility staff for assistance with their Activities of Daily Living (ADLs) received assistance to eat their meals in the dining room for 2 of 3 sampled residents (Resident 1 and 2) reviewed for quality of care. This failure placed residents at risk for lack of stimulation, decreased meal intake and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the development of a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure) when they failed to consistently complete pressure ulcer care for 1 of 3 sampled residents (Resident 2) reviewed for pressure ulcers. Resident 2 experienced harm when they developed an unstageable pressure ulcer (a pressure injury that is a full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen) to their right buttock that required debridement (a medical procedure that removes dead, damaged, or infected tissue from a wound). These failures placed residents at risk for infection, medical complications and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to follow accepted infection control practices during the provision of wound care for 1 of 3 residents (Residents 2) reviewed for wound care. This failure placed residents at risk for facility acquired or healthcare-associated infections and related complications.

Inspectors wroteBased on the observation, interview and record review, the staff failed to perform hand hygiene and change gloves when providing pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure) care for 3 of 3 sampled residents (Resident 2, 3 and 4) reviewed for pressure ulcers. This failure placed residents at risk of infection and medical complications.

Inspectors wroteBased on interview and record review, the facility failed to recognize a clinical change of condition from the resident's baseline for 1 of 1 sampled residents (Resident 1) reviewed for quality of care. This failure placed residents at risk for unmet care needs, poor decision making and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's emergency contact when 1 of 4 sampled residents (Resident 1) experienced a significant change of condition. This failure placed residents and their representatives at risk of not being able to participate in resident care decisions, providing support, delayed medical treatment, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement speech therapy's recommendations for safe oral intake for 1 of 1 sampled residents (Resident 2) reviewed for accidents. This failure placed residents at risk of medical complications, choking and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided care by outside healthcare providers in a timely manner for 1 of 3 (Resident 1) residents reviewed for outside resources. This failure placed residents at risk of unmet care needs and services.

Inspectors wroteBased on interview, observation and record review, the facility failed to implement their infection control program during an influenza outbreak. The facility failed to ensure personal protective equipment (PPE) was utilized correctly by 2 of 7 staff (Staff C and D) for 3 of 24 residents (Resident 1, 23 & 25) and failed to ensure the clinical status of residents with signs of influenza were monitored for 6 of 8 residents (Residents 5, 6, 8, 13, 15 and 23) reviewed for infection control system and tracking implementation during an outbreak. This failure placed residents at risk for facility acquired or healthcare-associated infections and related complications.

Inspectors wroteBased on interview and record review the facility failed to ensure staff performed timely Cardio-Pulmonary Resuscitation (CPR/an emergency procedure consisting of chest compressions combined with giving breaths of air) to 1 of 1 resident (Resident 1) who was found unresponsive and had a physician's order and had express the with for CPR. This failure to train staff on the facility's expectation on how to respond to a resident requiring CPR resulted in Resident 1 not receiving immediate staff action. The failure of facility staff to initiate timely basic life support potentially contributed to the resident's unsuccessful response to CPR and placed all residents who choose to have CPR initiated at risk for serious injury, harm, impairment or death and represented an Immediate Jeopardy (IJ) situation. [...]

Inspectors wroteBased on interview and record review the facility failed to prevent significant weight loss when a resident was not consistently administered their enteral feeding (nutrition delivered via a tube into the stomach) and the facility was neither aware of, nor addressed the lack of nutrition for 1 of 2 residents (Resident 1) reviewed for nutrition. Resident 1 experienced harm when they had a significant weight loss of 6.8 percent in one month. This failure placed residents at risk for weight loss, a lack of nutrition, hunger, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Infection Control (IC) and Infection Prevention (IP) practices and outbreak management interventions to prevent transmission of COVID-19 (a highly transmissible respiratory virus), ensure Transmission Based Precautions (TBP) were in place, and the proper Personal Protective Equipment (PPE) was donned (put on) and doffed (removed) according to acceptable IC/IP standards for 16 of 16 sampled residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16) who tested positive for COVID-19) and in 3 of 6 hallways (Olympic, Mount View, and Bayshore). Resident 2 experienced harm when they were hospitalized with COVID-19 pneumonia (a serious lung infection caused by the COVID-19 virus) and later expired at the hospital. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure influenza vaccines were provided for 13 of 15 residents (Residents 1, 3, 4, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16) reviewed for immunizations. These failures placed residents at risk for acquiring, transmitting, and/or experiencing potentially avoidable complications from the influenza virus.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician's orders for 1 of 3 residents (Resident 1) with skin conditions. This failure placed residents at risk for development and/or worsening of skin conditions, infection, and medical complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient staff were available to provide necessary care and services for 5 of 9 sampled residents (Residents 1, 2, 6, 7 and 4) reviewed for nursing services related to sufficient staffing. This failure placed residents at risk for unmet care needs, discomfort, medical complications, and a diminished quality of life.

Inspectors wroteBased on interview, observations and record review, the facility failed to ensure residents were free of physical restraints when 1 of 1 resident (Resident 3) had the wheelchair brakes locked to prevent them from self-propelling. This failure placed the residents at risk for injury, frustration, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement wound treatment orders and care interventions for 2 of 3 residents (Resident 4 and 5) with pressure ulcers (a skin wound caused by pressure which limits blood flow to the skin). This failure placed residents at risk for development and/or worsening of wounds, infection, and medical complications.

Inspectors wroteBased on interview and record review, the facility failed to provide physician ordered wound treatment for 1 of 3 sampled residents (Resident 1) reviewed for quality of care related to wound care. This failure placed residents at risk for worsening skin conditions, medical complications, and unnecessary pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure their surety bond (a written agreement wherein the facility and the insurance company agree to compensate the resident for any loss of residents' funds that the facility holds, safeguards, manages, and accounts for) covered an amount greater than or equal to the value of resident funds deposited in the facility's resident trust account. This failure placed 39 of 98 residents, who had trust accounts with the facility, at risk to be unable to recover their money in the event of loss of funds from their account.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure residents either had an advanced directive in place, or failed to provide the residents and/or their representatives written information of the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 10 residents (Resident (R) 30, R23, R27, R50, R45, R49, R70, R4, R56, R41) of 12 reviewed for Advanced Directives.

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe, sanitary, homelike environment was maintained on 2 of 5 halls (Olympic 1 & 2). Failure to provide necessary maintenance and repairs in resident rooms for damaged walls, furniture, blinds, and baseboard heating units, resulted in avoidable hazards, uncleanable surfaces, and an inability to ensure resident privacy. These failures placed residents at risk for accidents, injuries, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to have a system in place that ensured grievances were initiated, logged, addressed, and timely resolved in response to residents' verbal conveyance of care concerns during resident council meetings for 3 of 5 months (June, July, and August 2023) of resident council minutes that were reviewed. Additionally, there was no documentation or indication facility staff informed residents of the corrective actions taken, if any, to address the reported concerns. These failures prevented the facility from ensuring resident concerns were timely and effectively addressed, that care trends were identified, and placed residents at risk of feelings of powerlessness, frustration, diminished self-worth and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with nail care for 5 of 30 residents (Residents 50, 6, 2, 26 & 97) reviewed for activities of daily living (ADLs.) The failure to provide assistance with nail care to residents who were dependent on staff for the provision of such care, placed residents at risk for unmet care needs, poor hygiene, diminished self image and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory services consistent with professional standards of practice for 4 of 5 residents (Residents 26, 41, 50 and 27) reviewed for respiratory care. The fcility's failure to monitor, assess and address resident responses to oxygen (O2) therapy, follow physician's orders for the provision of humidified oxygen, ensure only residents with orders for O2 were administered it, and ensure oxygen concentrator filters (used to protect the resident from inhaling dust and particulate matter) were present and routinely cleaned and maintained, placed residents at risk for respiratory compromise, bloody noses and other potential negative healthcare outcomes.

Inspectors wroteBased on observations, interviews and review of policies and procedures, the facility failed to ensure that it stored, prepared, and served food in accordance with professional standards. This can affect 25 of 98 residents who ate food from the kitchen.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure each Medicare resident whose Medicare therapy services were terminated received a notice including the reason the services were ending or what the options were prior to the discontinuation of therapy services. This had the potential to affect one of three residents (Resident (R)82) who were reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents comprehensive plans of care were developed, implemented, and accurately reflected residents' care needs for 2 of 30 residents (Residents 26 & 42) reviewed. The failure to incorporate the specialized equipment residents were assessed to require into their plans of care, such as weighted silverware, tilt-in-space wheelchair and fall mats, placed the resident at risk for decreased independence, unmet care needs and a diminished quality of life. Findings Included . Resident 26 Resident 26 admitted to the facility on [DATE]. According to the 08/10/2023 quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact and required setup and supervision with eating. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 2 of 30 sample residents (Residents 56 & 97) reviewed. Facility nurses' failure to obtain, accurately transcribe, follow, and clarify Physician's orders when indicated, and to only sign for tasks that were completed, placed residents at risk for medication errors, delays in treatment, unmet care needs, and potential negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards for 1 of 6 residents (Resident 33) reviewed for accidents. The facility's failure to provide adequate supervision and to follow facility policy and procedures for a missing resident, resulted in the facility taking no action for 15 hours after Resident 33 was identified as missing. This failure placed Resident 33 at risk for serious harm and injury. Additionally, the facility failed to maintain a resident's environment free of hazards, by failing to identify and repair baseboard heaters in resident rooms that were bent and protruding from the wall, exposing residents to the sharp edges of sheet metal, and presenting a tripping hazard. These failures placed residents at risk for avoidable falls, injuries and/or lacerations.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 2 residents (Resident 6) reviewed for indwelling urinary catheters (a flexible tube used to empty the bladder and collect urine in a drainage bag) had a valid medical justification for urinary catheterization, was assessed for removal of the catheter timely, and received catheter care in accordance with professional standards of practice, and infection control and prevention guidelines. This failure placed the resident at risk for loss of bladder tone and normal bladder function, catheter associated urinary tract infections and other negative health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure enteral nutrition (delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered in accordance with Physician's orders and professional standards of practice for 1 of 2 residents (Residents 56) reviewed for enteral nutrition. The failure to administer enteral formula in accordance with physician's orders; to identify incomplete, duplicative and/or conflicting orders and clarify and/or correct those orders, placed residents at risk for inadequate nutrition, hydration, and other adverse health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adaptive equipment with meals, for 1 of 1 (Resident 26) of two residents reviewed who required it. Failure to provide adaptive equipment that the resident was assessed to require, placed the resident at risk for decreased independence, meal intake, unmet needs, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) care and maintenance, in accordance with accepted infection control practices for 1 of 4 residents (Resident 6) reviewed for urinary catheters. This failure placed the resident at risk for catheter associated urinary tract infections and/or transmission of infection to others. Additionally, the facility's failure to maintain and repair resident furniture and walls, resulted in multiple uncleanable surfaces, detracted from staffs' ability to maintain a clean sanitary environment and placed residents at risk for contracting communicable diseases.

Inspectors wroteBased on observations and interview, the facility failed to ensure the resident call system was functioning properly for 2 of 30 sampled residents (Residents 56 and 9) reviewed for call lights. This failure placed residents at risk for delayed staff response to potential emergencies and resident needs, falls, injury, frustration, and decreased quality of life.