Colville Tribal Convalescent C

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was not stored on the floor, hand hygiene was performed when indicated during the lunch meal service, food was served at the appropriate temperatures, expired foods were discarded, and donated food were dated when received in 1 of 1 dry storage areas and 1 of 2 refrigerators (refrigerator 1). The facility further failed to ensure the microwave and oven were clean. These failures placed residents at risk for food-borne illnesses and food served from unsanitary conditions.

Inspectors wroteBased on interview and record review, the facility failed to refer a resident for a PASRR Level II screening (Pre-admission Screening and Resident Review, a detailed mental health screening completed by a specialized evaluator to determine if a resident benefitted from behavioral health services. The PASRR Level II screening was required when a resident's PASRR Level I screen showed a serious mental illness), for 1 of 6 residents (Resident 26) reviewed for PASRR. This failed practice placed the resident at risk for missing beneficial mental health services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a process for the use of compression stockings (specialized snug fitting hosiery that applied graduated pressure to lower legs and ankles designed to boost blood circulation toward the heart) was fully developed for 1 of 4 sampled residents (Resident 14) reviewed for non-pressure related skin conditions. This failure caused Resident 14 to sustain redness and blisters on their upper thighs and put residents at risk for unintended consequences of ill-fitting compression stockings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were followed as care planned for 1 of 1 sampled residents (Resident 23) reviewed for range of motion/mobility. This failure placed the residents at risk for possible declines in range of motion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were given their medications as ordered and were free of significant medication errors for 2 of 5 sampled residents (Residents 3 and 22) reviewed for medication management. This failure placed residents at risk of exacerbations of their chronic health conditions, and unintended consequences when doses of their medications were omitted.

Inspectors wroteBased on observation and interview, the facility failed to ensure meals were served at palatable temperatures during 1 meal service observed. This failure put residents at risk of decreased enjoyment of their meals, and possible reduced dietary intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Specifically, expired foods were not discarded for 1 of 2 refrigerators, 1 of 1 dry storage areas, and food items in the refrigerator and freezer were not dated when opened. These failures placed residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control practices were followed during 1 of 1 meal services and 1 of 2 medication administration observations to include removal of gloves and performing hand hygiene (HH) when indicated and failed to sanitize a mechanical lift between resident transfers. Additionally, staff did not follow Enhanced Barrier Precautions when indicated for 2 of 3 sampled residents (Residents 13 and 21), reviewed for isolation precautions. These failures placed the residents at risk for the spread of infections, illnesses and unintended health consequences.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light (a device used to request help as needed) was accessible for 1 of 3 sampled residents (Resident 18), reviewed for environment. This failure placed the resident at risk for unmet needs, potentailly avoidable accidents, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were given as ordered for 1 of 6 sampled residents (Resident 13), reviewed for medication administration. This failure placed residents at risk for adverse health consequences and diminished quality of life when doses of medications were omitted.

Inspectors wroteBased on observation and interview, the facility failed to ensure expired medications were removed from inventory in 1 of 2 medication carts in use, and failed to ensure the temperature of the medication room was monitored in the facility medication room. These failures placed residents at risk of receiving medications that were expired or not properly stored.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident personal refrigerators were maintained in a clean manner, without expired foods and at the appropriate temperatures for 1 of 3 sampled residents (Resident 18), reviewed for a homelike environment. In addition, the facility failed to maintain a freezer in the dining room in a clean manner. This failure placed the residents at risk of eating spoiled foods and having an unclean environment.

Inspectors wroteBased on observation, interview, and record review failed to ensure submission of the Payroll Based Journal (PBJ) per the Centers of Medicare and Medicaid (CMS) requirement for 1 of 1 Fiscal Year (FY) Quarter (Q4 2023 [July 1 through September 30, 2023]), reviewed for PBJ submission. This failure constituted Past Non-Compliance (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified). The facility implemented and completed a plan of correction which was verified by surveyors. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge summary that included a physician recapitulation/summary of the resident's stay, as required, for 2 of 3 sampled residents (31, 82) reviewed for discharge. This failure placed the resident at risk for having an incomplete medical record.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Food Service Manager had the required credentials. This failure placed all residents at risk for receiving dietary services from staff without the required competencies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. Specifically, glove changes and hand hygiene was not done appropriately, contaminated gloves were set on a clean food prep counter during meal preparation and the sanitizing bucket solution was not monitored, as required. Additionally, meat sandwiches in the dining room refrigerator were not labeled with a made or discard by date. These failures placed residents at risk for consuming contaminated foods and food-borne illness.

Inspectors wroteBased on interview and record review, the facilty failed to ensure submission of the Payroll Based Journal (PBJ) per the Centers of Medicare and Medicaid (CMS) requirement for 1 of 1 Fiscal Year (FY) Quarter (Q1 2024 [October 1 through December 31 2023]), reviewed for PBJ submission. This failed practice resulted in CMS to have inaccurate data related to nursing home staffing levels which had the potential to impact the care and services provided to all the residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to provide two staff supervision required for transfers for 1 of 3 sampled residents (Resident 1), reviewed for accidents. Resident 1 experienced harm when they sustained a painful inoperatable right femur (thigh bone) fracture after a staff assisted fall. This failure placed residents at risk of potentially avoidable accidents, injuries, and diminished quality of life.