Edmonds Post Acute

Inspectors wroteBased on interview and record review, the facility failed to provide an effective plan to control insects for 2 of 3 nursing units (Southeast Wing and Northeast Wing) and for 1 of 1 kitchen, reviewed for pest control. This failure placed the residents at risk for poor living conditions, emotional distress and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean, safe, and homelike environment for 1 of 3 residents (Resident 5), reviewed for environment. This failure placed the residents at risk of injury, a less than homelike environment, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were implemented and followed in accordance with professional standards of practice for 1 of 1 resident (Resident 1), reviewed for quality of care. This failure placed residents at risk for not receiving necessary care services, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to provide necessary/adequate supervision for 1 of 1 resident (Resident 2), reviewed for elopement. This failure allowed Resident 2 to exit the facility unnoticed and placed the resident at risk for serious injury and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the needs of 2 of 7 residents (Residents 3 and 4), reviewed for medication administration. The failure to administer and/or document medication administration in accordance with professional standards of practice placed the residents at risk for negative outcomes and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure laundry was handled, stored and processed in a sanitary manner for 1 of 1 laundry room, reviewed for infection control. In addition, the facility failed to ensure Contact Enteric Precautions (measures put in place to prevent spread of infection by direct or indirect contact with the resident or environment by staff wearing gown and gloves before entering a resident's room or environment and washing hands with soap and water when leaving the room) practices were followed for 1 of 7 staff (Staff JJ) and 1 of 1 resident (Resident 25), reviewed for transmission based precautions (measures put in place to prevent spread of infection by staff wearing Personal Protective Equipment [PPE-use of gown, gloves, mask and/or face shield] before entering a resident's room or environment). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a homelike environment when medications were administered in the common area for 2 of 5 residents (Resident 47 &16), reviewed for medication administration. In addition, the facility failed to ensure a clean, safe, and homelike environment for 4 of 7 residents (23, 20, 27 & 65), reviewed for environment. These failures placed the residents at risk for injury, a less than homelike environment, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide written transfer/discharge notice to the residents and/or their representatives with the required information for 4 of 4 residents (Residents 30, 25, 52 & 14) and failed to provide a bed hold notice for 2 of 4 residents (Residents 52 & 14), reviewed for hospitalizations. These failures placed the residents at risk for not having opportunities to make informed decisions about transfer/discharge.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident assessments were completed accurately for 6 of 29 residents (Residents 4, 7, 103, 11,14, & 133), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments were marked on the MDS regarding indwelling catheter (a flexible, hollow tube inserted into the bladder to continuously drain urine into an external collection bag), insulin injections (medication used to manage blood sugar levels), ostomy (surgically created opening on the abdomen that allows waste to leave the body), turning/repositioning program, hospice (specialized care for people with a terminal illness) and prognosis placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 1 of 2 Refrigerators (Kitchen Walk-in Refrigerator), 1 of 1 Dry Storage Room, and 2 of 4 Staff (Staff GG & HH), reviewed for food services. The failure to label and discard food items past the use by date, perform hand hygiene and properly sanitized equipment, placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control system was in place for 1 of 1 kitchen and 1 of 29 residents (Resident 140), reviewed for pest control. This failure placed the residents at risk for unsafe living conditions, emotional distress, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident dignity for 3 of 29 residents (Resident 106, 121 & 60), reviewed for dignity. This failure placed the residents at risk for diminished self-worth, potential embarrassment, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy and confidentiality of resident's medical information were maintained for 1 of 3 Unit Resident List/Document (Midwest [MW] 2 Unit), reviewed for confidentiality of records. This failure placed the residents at risk of having their medical and personal information compromised and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to initiate and resolve a grievance for 1 of 2 residents (Resident 52), reviewed for grievances. The failure to initiate, investigate, and resolve grievances for missing personal item placed the resident at risk for feelings of frustration, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure admission Minimum Data Set (MDS-an assessment tool) was completed timely for 1 of 21 residents (Resident 4), reviewed for comprehensive assessments. This failure placed the resident at risk for delayed and/or unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete Quarterly Minimum Data Set (MDS - an assessment tool) assessments within the regulatory timeframe for 1 of 18 residents (Resident 25), reviewed for resident assessments. This failure placed the resident at risk for delayed care planning, unidentified care needs and services, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to transmit the resident Minimum Data Set (MDS-an assessment tool) to the Centers for Medicare & Medicaid Service within the required timeframe for 1 of 29 residents (Resident 14), reviewed for resident assessments. This failure 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 develop and/or implement care plans for 2 of 29 residents (Residents 7 & 121), reviewed for comprehensive care plans. The failure to develop/implement care plans for anticoagulant (medications that helps prevent blood clots) usage and Activities of Daily Living (ADL) placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to facilitate quarterly care conferences or care plan meetings for 1 of 1 resident (Resident 25), reviewed for care planning. In addition, the facility failed to ensure care plans were revised timely and accurately to reflect shower preferences for 1 of 5 residents (Resident 6), reviewed for Activities of Daily Living. These failures placed the residents at risk for unidentified and unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary assistance with Activities of Daily Living (ADL) for 2 of 6 residents (Residents 121 & 13), reviewed for ADLs. The failure to provide assistance with personal and oral hygiene placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to consistently monitor and manage constipation (passing fewer than three bowel movements a week or having a difficult time passing bowel movement) in accordance with professional standards of practice for 1 of 5 residents (Residents 52), reviewed for quality of care. In addition, the facility failed to ensure consistent communication and collaboration of care occurred between the facility and hospice staff for 1 of 2 residents (Resident 121), reviewed for hospice services. These failures placed the residents at risk for unmet care needs, related complications, not receiving necessary comfort care, services and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ongoing assessment, monitoring, and documentation of an identified pressure ulcer/injury (damage to the skin and underlying tissue, usually over a bony area, caused by prolonged pressure) were conducted for 1 of 4 residents (Resident 11), reviewed for pressure ulcer/injury. The failure to routinely assess and monitor pressure ulcer/injurie's characteristics and response to treatment placed the resident at risk for unidentified wound decline, delays in treatment, prolonged wound healing, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure smoking materials were properly stored for 1 of 4 residents (Resident 77), reviewed for accident hazards. This failure placed the resident at risk for injury and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store respiratory mask when not in use and ensure timely changing of oxygen (O2) tubing for 1 of 3 residents (Resident 27), reviewed for respiratory care. This failure placed the resident at risk of respiratory infection, related complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were trauma survivors and diagnosed with Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event that was either experienced or witnessed) received culturally competent, trauma-informed care and services in accordance with professional standards of practice for 1 of 2 residents (Resident 76), reviewed for mood/behavior. This failure placed the resident at risk for unidentified triggers, re-traumatization, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the daily nurse staffing was posted for 2 of 7 days (02/28/2026 and 03/01/2026), reviewed for posted nurse staffing information. The failure to post a complete and accurate form daily placed the residents, family members, and visitors, at risk of not being fully informed of the current staffing levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were discarded for 1 of 3 medication carts (Midwest [MW] 1 Cart), 1 of 2 medication rooms (West Medication Room), and failed to ensure medications were properly stored and secured for 1 of 1 residents (Resident 65), reviewed for medication storage. These failures placed the residents at risk of receiving compromised medications and unsafe storage practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident records were accurate for 1 of 5 residents (Resident 88), reviewed for Activities of Daily Living (ADL). The failure to accurately document ADL care placed the resident at risk for unmet care needs, inaccurate monitoring, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure essential equipment was in operating condition for 1 of 2 dryers (Uni-Dryer Model), reviewed for laundry equipment. This failure placed the residents at risk for shortage of clean linens, delay in laundry turnaround, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, comfortable and sanitary environment was maintained for 1 of 3 shower rooms (Southwest Hallway Shower Room), reviewed for environment. This failure placed residents at risk for infections, related complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) had the required 12 hours of training annually for 1 of 5 staff (Staff U). This failure placed the residents at risk for potential negative outcomes and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was evaluated, assessed, and a physician order was obtained for safe administration of a medication for 1 of 1 resident (Resident 1), reviewed for self-medication administration. This failure placed the resident at risk for medication errors, adverse medication interactions, and complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an appropriately sized bed for 1 of 1 resident (Resident 1), reviewed for accommodation of needs. This failure placed the resident at risk for discomfort, skin issues and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident had reasonable access to a telephone and a place where calls could be made without being overheard by others for 1 of 3 residents (Resident 1), reviewed for telephone access. In addition, the facility failed to ensure mail was delivered unopened for 1 of 3 residents (Resident 2), reviewed for resident rights. These failures placed the residents at risk for decreased communication with others inside and outside of the facility, lack of privacy 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 for 2 of 3 resident rooms (Rooms 14 & 15) and failed to maintain a clean and comfortable environment for 1 of 3 resident rooms (room [ROOM NUMBER]), reviewed for environment. These failures placed residents at risk for unmet care needs, a less than homelike environment, and potential infection control issues.

Inspectors wroteBased on interview and record review, the facility failed to ensure neurological assessments (set of tests nurses do to check how well a person's brain, nerves and muscles are working) were completed post fall and to ensure a physician's order for every 15-minute (observation performed at 15-minute intervals) check was followed for 1 of 3 residents (Resident 1), reviewed for quality of care. This failure placed the resident at risk of potential delay of immediate care and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate and promptly resolve a grievance for 1 of 1 resident (Resident 1), reviewed for grievances. 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 ensure infection prevention and control practices including proper use of Personal Protective Equipment (PPE-use of gown, gloves and respiratory/N95 respirator-mask) and closure of resident room doors with COVID-19 (an infectious virus causing respiratory illness) were followed to help prevent the transmission of disease during resident care and/or housekeeping for 4 of 5 staff (Staff D, E, F & G), reviewed for infection control. These failures placed the residents, staff, and visitors at risk for facility acquired or healthcare-associated infections and related complications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a care plan for 1 of 9 residents (Resident 1), reviewed for comprehensive care plans. The failure to implement a care plan for Activities of Daily Living (ADLs) placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegation of abuse was thoroughly investigated for 1 of 3 residents (Resident 1), reviewed for abuse investigations. This failure placed the resident at risk for repeated incidents, unidentified abuse, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to report a communicable disease (infectious disease that can spread through direct or indirect contact) outbreak (two or more cases of a highly contagious disease) for 1 of 2 outbreak, reviewed for infection control. This failure placed the residents, staff, and visitors at an increased risk of infection and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered by a trained and/or licensed nursing staff per professional standards of practice for 1 of 3 residents (Resident 1), reviewed for medication administration. This failure placed the resident at risk for unmet care needs, unrecognized medication adverse side effects, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to designate a qualified staff person to serve as an Infection Preventionist (IP) to oversee the facility's infection prevention and control program. This failure placed the residents, staff, and visitors at risk for unmet infection control issues and lack of oversite of infection control practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate water temperature used for showers/bathing were maintained for 3 of 3 residents (Residents 4, 25 & 73), failed to ensure blinds in resident's rooms were maintained or replaced when broken for 2 of 2 rooms (Rooms 63 & 64), and failed to ensure oxygen equipment was stored appropriately for 1 of 1 resident (Resident 88), reviewed for environment. These failures placed the residents at risk for a less than homelike environment, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 5 of 21 residents (Residents 61, 76, 62, 16 & 95), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding pressure ulcer/injury (wounds that occur from prolonged pressure on the skin), diagnosis, behavior, use of insulin (medication/hormone that regulates blood sugar levels) injections, hypoglycemic medication (drug that lowers blood sugar level) and discharge status placed the 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 professional standards of practice were followed when administering medications for 1 of 5 residents (Resident 26) and failed to ensure physician orders were followed for 3 of 5 residents (Residents 50, 38 & 61), reviewed for medication and treatment management. The failure to administer the right dosage form of medication for Resident 26, hold medication as ordered for Residents 50 & 38, and provide wound care treatment for Resident 61 placed the residents at risk for adverse side effects, worsening of pressure ulcer, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the daily nurse staffing form was accurately completed for the number of staff worked and actual hours worked for 6 of 31 days, reviewed for posted nurse staffing information. The failure to post a complete and accurate form daily placed the residents, family members, and visitors, at risk of not being fully informed of the current staffing levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately label and store drugs and/or biologicals (diverse group of medicines made from natural sources) for 1 of 2 refrigerators (East Medication Room Refrigerator), reviewed for medication storage. This failure placed the residents at risk for receiving compromised and ineffective medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were dated and discarded in accordance with professional standards for food safety for 1 of 2 unit refrigerators (West Nursing Station Unit Refrigerator and failed to ensure refrigerators' temperature were maintained for 2 of 2 unit refrigerators (West Nursing Station and East Nursing Station Refrigerators), reviewed for food services. In addition, the facility failed to ensure the dishwasher chemical solution was tested routinely in the Kitchen's dishwasher. These failures placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages) and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's water management program included a written description and a flow diagram that assessed the potential growth of Legionella (a water-borne bacteria that can cause pneumonia [a lung infection]) or other waterborne pathogens (an organism that can cause disease), failed to ensure appropriate catheter (a semi-flexible tube inserted into the bladder to drain urine) care was followed for Resident 36, and failed to ensure hand hygiene was performed during dining services for Resident 9, reviewed for infection control. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident dignity was maintained related to urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) use for 1 of 3 residents (Resident 88), reviewed for dignity. This failure placed the resident at risk for decreased self-worth and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and/or their designated representative before administering a psychotropic (mind altering) medication for 1 of 5 residents (Resident 78), reviewed for unnecessary medications. This failure placed the resident and/or their representatives at risk of not being fully informed of the risks and benefits before making decisions about their medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe self-administration of medication was clinically appropriate and/or an assessment or evaluation was done for 1 of 1 resident (Resident 56), reviewed for self-medication administration. This failure placed the resident at risk for inaccurate/unsafe medication administration, adverse side effects, and related medical complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure an advance directive (a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care-a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so) was obtained from the resident and/or their representative and ensure a copy was readily available in the medical records for 2 of 5 residents (Residents 76 & 73), reviewed for advance directives. This failure placed the residents and/or their representatives at risk for losing their right to have their preferences honored to receive or refuse/discontinue care according to their choice.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate, investigate, log, and promptly resolve a grievance for 1 of 3 residents (Resident 76), reviewed for grievances. This failure placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegation of abuse was thoroughly investigated for 2 of 2 residents (Residents 92 & 25), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.

Inspectors wroteBased on interview and record review, the facility failed to provide a written transfer/discharge notice to the resident and/or their representative for 2 of 4 residents (Residents 76 & 61), reviewed for hospitalization. This failure placed the residents and/or their representatives at risk for not having an opportunity to make informed decisions about transfers/discharges.

Inspectors wroteBased on interview and record review, the facility failed to ensure bed hold (the opportunity to reserve a resident's current occupied bed while out of the facility to ensure their room was available when ready to return) notice was offered for 1 of 4 residents (Resident 61), reviewed for hospitalization. This failure placed the resident or their representative at risk for lack of knowledge regarding the right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed timely for 1 of 1 resident (Resident 16), reviewed for significant change in condition. The failure to complete a SCSA timely placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete a new Level I Preadmission Screening and Resident Review (PASARR- an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], intellectual disabilities, or related conditions) and referral for Level II evaluation (a comprehensive evaluation for positive Level I screening) when a significant change in status occurred and new diagnoses of mental illness were identified for 2 of 7 residents (Residents 76 & 38), reviewed for PASRR. This failure placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR - a federally required screening of all individuals who have an Intellectual Disability [ID], Related Condition [RC], or Serious Mental Illness [SMI] prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form for 3 of 7 residents (Residents 50, 78 & 62), reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement care plans for 3 of 18 residents (Residents 78, 46 & 77), reviewed for comprehensive care plans. The failure to implement care plans for diuretic (medications that help move extra fluid out of the body) use, resident preferences, and antibiotic (medications to treat infections) use, put the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to revise comprehensive care plan for 1 of 18 residents (Resident 38), reviewed for care plan revision. The failure to revise the care plan to include current dialysis (a treatment to remove extra fluid and waste when kidneys fail) services placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure skin assessments were consistently evaluated for 1of 1 Resident (Resident 73), reviewed for quality of care. This failure placed the resident at risk for not receiving necessary care services, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure ulcer/pressure injury (wound that occur due to prolonged pressure on the skin) was provided the necessary treatment and services consistent with professional standards of practice for 1 of 2 residents (Resident 61), reviewed for pressure ulcer care. This failure placed the resident at risk for deterioration of their pressure ulcer and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate oxygen storage and use of respiratory equipment were maintained to include care of oxygen tubing and nasal cannula (flexible tubing that sits inside the nostrils and delivers oxygen) in accordance with professional standards of practice for 2 of 3 residents (Residents 36 & 18), reviewed for respiratory care. This failure placed the residents at risk for respiratory infections and complications due to improper oxygen storage.

Inspectors wroteBased on interview and record review, the facility failed to provide the required Registered Nurse (RN) coverage for 1 of 31 days (10/08/2024), reviewed for staffing. This failure placed the residents at risk for inadequate assessments, delay in care services by an RN, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 3 of 6 residents (Resident 77, 78 & 38), reviewed for unnecessary medications. The failure to monitor for adverse side effects for use of antibiotics (a medication to treat infections) and diuretics (a medication to move extra fluid out of the body) and follow insulin (medication/hormone that regulates blood sugar levels) parameters placed the residents at risk for unmet care needs, adverse side effects, and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received the ordered medication dosage for residents receiving psychotropic medications (drugs that affects how the brain works, and causes changes in mood, awareness, thoughts, feelings or behavior) for 1 of 5 residents (Residents 50), reviewed for unnecessary medications. This failure placed the resident at risk for receiving unnecessary medications, adverse side effects, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representatives were provided information about the influenza vaccine (used to prevent influenza [an infection of the nose, throat, and lungs]), including risks, benefits, potential side effects, documented if the vaccine was accepted and/or refused in the medical record, and as to why the vaccine was refused for 2 of 5 residents (Residents 22 and 78), reviewed for immunizations and infection control. This failure placed the residents at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from influenza disease and denied the residents and/or their representative of the right to make informed decisions.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representative were provided information about COVID-19 (an infectious disease-causing respiratory illness) vaccinations, including risks, benefits, potential side effects, documented if the vaccine was accepted and/or refused in the medical record, and as to why the vaccine was refused for 2 of 5 residents (Residents 22 and 78), reviewed for COVID-19 immunizations. This failure placed the residents at risk for a COVID-19 infection and denied the residents and/or their representative of the right to make informed decisions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) was updated to accurately determine and identify the resources needed for the facility's resident care needs. This failure placed the residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to document on the State Reporting form and complete an investigation for an allegation of neglect within the required time frame for 1 of 3 residents (Resident 1), reviewed for abuse/neglect investigations. These failures had the potential to cause unrecognized abuse/neglect, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall care plan intervention for 1 of 3 residents (Resident 2), reviewed for falls. This failure placed the resident at risk for falls, injury, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to revise the comprehensive care plan for 1 of 3 residents (Resident 1), reviewed for care plan revision. The failure to revise care plan for fall placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 4 residents (Resident 2) was free from physical abuse when Resident 1 wandered into Resident 2's room and hit them across the face when asked to leave. This failure placed the residents at increased risk for injury, emotional distress, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 4 residents (Resident 1), reviewed for discharge care plans. The failure to develop a care plan to address necessary care and services for a planned discharge placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, comfortable, homelike, and safe environment for 2 of 4 rooms (Rooms 14 &15), reviewed for safe and sanitary environment. The failure to ensure rooms were free from odors and maintained in safe and sanitary conditions placed the residents at risk for infection, poor living conditions, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services as ordered by a provider (medical doctor or nurse practitioner) for 1 of 3 residents (Resident 1), reviewed for urinary (eliminate body waste in the form of urine) care. This failure placed the resident at risk of unmet care needs, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately label and store drugs and/or biologicals for 1 of 2 medication storage rooms (West Medication Storage Room), and 2 of 5 medication carts (Southwest and [NAME] middle Medication Cart), reviewed for medication storage. This failure placed the residents at risk for receiving compromised, incorrect, and ineffective medications.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure there was sufficient dietary support personnel to serve meals and menus prepared on time. In addition, the facility failed to ensure sanitizing procedures were implemented in the kitchen. These failures placed the residents at risk for poor dining experience, poor nutrition, foodborne illness (caused by the ingestion of contaminated food or beverages), and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure menus were adequate, followed, and met the nutritional needs for 10 of 84 residents (Residents 68, 73, 50, 187, 74, 39, 27, 188,189 & 42) reviewed for menus and food preferences. Specifically, the menus were revised resulting in menu repetition and unappetizing foods/food combinations, there was a lack of hot foods available for alternate menu selections, and the food options that residents selected from the menus were not served. This failure placed the residents at risk for not having their food choices honored, unmet nutritional needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the walk in freezer in the kitchen was maintained properly, and failed to ensure the sanitizing solution used to wipe kitchen surfaces had the proper amount of disinfectant in it. In addition, the facility failed to ensure ready-to-eat food was handled appropriately in accordance with professional standards for food service safety, and failed to ensure the walk- in freezer temperature was maintained appropriately. These failures placed the residents at risk for food borne illness (an illness caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure pneumococcal vaccinations (vaccines use to prevent pneumonia [lung infection]) were offered for 5 of 5 residents (Residents 25, 39, 52, 58 & 88) reviewed for pneumococcal immunizations. This failure placed the resident at risk for acquiring, contracting, and/or experience potential avoidable complications of pneumonia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure essential operating equipment in the kitchen was maintained in satisfactory condition and fail to ensure the temperature was maintained for 1 of 1 walk-in freezer in the kitchen. This failure placed the residents at risk for decrease food quality, foodborne illness (caused by the ingestion of contaminated food or beverages), and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure recommended equipment was provided in 1 of 1 resident (Resident 72), reviewed for reasonable accommodation of needs. The failure to provide recommended equipment in resident room placed the resident at risk for diminished independent functioning, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide written notices of transfer and failed to properly notify the Office of the State Long Term Care Ombudsman (an advocacy group for residents) of discharges to the hospital for 3 of 3 residents (Residents 34, 58 and 186) reviewed for hospitalization. This failure placed the residents at risk of not having the opportunity to make informed decisions about transfers and access to an advocate who informed residents about options and resident rights.

Inspectors wroteBased on interview and record review, the facility failed to provide a written bed-hold notification to the resident and/or their representative for 1 of 3 residents (Resident 34) reviewed for hospital transfers. This failure placed the residents at risk of lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure the baseline care plan was completed within 48 hours of admission and ensure a copy of the baseline care plan was provided to the resident or their representative for 1 of 5 residents (Resident 187) reviewed for baseline care plans. The written summary of the baseline care plan was not provided to the resident and/or family in a timely manner to ensure they were informed of the initial plan for delivery of care and services.

Inspectors wroteBased on interview and record review, and facility failed to ensure residents and/or their representatives were invited to participate in their care plan meetings/care conferences for 2 of 5 residents (Residents 27 & 68) reviewed for care planning. This failure placed the residents at risk for not having input regarding care goals, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a discharge summary included a recapitulation (overview) of the resident's stay that reflected their course of treatment in the facility for 1 of 1 resident (Resident 85) reviewed for discharge planning. This failure had the potential to prevent the resident from having the necessary information to ensure continuity of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bathing/showers, meals, and toileting were consistently provided for 3 of 6 residents (Residents 82, 73 & 27) reviewed for activities of daily living (ADL). This failure placed the residents at risk for poor hygiene, unmet care needs, decrease self-esteem, and a diminished qualify of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutrition care and services was provided to address low body weight, low protein levels, and nutritional needs for healing of the pressure ulcer (bed sore) for 1 of 4 residents (Resident 21) reviewed for nutrition maintenance. This failure placed the resident at risk for medical complication, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper care of a Continued Positive Airway Pressure (CPAP- a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) machine for 1 of 1 resident (Resident 27) reviewed for respiratory services. This failure placed the resident at risk for unmet care needs, respiratory infections, and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure new nurse aide (NA) received dementia training and/or the 12 hour NA training per year based on their date of hire for 1 of 1 staff (Staff W) reviewed for NA in-service training. This failure placed the residents at risk for not receiving adequate care and services and a diminished quality of life.