Enumclaw Health and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement pressure offloading interventions timely for resident's assessed to be at increased risk for skin breakdown to prevent the development of pressure injuries (PI) for 2 of 3 residents (Residents 1 & 2) investigated for development of new PI after admission. Resident 1 experienced harm when they developed two avoidable deep tissue pressure injuries (DTPI) after admission, one on each heel, that resulted in pain, affected their mobility and care routines, and delayed their rehabilitation and discharge goals. Resident 2 experienced harm when they developed a Stage 3 PI on their sacrum that resulted in pain, affected their ability to sleep, comfort, and decreased their bed mobility. These failures placed residents at risk for injury, infection, pain, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to initiate, investigate, and resolve grievances for 6 of 12 sampled residents (Residents 2, 3, 4, 5, 6, 7, 8 ) reviewed for grievances. This failure placed residents at risk for emotional distress, unresolved frustration, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were dependent on staff for assistance with Activities of Daily Living (ADLs - i.e. grooming, bathing, eating, etc.) received the assistance they required for 1 of 4 sample residents (Resident 1) reviewed for ADLs. The failure to provide ADL assistance to dependent residents as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes. According to a 07/25/2025 Quarterly MDS, Resident 1 had clear speech, was able to understand, and be understood by others. This MDS showed Resident 1 was dependent on staff for bathing and required partial/moderate assistance from staff for personal hygiene, showers, transfers and mobility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure specialized rehabilitative services were provided as determined by the physician's orders for 1 (Resident 53) of 2 residents who were reviewed for position/mobility. This failure placed residents at risk for decline in physical and functional mobility, and a diminished quality of life. According to 07/25/2025 Quarterly MDS, Resident 1 had multiple diagnoses considered Medically Complex Conditions. This MDS showed Resident 1 required substantial/maximal assistance with upper and lower body dressing, rolling from side to side, sitting to lying, lying to sitting, toilet transfers, and wheelchair mobility. The MDS showed Resident 1 did not attempt to walk due to medical conditions or safety concerns. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, and serve food under sanitary conditions. Failure to ensure food items in the dietary department were properly stored, labeled, and out-of-date foods were identified and discarded, staff used appropriate hand washing and sanitation, placed residents at risk for consuming expired/contaminated foods, and potential exposure to food-borne illness.

Inspectors wrote<Carpet> Observations on 06/08/2025 at 8:52 AM, 06/11/2025 at 5:54 AM, and 06/13/2025 at 11:29 AM showed a large carpet stain in the hallway across from room [ROOM NUMBER]. In an observation and interview on 06/13/2025 at 11:29 AM, Staff K stated it was their expectation housekeeping staff would address carpet stains promptly. <Blinds> Observations on 06/08/2025 at 8:52 AM, 06/11/2025 at 5:54 AM, and 06/13/2025 at 11:29 AM showed there were missing and broken window blinds to the windows at the end of the 100-hall and the 200-hall. An observation of the 200-hall window with Staff K on 06/13/2025 at 11:29 AM showed Staff K pick up a broken blind lying on the floor under the window. In an interview at this time, Staff K stated the broken blinds needed to be fixed and the missing blinds replaced. [...]

Inspectors wrote<Resident 3> According to a 04/25/2025 Quarterly MDS, Resident 3 had multiple medically complex diagnoses including a history of falling, required substantial assistance with transfers, and was dependent on staff for toileting hygiene. In an interview on 06/09/2025 at 10:18 AM, Resident 3's family stated they were concerned about the resident having recent falls. Observations on 06/09/2025 at 12:38 PM, showed Resident 3 lying in bed with their call light in reach. Review of a revised 08/16/2024 risk for falls CP showed Resident 3 had a history of frequent falls and gave directions to staff to anticipate resident needs, ensure the resident's call light was within reach, and keep the room free of clutter due to poor eyesight. Review of a revised 05/18/2024 actual fall CP showed an intervention to assist Resident 3 with the bathroom upon awakening, before/after meals, and at bedtime. [...]

Inspectors wrote<Resident 24> Review of Resident 24's 07/15/2024 and 10/15/2024 Discharge MDS showed the resident was transferred to an acute care hospital on [DATE] and 10/15/2024, with their return anticipated. <Report to Receiving Facility> Review of Resident 24's records showed staff did not document the hospital was given report of the resident's condition at the time of transfer and no e-interact form was completed by staff for the resident's 10/15/2024 transfer. <Written Notice> Record review showed no documentation staff provided written notification to Resident 24 and/or the resident's representative regarding their discharge on [DATE] or 10/15/2024 as required. <LTCO Notification> Record review showed no documentation indicating the LTCO was notified of Resident 24's 07/15/2024 or 10/15/2024 transfer as required. [...]

Inspectors wrote<Resident 24> According to a 05/09/2025 Quarterly MDS, Resident 24 had clear speech, understands, and was understood by others. In an interview on 06/08/2025 at 12:09 PM, Resident 24 stated they felt staff did not include them in their plan of care and did not have any recent care conference meetings with the different departments to discuss their care. Review of Resident 24's records showed a 04/04/2025 care conference was held with the only IDT members in attendance listed were Staff R (RCM) and Staff DD (Social Services Assistant - SSA). Staff documented, none for the other categories of: MDS, Executive Director, CNA (Certified Nursing Assistant) responsible; DNS (Director of Nursing), Therapy, FANS (Dietary department); and activities. Similar observations were noted of only the RCM and SSA attending care conferences with Resident 24 on 01/09/2025 and 09/11/2024. [...]

Inspectors wrote<Resident 24> According to a 05/09/2025 Quarterly MDS, Resident 24 had clear speech, was able to understand, and be understood by others. This MDS showed Resident 24 was dependent on staff for bathing, required substantial assistance from staff for personal hygiene, and had no rejection of care. Review of a revised 02/29/2024 functional abilities Care Plan (CP) showed directions to staff for Resident 24 to have a shower twice weekly and the resident required assistance from staff for personal hygiene. Observations on 06/08/2025 at 12:03 PM showed Resident 24 with facial hair on their chin and fingernails that extended past their fingertips with debris underneath. In an interview at this time, Resident 24 stated they preferred to be clean shaven and stated it was a couple of weeks since staff assisted them with shaving. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure treatments were done as ordered and documented by staff for 2 of 2 residents (Residents 52 & 28) reviewed for antibiotic use and 1 supplemental resident (Resident 47). Failure to change Intravenous (IV) dressings as ordered by the physician and as documented placed residents at risk for infection, skin impairment, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Narcotic Ledgers were accurate for 2 of 2 Narcotic Ledgers (500 cart & 200/300 cart) reviewed for accuracy. Failure to ensure accurate account of resident narcotic medications placed residents at risk for uncontrolled pain, decreased quality of life, and possible diversion of controlled substances.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to properly administer 5 of 28 medications for 2 of 5 residents (Resident 43 & 13) observed during medication pass resulted in a medication error rate of 17.86%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication.

Inspectors wrote<100 Unit> <Resident 44> Review of Resident 44's 06/09/2025 physician orders showed the resident did not have an order directing staff to keep medications at the resident's bedside. Observation on 06/08/2025 at 8:33 AM showed a topical pain-relieving patch on Resident 44's nightstand. Observation on 06/13/2025 at 10:32 AM showed the topical pain-relieving patch remained on Resident 44's nightstand. In an interview at that time, Staff P (Registered Nurse) stated the topical pain-relieving patch should not be left on the resident's nightstand. Staff P removed the unsecured patch from the resident's room. Reference: WAC 388-97-1300(2), -2340. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care in a manner that promoted dignity for 2 (Resident 13 & 18) of 17 sample residents reviewed. The facility failed to provide privacy during medication pass for Resident 13 and have washcloths available for staff and residents to use for personal care for Resident 18. These failures placed residents at risk for feelings of diminished self-worth and embarrassment.

Inspectors wroteBased on interview and record review the facility failed to ensure funds were reimbursed to the state Office of Financial Recovery (OFR), within 30 days of resident discharge or death, for 2 (Residents 73 & 74) of 3 discharged residents reviewed. This failure caused a delay in reconciling residents' accounts within 30 days as required.

Inspectors wrote<Resident 24> According to a 02/10/2025 Annual MDS, Resident 24 had no areas of concern for their dental status. In an interview on 06/08/2025 at 12:06 PM, Resident 24 stated they had some broken teeth that needed to be fixed for a while. Review of Resident 24's revised 02/29/2024 dental health CP showed tooth decay was found on an oral assessment and gave instructions to staff to coordinate arrangements for dental care, transportation as needed. Record review showed Resident 24 was seen by dental on 05/05/2025 with documentation showing the resident had several decayed and broken teeth and required a referral for evaluation and extractions. In an interview on 06/13/2025 at 10:31 AM, Staff D stated it was important to have an accurate MDS to provide a proper picture of the resident and to CP appropriately. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the recommendation of a Level II Preadmission Screen and Resident Review (PASRR) evaluation was incorporated into the Care Plan (CP) upon receiving recommendations for 2 (Resident 46 & 32) of 5 sampled residents reviewed for coordination of PASRR and assessments. This failure placed residents at risk for unmet mental health care needs and a diminished quality of life.

Inspectors wrote<Medications Given Outside of Parameters> <Resident 45> According to a 05/27/2025 Significant Change Minimum Data Set (MDS- an assessment tool), Resident 45 had multiple medically complex diagnoses including high Blood Pressure (BP). Review of Resident 45's May 2025 Medication Administration Records (MAR) showed the resident was receiving two different medications for high BP with directions to staff to hold doses if the Systolic BP (SBP - a measure of the pressure in your arteries when your heart beats) was less than 110. This MAR showed staff gave the medications outside of these parameters on three occasions. Review of Resident 45's June 2025 MAR showed staff administered these medications outside of parameters on two occasions. <Resident 26> According to a 04/16/2025 Significant Change MDS, Resident 26 had multiple medically complex diagnoses including high BP. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received proper assistive devices to maintain vision and hearing abilities for 1 (Resident 46) of 2 residents reviewed for hearing services. Failure to ensure Resident 46 received assistance in obtaining hearing devices placed this resident at risk for a decline in hearing abilities and frustration.

Inspectors wrote<Resident 3> According to an 04/25/2025 Quarterly MDS, Resident 3 had multiple medically complex diagnoses, was dependent on staff for wheelchair mobility, and had a history of falling. In an interview on 06/09/2025 at 10:18 AM, Resident 3's family stated they were concerned about the resident having recent falls. Observations on 06/09/2025 at 12:38 PM, showed Resident 3 lying in bed with their call light in reach. Review of a 01/05/2025 12:00 PM facility incident report showed Resident 3 had a fall in their room. This report showed staff were educated not to leave Resident 3 in their room alone and an intervention was added to their CP to place the resident in a wheelchair near the nurse's station and to encourage them to participate in activities of choice. On 01/20/2025 at 6:30 PM, Resident 3 had another fall and was found on the floor in their room with their wheelchair behind them. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure specialized rehabilitative services were provided as determined by the physician's orders for 1 (Resident 53) of 2 residents who were reviewed for position/mobility. This failure placed residents at risk for decline in physical and functional mobility, and a diminished quality of life.

Inspectors wrote<Unit 500> Observation on 06/12/2025 at 9:50 AM showed a unit 500 nurse run sheet left unattended in view on the unit 500 medication cart. The unit 500 nurse run sheet included resident's names, room number, and diagnoses on it. In an interview on 06/12/2025 at 9:52 AM Staff W (Licensed Practical Nurse) stated the nurse run sheet should be protected and not visible for all. Staff W stated it was important to protect PHI for resident rights. In an interview on 06/13/2025 at 11:02 AM Staff A (Administrator), Staff B (Director of Nursing), and Staff G (Regional Director of Clinical Operations) stated they expected staff to protect residents PHI for residents rights to privacy. Reference: WAC 388-97-1720(1)(c), -0360(1-3). [...]

Inspectors wrote<Hand Hygiene> <Dining> Observations of meal tray pass on 06/08/2025 at 12:53 PM, showed Staff V delivering a lunch tray to a resident in room [ROOM NUMBER]. While in the room, Staff V touched items on the bedside table and exited the room without performing HH. Staff V then wiped their face with their hand, picked up another tray, delivered the tray to a resident in room [ROOM NUMBER], and exited the room without performing HH. At that time, Staff V approached a resident in a wheelchair and pushed them to room [ROOM NUMBER]. At 12:59 PM, Staff V picked up another tray to deliver to a resident in a room with TBP. Staff V did not perform HH since observations started at 12:53 PM. In an interview on 06/13/2025 at 10:42 AM, Staff H stated it was their expectation staff complete HH before entering resident rooms, after touching items in a resident's room, and after exiting rooms. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure the correct type of sling was used to safely transfer 1 of 3 residents (Resident 1) reviewed for mechanical lift transfers. Resident 1 experienced harm when they were transferred incorrectly and sustained a spinal injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 of 6 residents (Residents 218 & 15) reviewed for nutrition and hydration, and one supplemental resident (Resident 57) maintained acceptable parameters of nutritional status. The failure to ensure residents were consistently provided required eating assistance, and ordered weights were obtained and analyzed to determine the need for new interventions as ordered placed residents at risk for unwanted weight loss, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to consistently serve meals within the posted timeframe's for 2 of 3 hallways (100/200 Hall Dining Cart) for meals served to residents who ate in their rooms. Failure to serve meals in a timely manner placed residents at risk of nutritional concerns, food temperatures served outside the of the desired temperature range, and a decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident meals were prepared or stored in accordance with professional standards of food safety for 1 of 1 facility kitchens, and 1 of 2 unit refrigerators. The failure to ensure staff hair was secured in food preparation areas, that all refrigerated food was dated and labeled as required, and food was covered when in the hall left residents at risk for food contamination, food borne illnesses, and spoiled food.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and services in a manner that maintained and promoted dignity while assisting with meals for 3 of 18 residents (Resident 29, 5, & 12) reviewed for dining observations. This failure placed the resident at risk for a diminished self-worth and over-all well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a comfortable, appropriately sized bed for 1 of 1 resident (Resident 15) reviewed for accommodation of needs. This failed practice placed the resident at risk for discomfort and skin issues.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge for 2 (Residents 23 & 28) of 2 residents reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge, in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA), including Care Area Assessments (CAAs), was completed within 14 days for 1 of 1 resident (Resident 57) reviewed for a decline in nutritional intake and a change in skin integrity. Failure to identify Resident 57's change in status and complete a SCSA placed the resident at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was obtained, accurate, and/or available in the resident's records to reflect the residents' mental health conditions for 2 of 6 (Resident 61 & 29) residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop comprehensive Care Plans (CP) for 3 (Residents 5, 34, & 8) of 18 sampled residents whose comprehensive CPs were reviewed. Failure to establish individualized CPs with identified goals that accurately reflected the resident's condition, placed residents at risk for unmet care needs.

Inspectors wrote<Resident 53> Review of the 03/25/2024 Quarterly MDS, showed Resident 53 had no memory impairment and had diagnoses of a stroke with limited mobility to one side of their body. This assessment showed Resident 53 required staff assistance with set up and clean up of the resident's meal. Resident 53 did not require assistance from staff to feed themself. Review of Resident 53's 02/28/2024 revised Baseline CP, showed Resident 53 required moderate assistance and was dependent on staff to eat their meals. Observation on 05/09/2024 at 8:40 AM showed Resident 53 sitting up in bed feeding themself breakfast. Similar observations were made on 05/13/2024 at 1:45 PM and 05/14/2024 at 1:08 PM. In an interview on 05/16/2024 at 11:27 AM, Staff B stated Resident 53 was independent with eating and confirmed staff needed to updated Resident 53's CP but did not. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: Physician's Orders (POs) were followed and/or clarified for 4 (Residents 50, 19, 29, & 57) and nurses signed only for tasks completed for 2 (Residents 57 & 29) of 18 sample residents. These failures left residents at risk for unmet care needs, unnecessary treatment, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs) for 3 (Residents 25, 15, & 218) of 3 residents who were assessed to be dependent on staff for ADLs. The failure to provide ADL assistance as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with Diabetes Mellitus (DM - a condition making the regulation of Blood Glucose [BG] more difficult) received the care and services needed to manage their blood sugar for 1 of 1 residents (Resident 50) reviewed for administration of a BG lowering medication. The failure to notify the physician when the resident's BG fell below 80 milligrams per deciliter (mg/dl) left the resident at risk for blurred vision, fatigue, confusion, delirium, loss of consciousness, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with hearing deficits were provided the assistance they were assessed to require for 1 of 1 residents (Resident 218) reviewed for hearing needs. These failures placed Resident 218 and other residents at risk for ineffective communication, unmet care needs, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a restorative program was provided for 4 of 5 (1, 29, 22, & 8) sample residents identified by staff with mobility limitations and reviewed for Range of Motion (ROM). These failures placed residents at risk for declines in ROM, reduction in mobility, increased dependence on staff, and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure 2 (Residents 9 & 118) of 5 residents reviewed for unnecessary medications were free from unnecessary psychotropic drugs. Failure to document rationale and identify a failed Gradual Dose Reduction (GDR) for Resident 9 and ensure informed consent was obtained prior to administration (Resident 118) placed residents at risk to receive unnecessary medications and/or adverse side effects.

Inspectors wroteBased on observation and interview, the facility failed to ensure expired medications were disposed of timely for 2 of 2 medication carts and 1 of 1 central supply room and medications were stored securely in accordance with professional standards for one supplementary treatment cart. This failure placed residents at risk for receiving expired medications and at risk for medication errors.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure prompt dental services were provided for 2 (Resident 45 & 35) of 6 sample residents reviewed for dental services. This failure placed the residents at risk for unmet dental needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide meals that accommodated resident food preferences for 2 (Resident 8 & 45) of 6 sample residents reviewed for preferences, and one supplementary resident (Resident 55). This failure placed residents at risk for weight loss, frustration, and a diminished quality of life.

Inspectors wrote<Resident 25> According to a 04/18/2024 Annual MDS, Resident 25 was assessed to require hospice services. Review of Resident 25's records showed hospice notes from February, March, and April 2024 were not scanned into the resident's records by staff until May 2024. Review of a hospice binder located at the nurse's station on 05/10/2024 at 12:18 PM showed no hospice notes for Resident 25 after 11/08/2023. In an interview on 05/14/2024 at 11:39 AM, Staff M (Medical Records) stated they had some hospice notes that needed to be scanned for Resident 25 that were, put in my box within the last week. Staff M stated they expected the hospice records to be readily available in the resident records and stated hospice leaves their notes with the resident care manager. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection control practices that provided a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to ensure staff followed the instructions as written on signs posted on resident doors requiring staff to wear Personal Protective Equipment (PPE) for 1 (Residents 36) of 4 residents reviewed and 1 supplemental (Resident 16) resident reviewed, properly store resident urinals for 2 (Residents 46 & 57) of 3 residents reviewed, and maintain clean resident equipment for 1 (Resident 29). These failures placed residents at risk for the development and transmission of communicable disease and infections.

Inspectors wroteBased on interview and record review the facility failed to provide the Specialized Rehabilitative Services of Physical Therapy, (PT) , that 14 ( Residents 53, 15, 59, 7, 26, 12, 51, 45, 43, 35, 1, 36, 63, 10, ) of 22 residents reviewed for therapy services were assessed to require. Failure to provide PT placed residents at risk for decline in physical and functional mobility, deterioration of muscle strength, delay of discharge, non payment of Skilled Nursing Facility stay by their insurance companies, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility administration failed to obtain and use resources to manage the facility effectively and efficiently to maintain substantial compliance with federal regulatory requirements. The Administration failed to ensure residents received the Specialized Rehabilitation Services they were assessed to require, failed to ensure the facility could meet the needs of the resident population by not admitting residents with Specialized Rehabilitation Services needs and/or retaining residents whose needs the facility could not meet. In addition, the Administration failed to provide administrative oversight and monitoring of facility personnel, systems, practices, and policies related to infection control. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases, including COVID-19 and infections. COVID-19 is an infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death. The facility failed to ensure infection control interventions, intended to mitigate the risk of COVID-19 were consistently implemented for 32 (Residents 31, 10, 26, 29, 32, 52, 62, 56, 24, 9, 54, 28, 37, 57, 18, 53, 60, 2, 3, 45, 42, 47, 6, 39, 11, 48, 13, 61, 49, 17, 44 & 43) of 36 sampled residents. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop comprehensive person-centered Care Plans (CP) for 6 (Residents 10, 13, 19, 39, 45 & 32) of 16 residents reviewed for COVID-19 Care Plans. Failure to develop comprehensive CPs for refusal to comply with infection control procedures (Resident 10, 13, 19, 39 & 45), or potential psychological adjustment to restrictions (Resident 13) left residents at risk for unmet care needs, and negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to post the daily nurse staffing information including the total number of and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift and the number of current residents residing in the facility. The failure to post required nurse staffing information daily and failure to retain the daily posted documents for a minimum of 18 months. This failure prevented the residents, family members, and visitors from exercising their rights to know the actual numbers of available nursing staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain a Quality Assurance and Performance Improvement program (QAPI) that identified deficiencies and implemented appropriate preventative or corrective actions. The facility's QAPI program failed to timely recognize noncompliance with facility systems that resulted in deficiencies in Rehabilitation Services, placing residents at risk of unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure notification of room change was consistently provided prior to room changes for 4 of 4 residents (Resident 26, 17, 3 & 35) reviewed. This failure created confusion and anxiety and placed residents at risk for a diminished quality of life when decisions were made without their input.

Inspectors wroteBased on interview and record review, the facility failed to establish a system that ensured residents who were transferred to the hospital or went on therapeutic leave were provided a written notice of bed hold that specified the duration of the bed-hold policy upon transfer or attempted to contact the resident and/or resident representative within 24 hours from an emergency transfer for 5 of 7 sampled residents (Resident 35, 37, 41, 18 & 5) reviewed for hospital transfers. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nursing services were provided within professional standards of nursing for 6 of 17 (Residents 28, 5, 30, 37, 15 & 35) residents reviewed. Nursing staff failed to follow physician orders (Residents 28), signed for tasks not performed (Residents 5 & 30), clarify physician orders (Residents 37 & 15), and notify a physician of elevated blood sugar levels according to order parameters (Resident 35). These failures placed the residents at risk for medication and treatment errors, and adverse outcomes.

Inspectors wroteBased on interview and record review the facility failed to ensure 3 (Residents 28, 3, & 10) of 5 residents reviewed for unnecessary medications were free from unnecessary psychotropic drugs. Failure to attempt Gradual Dose Reductions (GDRs) for the administration of psychotropic medications. placed residents at risk to receive unnecessary medications and/or adverse side effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain infection control practices that provided a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to ensure staff: followed the instructions as written on signs posted on resident doors requiring staff to wear Personal Protective Equipment (PPE) for 3 (Residents 37, 10, & 36) of 7 residents in accordance with the Centers for Disease Control (CDC) recommendations, cleaned equipment used for 2 (Resident 17 & 3) of 5 residents, and performed hand hygiene and changed gloves while providing care for 3 (Residents 9, 25, & 35) of 16 residents. These failures placed residents at risk for the development and transmission of communicable disease and infections.

Inspectors wroteBased on interview and record review the facility to notify 3 (Residents 3, 24, & 26) of 4 residents reviewed, who were Medicaid recipients, when their personal fund account balances reached $1800 (i.e. within $200 of the $2,000 resource limit beneficiaries could possess, without their Medicaid coverage being impacted). This failure placed residents at risk for personal financial liability for their care.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were informed and provided written information concerning their rights to accept, refuse, or formulate an Advance Directive (AD) for 2 (Residents 37 and 36) of 16 residents reviewed for ADs. This failure placed residents at risk for not having a surrogate decision maker when unable to make their own healthcare decisions. This failure placed the residents at risk of losing their rights to have their stated preferences/decisions regarding end-of-life care followed.

Inspectors wroteBased on interview and record review, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABN: a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare. Beneficiaries may choose to continue the services but may be financially liable.) as required for 1 (Resident 450) of 3 residents, reviewed for SNF ABN, whose Medicare stay ended. This failure placed residents at risk for not having adequate information to make care and financial decisions during their continued stay.

Inspectors wroteBased on observation, interview and record review the facility failed to develop comprehensive Care Plans (CP) for 3 (Resident 41, 3 and 37) of 17 sampled residents whose comprehensive CPs were reviewed. Failure to establish individualized CPs with identified goals that accurately reflected the resident's condition, placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Care Plans (CP) were reviewed and revised for 4 (Resident 5, 30, 15, & 7) of 17 residents whose CPs were reviewed. This failure placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a restorative program was developed and initiated for 2 of 5 residents (Resident 3 & 18) identified by staff with mobility limitation and reviewed for Range of Motion (ROM). These failures placed residents at risk for decline in ROM, a reduction in mobility, increased dependence on staff, and decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure expired medications, liquid feeding supplement, medical supplies, and intravenous (IV) solution were disposed of timely for 1 of 1 central supply/medication room, 2 of 4 medication carts, and 1 of 1 Automated Medication Dispensing (AMD) system reviewed for medication storage. The facility failed to secure resident medications safely for 2 residents (Resident 20 & 37) and failed to label multi-dose medications with the open date for 3 residents (Resident 6, 37 & 299) in accordance with current accepted professional standards of practice. These failures placed residents at risk for accidental ingestion of medications, receiving medications with decreased or no potency, and use of medical supplies with compromised integrity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that accommodated resident's identified food preferences and/or intolerances for 2 of 7 sampled residents (Residents 5 & 3) and 2 supplemental residents (Resident 20 & 16) reviewed for food preferences. The failure to provide food that met the resident's individual needs and preferences, placed residents at risk for weight loss and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain a Physician Order (PO) for hospice care, and to ensure the development of a coordinated Care Plan (CP) for 1 of 2 residents (Resident 15) reviewed for hospice care services. These failures placed the resident at risk for not receiving necessary hospice services, lack of continuity of care, and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 (Residents 37 & 10) of 5 residents reviewed for vaccinations, were offered the recommended Pneumonia vaccinations in accordance with the Centers for Disease Control (CDC) guidelines. This failure placed residents at risk for contracting pneumonia, with the associated complications of infection.