Gig Harbor Health and Rehabilitation

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean and comfortable environment for 4 of 4 hallways (hallways 100, 200, 300, and 400) reviewed for physical environment. This failure placed residents at risk of unsanitary conditions, less than a homelike environment , and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care for 3 of 6 residents (Resident 1, Resident 2, and Resident 3) and failed to provide timely hygiene for 2 of 6 residents (Resident 4 and Resident 5) reviewed for ADLs (activities of daily living). This failure placed residents at risk of pain, infection, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to prevent significant medication errors by administering medications to the wrong resident for 1 of 3 residents (Resident 1) reviewed for medication errors. Resident 1 experienced harm when they were transferred to the hospital for a life-threatening medication overdose requiring life support. This failure placed residents at risk for negative side effects of medications, hospitalization, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to protect resident's right to be free from physical abuse for 2 of 4 sampled residents (Residents 1 and 3) reviewed for resident-to-resident altercations. This failure placed residents at risk for abuse, psychosocial harm, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to thoroughly and accurately document incidents for 2 of 5 sampled residents (Resident 3 and Resident 5) reviewed for professional standards in quality of care. This failure placed residents at risk for unmet care needs, medical complications, and decision makers having an incomplete picture of resident progress.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse timely for 1 of 3 sampled residents (Resident 1) reviewed for abuse. This failure placed residents at risk of abuse, mental anguish, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect a resident's right to be free from sexual abuse and timely put appropriate interventions in place to protect vulnerable residents for 1of 2 sampled residents (Resident 1) reviewed for abuse. This failure placed residents at risk of further abuse, mental anguish, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to immediately report to the state agency, witnessed sexual abuse for 1 of 2 residents (Resident 1) reviewed for abuse. This failure placed residents at risk of further abuse, psychological distress, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program to correct identified noncompliance and ensure changes were maintained to ensure ongoing compliance. This failure placed residents at risk of lacking quality medical care, abuse/neglect, foodborne illness, preventable infections, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain consent for mental health medications for 4 of 5 sampled residents (Resident 3, 7, 5, and 78) when reviewed for unnecessary medications. This failure placed residents at risk of unwanted side effects, lack of knowledge regarding medication side effects, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to address grievances brought by the resident council related to resident care, staff concerns, and dietary for 5 of 5 sampled months of resident council meetings (July, August, September, October, and November 2025) when reviewed for resident council. This failure placed 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 minimum data set assessment (MDS) accurately reflected the status for 4 of 22 sampled residents (Residents 45, 7, 5, and 83) when reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to initiate a baseline care plan for 2 of 19 sampled residents (Residents 8 and 6) when reviewed for baseline care plans. Failure to timely initiate a dental or bathing care plan for resident 8 and/or a skin risk care plan for Resident 6 placed the residents at risk for unmet care needs and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to conduct timely care conferences with the resident/responsible party for 3 of 22 sampled residents (Residents 45, 11, and 6) when reviewed for care planning. This failure placed the residents at risk for unmet needs, not being involved or informed of their plan of care and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice and the comprehensive person-centered care plan for 4 of 22 residents (Residents 96, 24, 11, and 14) when reviewed for quality of care and/or Hospice services. Failure to provide bowel management for Resident 14, to obtain and review hospice services notes for Residents 96, 24, and 11, and to develop a collaborative comprehensive care plan involving Hospice service for Residents 24 and 11, placed the residents at risk for unmet needs, clinical complications and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for 2 of 2 sampled residents (Residents 86 and 14) when reviewed for fluid restrictions. This failure placed the residents at risk for medical complications and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe food storage in 3 of 3 resident refrigerators (100 Hall, 300 Hall, and Serenity Unit Refrigerators) and failed to ensure safe food re-heating for 1 of 2 re-heating microwaves (300 Hall Microwave) when reviewed for kitchen. This failure placed residents at risk of eating expired and/or contaminated foods, foodborne illness, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an infection control program to monitor for and manage infections for 2 of 3 months (September and October 2025) and 2 of 22 residents (Residents 73 and 12) when reviewed for infection control. Failure to collect and analyze the infection control data and implement measures to reduce infections for the months of September and October 2025 and failure to provide infection prevention measures for an indwelling urinary device and abdominal drain for Residents 12 and 73 placed the residents at risk for infections, poor clinical outcomes, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to offer, educate, and obtain consent for influenza and pneumococcal vaccines for 3 of 5 sampled residents (Residents 6, 15, and 23) when reviewed for influenza and pneumococcal immunizations. These failures denied residents the opportunity to make an informed decision regarding receiving immunizations and/or placed the residents at risk for communicable diseases, complications of other medical conditions, hospitalization, and death.

Inspectors wroteBased on interview and record review, the facility failed to offer, educate, and obtain consent for Covid-19 vaccines for 3 of 5 sampled residents (Residents 6, 15 and 23) when reviewed for immunizations. This failure denied residents the opportunity to make an informed decision regarding receiving immunizations and/or placed the residents at risk for communicable diseases, complications of other medical conditions, hospitalization, and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure mechanical lifts were in safe working order for 2 of 2 mechanical lifts (Free Spirit and Tenor) when reviewed for activities of daily leaving. This failure placed the residents at risk of avoidable injuries, falls and diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide necessary housekeeping in resident rooms for 3 of 4 halls (Halls 100, 200 and 300) reviewed for safe, clean, functional and comfortable environment. These failures placed residents at risk for unsanitary conditions, less than a homelike environment and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and provide appropriately sized wheelchairs for 1 of 3 sampled residents (Resident 1) when reviewed for accommodation of needs. This failure placed the Resident at risk for skin breakdown, pain in lower back and hips, inability to use the wheelchair for an extended time, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor resident choices for 1 of 22 sampled residents (Resident 78) when reviewed for choices. Failure to accommodate Resident 78's choice for ice water when requested placed the resident at risk for decreased quality of life and diminished self-worth.

Inspectors wroteBased on interview and record review, the facility failed to periodically review a residents advanced directive for 1 of 4 sampled residents (Resident 96) when reviewed for advanced directive. This failure placed the residents at risk of not being able to designate a healthcare designee and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete and/or implement thorough investigations to rule out abuse or neglect related to falls for 1 of 3 sampled residents (Resident 11) when reviewed for accidents/falls. These failures placed Resident 11 at risk for unidentified abuse or neglect, continued exposure to abuse and/or neglect, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to follow up on a Preadmission Screening and Resident Review (PASRR, a mental health screening tool) for 1 of 7 sampled residents (Resident 4) when reviewed for PASRR. This failure placed residents at risk for unmet needs and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate comprehensive care plans for 2 of 22 sampled residents (Residents 4 and 78) when reviewed for comprehensive care plans. Failure to initiate a plan of care for epilepsy for Resident 4 and ensure the care plan was accurate and included monitoring behaviors and side effects for use of antidepressant and antianxiety medication use for Resident 78 placed the residents at risk for unmet needs and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure provider's orders to monitor orthostatic blood pressure was followed for 1 of 5 sampled residents (Resident 5) when reviewed for unnecessary medications. This failure placed the resident at risk for dizziness when laying and sitting, avoidable falls, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to maintain physical and psychosocial well-being for 1 of 22 sampled residents (Resident 14) when reviewed for quality of life. Failure to provide an escort/caregiver for a dependent resident when going to a doctor's appointment placed the resident at risk for unmet care needs, diminished self-worth, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure a resident's ability to participate in activities of daily living did not diminish for 1 of 22 sampled resident (Resident 45) reviewed for activities of daily living (ADLs) and therapy services. Residents 45 experienced harm when they had a decline in mobility in the areas of sit to stand, toilet transfers and ambulation. This failure placed residents at risk of decreased mobility and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services to maintain vision for 1 of 3 sampled residents (Resident 15) when reviewed for communication/sensory. This failure placed the resident at risk for unmet needs, continued visual impairment, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to investigate the root cause of a fall, ensure new interventions were developed or timely initiated, and/or referrals/screenings were completed to minimize falls for 1 of 3 sampled residents (Resident 11) when reviewed for accidents/falls. This failure placed Resident 11 at risk for falls, injuries, medical complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a behavioral health provider's recommendations for changes in mental health medications were considered/implemented for 1 of 5 sampled residents (Resident 5) when reviewed for unnecessary medications. This failure placed the resident at risk of ineffective mental health medication regimen, increase of avoidable behaviors, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure medically related social services, including follow up, monitoring and assessment of intervention effectiveness, were provided for a resident with a mental health diagnosis and a history of making negative statements for 1 of 22 sampled residents (Resident 30) when reviewed for medically related social services. This failure placed residents at risk for unwanted behaviors, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including providing medication without a dosage and not following a prescribed order) to meet the needs of 2 out of 3 sampled residents (Residents 51 and 37) when reviewed for medication administration. Failure to timely remove a medicated topical patch for Resident 51 and to provide medication without a dosage to Resident 37, placed residents at risk for medical complications and a poor quality of life.

Inspectors wroteBased on interview and record review, the facility failed to consistently provide non-pharmacological interventions (NPI, health interventions/approaches used instead of medication) for 2 of 5 sampled residents (Residents 5 and 78) when reviewed for unnecessary medications. This failure placed the residents at risk of receiving unnecessary medications, avoidable medication side effects, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in 1 of 3 medication carts (Run Four Medication Cart) and 1 of 2 medication rooms (Peak Medication Room) when reviewed for medication storage. This failure placed residents at risk of receiving expired medications, ineffective treatment, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental services for 1 of 2 sampled residents (Resident 1) reviewed for dental needs. This failure placed the resident at risk of having discomfort, difficulties eating, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure quality of care was provided by timely obtaining emergency services and thoroughly documenting alert charting for 3 of 3 sampled residents (Resident 1, 2, and 3) reviewed for falls. Resident 1, who was on a blood thinning medication, experienced harm when the facility failed to obtain immediate medical care after an unwitnessed fall with a head injury; the resident developed a latent post fall subdural hematoma (a brain bleed that can happen after a head injury) that required emergency room transfer, surgery, and hospitalization. This failure placed the residents at risk for medical complications, delay in care and services, potential death, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide necessary supplies for toileting needs for 2 of 3 residents (Residents 5 and 6) reviewed for Activities of Daily Living. This failure placed residents at risk for increased discomfort and a diminished quality of life. RESIDENT 5Resident 5 admitted to the facility on [DATE] with multiple diagnoses. The admission minimum data set (MDS, an assessment tool), dated 06/17/2025 showed Resident 5 had moderate cognitive impairment, but was able to make their needs known and was moderately dependent on staff for toileting hygiene. During an interview on 07/24/2025 at 2:02 PM, Resident 5 said the facility had run out of briefs three times since their admission to the facility. Resident 5 said it could take the facility between 3-5 days to get their size of brief in the building. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure infection control standards were followed related to not following the Centers for Disease Control and Prevention (CDC) by implementing droplet precautions with residents suspected of having Tuberculosis (TB: an infectious disease caused by bacteria called Mycobacterium tuberculosis, primarily affecting the lungs but potentially impacting other parts of the body) for 1 of 5 residents (Resident 1), reviewed for infection control. This failure placed residents, staff and visitors at risk for possibly contracting and spreading infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staff were available to provide assistance with activities of daily living and prevent falls for 3 of 4 halls (100, 200 & 300) reviewed for sufficient staffing. This failure placed residents at risk for unmet care needs, risk if increased falls and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors when medications were not administered in accordance with provider orders for 1 of 8 sample residents (Resident 1) reviewed for medication errors. This placed residents at risk for adverse medical conditions, changes in health conditions, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to conduct a prompt and thorough investigation that included immediate interventions and reporting for 1 of 8 sample residents (Resident 1) reviewed for falls. The failure to implement the facility's accidents and incident policy and procedure, placed residents at risk for further exposure to falls/injuries, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from abuse for 1 of 6 sample residents (Resident 1) reviewed for abuse. Resident 1 experienced physical harm when the resident was moved out of the way abruptly while sitting in their wheelchair causing injury to their knee. This failure placed residents at risk for ongoing abuse and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain medications were available and failed to obtain provider's orders for an alternate pain medication of similar strength, for 1 of 3 sampled residents (Resident 1) reviewed for pain management. This failure placed residents at risk for increased pain and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision of two person staff assistance with bed mobility while providing care to prevent accident/falls for 2 of 3 sampled residents (Resident 1 and 2) reviewed for falls. Resident 1 experienced harm when care was provided by one staff that resulted in a fall from bed and injury requiring hospital evaluation. This failure placed residents at risk of injury, unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the transmission of a communicable disease by implementing facility policies and/or outbreak protocols timely for 10 of 94 sampled residents (Residents 15, 14, 83, 352, 9, 351, 91, 344, 346 and 81) when reviewed for infection control/outbreak management. Residents 14, 83 and 9 experienced harm when they were sent to the hospital for illness and/or treated for complications after the facility failed to recognize an illness related to an infectious disease. The facility failed to implement transmission-based precautions (TBP) for 2 of 4 halls (100 and 200 Halls) when reviewed for TBP and ensure sanitary use of washing machines when reviewed for laundry. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program self-identified deficiencies and failed to develop/implement effective plans of action to sustain plan of corrections for previous deficiencies. Failure to have an effectively functioning QAPI program that consistently self-identified deficient practices led to repeated deficiencies, a pattern of deficiencies, widespread deficiencies, and a pattern of actual harm that placed residents at repeated risk for unmet needs that could negatively impact their safety, quality of life and quality of care.

Inspectors wroteBased on interview and record review, the facility failed to initiate, investigate, and resolve a grievance for 2 of 2 sampled residents (Residents 14 and 66) reviewed for personal property and grievances. This failure placed the residents at risk for emotional distress and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the reason for transfer/discharge to the resident or responsible party of discharges to the hospital for 2 of 2 sampled residents (Residents 38 and 66) reviewed for hospitalization. This failure denied the resident or responsible party knowledge of their rights regarding transfer/discharge from the facility.

Inspectors wroteResident 5 Review of the EHR showed Resident 5 readmitted to the facility on [DATE] with diagnoses to included anxiety disorder, depression, and bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). Resident 5 was able to make needs known. Review of the PASRR level one, dated 05/18/2022, showed Resident 5 had mood disorder- depressive, bipolar disorder and anxiety disorder; however, it showed No Level II [two] evaluation indicated. During an interview on 12/09/2024 at 9:22 AM, Staff F, SSD, stated Resident 5's PASRR level one dated 05/09/2024 showed the resident had serious mental illness indicators marked and should have had a referral for a PASRR level two evaluation. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct timely care conferences with the resident/responsible party for 4 of 17 sampled residents (Residents 17, 35, 47, and 65) when reviewed for care planning. This failure placed the residents at risk for unmet needs, not being involved or informed of their plan of care, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services to ensure residents increased or maintained range of motion (ROM) were provided for 3 of 5 sampled residents (Resident 17, 35, and 20) reviewed for position, range of motion/mobility. This failure placed the residents at risk for worsening mobility, developing of contractures (permanent tightening of muscle, tendons and skin, leading to deformity), and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to consistently conduct and document pre and post dialysis (treatment to filter wastes and water from the blood) assessments and ensure consistent ongoing communication and collaboration with the dialysis center regarding dialysis care and services for 2 of 2 sampled residents (Residents 65 and 66) reviewed for dialysis. This failure placed the residents at risk for unmet care needs and medical complications.

Inspectors wroteBased on interview and record review, the facility failed to use nonpharmacological interventions (NPI, nonmedicated methods of achieving an outcome) prior to the use of as needed (PRN) pain medications for 3 of 5 sampled residents (Residents 53, 14, and 66) when reviewed for unnecessary medications. This failure placed residents at risk of avoidable side effects, taking unneeded medications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of 13 errors were made in 31 opportunities during a medication administration for 1 of 3 sampled residents (Resident 396) reviewed for medication administration. This placed the residents at risk for receiving medications that were not effective or less effective and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in 3 of 3 medication carts (Run 3, Peak 1, and Run 4) and 2 of 2 medication rooms (South and North) when reviewed for medication storage. The facility failed to have prescription medications locked in the medication room for 1 of 2 nurses' stations (North Nurses' Station). This failure placed residents at risk for receiving expired medications, ineffective treatment, accidental ingestion of medication, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed explain and ensure residents understood the arbitration agreement for 3 of 3 residents (Residents 75, 14, and 31) when reviewed for arbitration agreement. This failure placed residents at risk of forfeiting their right to a jury trial, inability to seek restitution for errors made by the facility, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use, and decrease the development of antibiotic resistance by not ensuring criteria were met for the use of antibiotics and an indication for use/type of infection was included in the provider orders for 6 of 10 sampled residents (Residents 9, 45, 15, 14 , 63 and 26) when reviewed for antibiotic stewardship. These failures placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide risks/benefits and obtain consent for the use of an antidepressant for 1 of 5 sampled residents (Resident 53) when reviewed for unnecessary medication. This failure placed the resident at risk of unknown side effects of the medication, lack of decision-making power in treatment decisions, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure an environment free from verbal abuse for 1 of 3 sampled residents (Resident 45) reviewed for abuse. This failure placed residents at risk for ongoing abuse and neglect, unmet needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify and report an allegation of abuse for 1 of 3 sampled residents (Resident 45) reviewed for abuse. This failure placed residents at risk for unidentified and repeated potential abuse, neglect, or mistreatment, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly report allegations of abuse for 1 of 3 sampled residents (Residents 85) reviewed for abuse. This failure placed residents at risk repeated potential abuse, neglect, or mistreatment, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected the status for 2 of 20 sampled residents (Residents 69 and 346) reviewed for accuracy of assessments. Failure to accurately code Resident 69's use of corrective lenses, and Resident 346's antibiotic therapy and continuous oxygen therapy, placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and/or implement a comprehensive care plan for 4 of 20 sampled residents (Residents 17, 35, 20, and 346) when reviewed for care plan. Failure to develop and implement care plans that were individualized, and accurately reflected resident care needs related to, limited range of motion/impaired mobility, restorative nursing services, palm guard and/or splint application, peripherally inserted central catheter (PICC, a tube inserted through the arm and into the heart), antibiotic therapy, and sepsis (a life-threatening complication of an infection), placed residents at risk for unmet care needs and potential negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide and accurately document the necessary care and services to ensure that a resident received showers as scheduled and had facial hair removed for 1 of 4 sampled residents (Resident 35) reviewed for activities of daily living (ADLs). This failure placed the resident at risk for continued unmet needs and a poor quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow provider's orders for 2 of 7 sampled residents (Residents 66 and 8) when reviewed for non-pressure related skin conditions and unnecessary medications and failed to evaluate wheelchair positioning for 1 of 5 residents (Resident 17) when reviewed for positioning/mobility. These failures placed the residents at risk for poor clinical outcomes and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide services to maintain vision for 1 of 3 residents (Resident 65) reviewed for communication sensory. This failure placed the resident at risk of unmet vision needs, inability to perform activities of daily living, inability to participate in leisure activities and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received necessary care and assistance to maintain continence for 1 of 6 sampled residents (Resident 394) reviewed for bowel and bladder incontinence, and unnecessary medications. This failure placed the resident at risk for incontinence, skin injuries, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received the correct amounts of supplemental nutrition for 2 of 2 sampled residents (Residents 34 and 81) and failed ensure diet recomendations and fluid restrictions were implemented for 2 of 5 sampled residents (Residents 19 and 74) reviewed for nutrition. These failures placed residents at risk for medical complications, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care according to professional standards of practice for 1 of 3 sampled residents (Resident 74) reviewed for respiratory care. This failure placed the resident at risk for infection, unmet needs, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 3 sampled residents (Resident 85) reviewed for abuse. The facility failed to recognize and follow-up on a resident after a traumatic experience in their room. This failure placed the residents at risk for unmet needs, continued emotional disturbance, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor for behaviors for 2 of 5 sampled residents (Residents 57 and 8) review for use of psychotropic medications (medications that affect a person's mental status). This failure placed the residents at risk for adverse side effects, unknown behaviors, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitored refrigerator temperatures and take corrective action as needed for 1 of 3 resident refrigerators (South Clean Utility Fridge) when reviewed for kitchen. This failure placed residents at risk of consuming spoiled food goods, avoidable foodborne illnesses, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from physical restraints for 1 of 3 sampled residents (Resident 1) reviewed for Abuse. This failure placed the resident at risk for injury, limited freedom of movement and a decreased quality of life. The facility has corrected the above deficiency prior to the abbreviated survey and constituted as past non-compliance (the facility was not in compliance at the time the incident occurred; however, there was sufficient evidence the facility corrected the non-compliance after it was identified) and is no longer outstanding.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided timely for one of three residents (Resident 1) reviewed for falls. The facility's failure to obtain immediate medical care placed Resident 1 at risk for distress and delay in evaluation and treatment when the resident sustained a head injury after a fall.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when 3 of 3 residents' (Residents 1, 2, 3) physician recommendations or orders were not carried out timely, assessment and monitoring of wounds and changes in condition were not done, and coordination of care with providers was incomplete. These failures placed residents at risk for harm from worsening or potential infections and wounds and placed residents at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 3 residents (Resident 1 and 2), reviewed for accidents, were assessed or re-assessed for elopement risk and care plans were revised to include interventions to migitate risk for or prevent elopement. In addition, facility failed to ensure staff received education regarding prevention of elopement. These failures placed Resident 1 at risk for injury when the resident eloped to a potentially unsafe home setting and interventions to prevent elopement were not in place; and placed Resident 2 at risk for injury when the resident was not re-assessed for elopement risk and care plan was not revised after being moved from an alarmed unit to an unalarmed unit upon a change in medical condition and the resident was found attempting to leave the facility through an employee exit.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when a change of condition was not assessed timely and when wound closure device interventions were not consistently provided for a non-pressure skin conditions for 2 of 22 sampled residents (85 & 71) reviewed for quality of care related to change of condition and non-pressure skin condition. This caused harm to Resident 85 when the resident's change of condition was not assessed and monitored timely by staff and not reported to the medical provider for evaluation which delayed interventions and the resident being emergently transferred to the hospital for treatment. These failures placed residents at risk for unmet care needs, poor clinical outcomes and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a kitchen environment which allowed each resident to receive nourishing, palatable, and well-balanced meals when reviewed for kitchen. This failure placed residents at risk of decreased mood, feelings of worthlessness, lack of nutritional intake, avoidable weight loss, foodborne illness, and a diminished quality of life.

Inspectors wroteBased on interview, the facility failed to ensure the dietary manager (DM) was qualified for food and nutrition services for 1 of 1 DM (Staff P) reviewed for qualified dietary staff. This failure placed residents at risk of foodborne illness, avoidable discomfort, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen had sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 facility kitchen. This failure placed residents at risk of delayed mealtimes, lack of sanitation in the kitchen, foodborne illness, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to prepare meals that were palatable and appetizing for 8 of 8 sampled residents (64, 71, 30, 82, 36, 25, 77 & 17) reviewed for food value and palatability. This failure placed residents at risk of decreased nutritional intake, depressed mood, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that accommodated resident preferences for 1 of 6 sampled residents (Resident 64) reviewed for food preferences. This failure placed residents at risk of reduced nutritional intake, decreased mood, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared, served and stored, in a sanitary manner for 3 of 3 kitchen refrigerators (Refrigerator #1, Refrigerator #2, and Walk-in Refrigerator), 3 of 3 resident use refrigerators (North Hall Refrigerator, South Hall Refrigerator, and Minifridge) and 5 of 5 other food storage areas (Dry Storage, Bread Shelves, Back Preparation Area, Spice Shelf, and Under Preparation Table) reviewed for sanitary food preparation, service and storage. This failure placed residents at risk of consuming expired food items, foodborne illness, avoidable discomfort, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program to control and prevent the transmission of communicable diseases by ensuring the proper application of transmission-based precautions (TBP) to ensure the proper use of personal protective equipment (PPE) by staff during a respiratory virus outbreak on 2 of 4 sampled hallways (100 & 200) and the facility failed to track infectious organisms present in the facility for 3 of 3 sampled months (November 2023, December 2023 & January 2024) reviewed for infection prevention and control. These failures placed residents, visitors and staff at risk for communicable diseases, infections, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the infection prevention and control program (IPCP) was overseen by a qualified individual with the time and training necessary to properly assess, develop, implement, monitor, and manage the IPCP for the facility, address training requirements, and participate in required committees such as Quality Assurance and Performance Improvement for 1 of 1 infection control preventionist (ICP) (Staff U) reviewed for infection preventionist qualifications. This failure placed residents, family members and staff at risk of contracting communicable diseases and a decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure kitchen equipment, that was powered by a gas line, was maintained to prevent a grease build-up which could create a fire hazard and placed residents at risk for smoke inhalation in 1 of 1 kitchen reviewed for safe operating equipment.

Inspectors wrote<Resident 10> Review of the quarterly MDS, dated [DATE], showed Resident 10 admitted on [DATE] with diagnoses including heart and lung disease, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the inability to carry out simple tasks), and depression. In addition, the resident's EHR showed diagnoses of dementia with psychotic disturbances, bipolar (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and anxiety. The MDS further showed that the resident was able to make needs known. Review of Resident 36's providers orders for January and February 2024 MAR showed multiple orders for staff to administer several psychotropic medication to include: [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain or offer assistance in formulating or periodically checking if residents had an advance directive (AD) for 4 of 5 residents (Residents 10, 17, 31 and 71) reviewed for AD. This failure placed the residents at risk to be denied the opportunity to direct their health care if they were to become unable to make decisions or communicate their health care preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report allegations of abuse for 2 of 6 residents (Residents 82 and 13) reviewed for abuse and neglect. This failure placed residents at risk of repeated abuse, injury, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a baseline care plan (CP), within 48 hours of admission, which provided the minimum healthcare information necessary to meet the immediate care needs for 3 of 19 residents (Residents 30, 55 and 85) reviewed for care planning. This failure placed the residents at risk for medical complications and unmet care needs. <Resident 30> Review of Resident 30's Minimum Data Set assessment (MDS, an assessment tool) showed the resident admitted on [DATE] with diagnoses including pneumonia (a lung infection), respiratory failure, and cancer, The MDS showed the resident required assistance with showering/bathing, was receiving scheduled and as needed pain medications and was receiving continuous oxygen therapy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans were reviewed, revised, and accurately reflected residents' care needs for 1 out of 4 residents (Residents 28) reviewed for falls and 1 of 3 residents (Resident 71) reviewed for non-pressure skin conditions and failed to provide quarterly care conferences in a timely manner and included the resident and/or their representative for 3 of 19 residents (Residents 7, 13, and 36) reviewed for care planning. These failures placed residents at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary pain medication and ensure provider orders were followed (blood pressure parameters) prior to medication administration for 2 of 5 sampled residents (17 & 71) reviewed for unnecessary medications. These failures placed residents at risk for side-effects, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure monitoring of potential side effects, conducting Abnormal Involuntary Movement Scale (AIMS) at least every six months and monitoring orthostatic blood pressures (blood pressures while lying, sitting and standing), related to the use of psychoactive medications was completed for 6 of 6 sampled residents (Residents 36, 10, 17, 71, 7, and 25) reviewed for unnecessary psychotropic medications. These failures placed residents at risk for adverse side effects, medical complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to offer, educate, and obtain consent for and administer influenza and pneumococcal vaccines for 5 of 5 sampled residents (Residents 11, 32, 48, 55 & 79) reviewed for influenza and pneumococcal immunizations. These failures placed residents at risk for not having the opportunity to make an informed decision regarding receiving immunizations, exposure to communicable diseases, health complications, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents or resident representatives were provided education regarding the benefits and potential side effects of the COVID-19 vaccine and were offered the vaccine for 5 of 5 sampled residents (11, 32, 48, 55 & 79) reviewed for COVID-19 immunizations. This failure placed residents and their representatives at risk of not being given the opportunity to make an informed decision regarding their medical care, of potential complications of a communicable disease, and a decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide necessary housekeeping and maintenance to maintain resident rooms and common areas for 2 of 4 halls (Halls 400 & 200) reviewed for safe, clean, functional and comfortable environment. These failures placed residents at risk for unsanitary conditions, less than a homelike environment and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify, initiate, thoroughly investigate and promptly resolve a grievance for one of one resident (Resident 13) reviewed for concerns/grievances. This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to respond timely to allegations, thoroughly investigate and/or follow up on identified interventions for incidents of skin impairment or fall and allegations of abuse or neglect for 1 of 4 residents (Residents 94) reviewed for abuse or neglect and 1 of 4 residents (Resident 28) reviewed for falls. Thes failures placed residents at risk for potential ongoing abuse/neglect, continued falls, unmet needs, and a decrease quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement identified mental health interventions for 1 of 6 residents (Resident 25) reviewed for Pre-admission Screening and Resident Review (PASRR). This failure placed residents at risk of anxiety, depressed mood, emotional distress, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were accurately completed for 2 of 5 residents (Resident 10 and 17) reviewed for PASRRs and unnecessary medications. This failure placed the residents at risk for unidentified mental health care needs.

Inspectors wroteBased on interview and record review, the facility failed to implement a discharge plan that included special precautions and instructions for ongoing care to the receiving facility for 1 of 1 resident (Resident 294) reviewed for discharge planning. This failure placed the resident at risk for unmet needs, medical complications, and poor adjustment at the receiving long term care nursing facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to ensure residents received their showers as scheduled for 2 of 4 residents (Resident 17 and 30) reviewed for activities of daily living (ADLs). This failure placed the residents at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide services and devices to maintain vision and/or hearing for 1 of 3 residents (Residents 13) reviewed for communication/sensory. This failure placed residents at risk for decreased visual acuity, inability to perform activities of daily living and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement pressure ulcer care and prevention measures for 1 of 3 residents (Resident 55) reviewed for pressure injuries (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). This failure placed residents at risk for new and worsening pressure injuries, pain, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment free of accidents by providing supervision/assistance during toilet transfers, assistance needed for walking, and self-medication administration for 2 of 5 sampled residents (Residents 28 and 295) reviewed for accident hazards. This failure placed residents at risk for falls, injuries, medical complications and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with indwelling urinary catheters (a flexible tube inserted into the bladder through the urethra that drains into a bag) had orders for the presence of the catheter and provided catheter care and management that minimized the risk for complications for 1 of 1 sampled resident (Resident 294) reviewed for catheter care. This failure placed residents at risk for catheter associated urinarty tract infections, dislodgement and other complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and accurately document fluids consumed for a resident on dialysis (treatment to filter wastes and water from the blood) to ensure fluid restrictions (a diet which limits the amount of daily fluid intake) was implemented per physician's orders for 1 of 1 sampled resident (Residents 71) reviewed for hydration status maintenance. This failure placed residents at risk for medical complications and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and provide oxygen services to meet professional standard for 2 of 2 sampled residents (Residents 25 and 30) reviewed for respiratory services. This failure placed residents at risk of oxygen toxicity, injury, infection, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess the need for and administer pain relief medications in a timely manner for 2 of 3 sampled residents (Residents 1 and 30) reviewed for pain. This failure placed residents at risk for unrelieved pain, lack of participation in therapy and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently conduct and document pre and post dialysis (treatment to filter wastes and water from the blood) assessments and ensure consistent ongoing communication and collaboration with the dialysis center regarding dialysis care and services to include medications provided at dialysis and maintaining dialysis communication forms in the residents medical record for 1 of 1 sampled resident (Resident 71) reviewed for dialysis. These failures placed residents at risk for unmet care needs, not having a record of dialysis communication forms, medical complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to act on and/or consistently follow the pharmacy consultant's Medication Regimen Review (MRR) recommendations in a timely manner and maintain MRR documentation for 1 of 5 sampled residents (Resident 71) reviewed for drug regimen review. This failure placed residents at risk for not having all MRR documentation in the medical record, experiencing adverse side effects, medical complications, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program (ASP), to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of antibiotic resistance and adverse side effects for 2 of 2 sampled residents (73 & 347) reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the actual nursing staffing hours daily. This failure placed residents, family members, and visitors at risk of not knowing the actual number of available nursing staff in the facility.