Harborview Post Acute

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to assess and monitor surgical incision sites for 1 of 1 (Resident #102) sampled residents with a surgical wound.

Inspectors wroteBased on the Facility Assessment review, policy review, job description review, medical record review, facility investigation review, [Named Hospital] emergency room (ER) report, and interview, the facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights and physical, mental and psychosocial well-being for 1 of 3 (Resident #1) sampled residents reviewed for falls. On 3/30/2023, Resident #1 sustained an unwitnessed fall with head injuries. Staff failed to conduct assessments, recognize injuries, and delayed transfer for medical treatment for 7 hours, resulting in actual harm to Resident #1.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by carbon build-up on the pots and pans, dirty storage racks, pink substance build-up on the water curtain of the ice machines, dirty floors, a dirty dish machine, dirty utility carts and a dirty prep (prepare and make ready) table. The facility had a census of 93 with 85 of those residents receiving a tray from the Kitchen.

Inspectors wroteBased on the Centers for Disease Control and Prevention (CDC) guidelines, Employee Screening Logs, Employee Schedules, and interview, the facility failed to follow CDC infection control guidelines to ensure practices to prevent the potential spread of COVID-19 when 11 of 93 staff members (Certified Nursing Assistant (CNA) #1 and #2, Licensed Practical Nurse (LPN) #1 and #2, Dietary Staff #1, #2, #3, and #4, Housekeeping Staff #1, Business Office Staff #1, and admission Nurse #1) failed to complete screenings for the prevention and detection of COVID-19 prior to working for 3 of 4 days (4/8/2022, 4/9/2022, and 4/11/2022) reviewed and when 4 of 4 staff members (CNA #3, #4, #5, and #6) failed to perform appropriate hand hygiene and appropriate infection control practices during perineal care. The facility had a census of 89.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure assessments were completed to accurately reflect the residents' status for 1 or 1 sampled residents (Resident #95) reviewed for tracheostomy care.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure residents were assisted with Activities of Daily Living (ADLs) for 2 of 3 sampled residents (Resident #11 and #45) reviewed for ADLs.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to provide care and services for residents with enteral feedings when residents received the incorrect enteral feeding and enteral feedings were administered at the incorrect rate for 2 of 3 sampled residents (Resident #11 and #80) reviewed with Percutaneous Endoscopic Gastrostomy (PEG) tube feedings.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to follow professional standards of practice for a Midline Catheter for 1 of 1 sampled residents (Resident #75) reviewed for a Midline Catheter.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to obtain orders for oxygen for 2 of 2 sampled residents (Resident #11 and Resident #95) reviewed for Respiratory Care.

Inspectors wroteBased on the policy review, medical record review, and interview, the facility failed to communicate with Dialysis for 1 of 1 sampled residents (Resident #67) reviewed for Dialysis.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure a medication administration rate of less than 5% (percent) when 2 of 4 nurses (Licensed Practical Nurse (LPN) #2 and #3) failed to properly administer medications for 2 of 5 sampled residents (Resident #80 and #95) observed during medication administration. This resulted in a medication administration error rate of 7.41%.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 2 of 10 medication storage areas (the 200 Hall Medication Cart and the Treatment Cart) were observed unlocked, unsecured, and unattended.

Inspectors wroteBased on observation and interview, the facility failed to ensure that waste was properly contained and maintained in a sanitary condition to prevent the harborage and feeding of pests when 2 of 2 dumpsters (Dumpster #1 and #2) were observed open with a large amount of garbage lying in front and around the bases.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to maintain accurate medical records related to dietary intake and weights on 2 of 5 sampled residents (Resident #39 and #70) reviewed for Nutrition.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to follow the facility policy for abuse and failed to thoroughly investigate an allegation of abuse for 4 of 5 (Resident #38, #237, #238, and #239) Facility Reported Incidences reviewed.

Inspectors wroteBased on review of Mosby's Pocket Guide To Nursing Skills & Procedures, policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 2 of 2 (Assistant Director of Nursing (ADON) and RN #2) did not maintain a sterile technique during a sterile dressing change and 2 of 4 (Licensed Practical Nurse (LPN) #2 and Registered Nurse (RN) #1) nurses did not perform hand hygiene, contaminated medications, and did not rinse a nebulizer cup after a nebulizer treatment during medication administration.

Inspectors wroteBased on policy review, observation, and interview, that the facility failed to maintain or enhance respect and dignity when 1 of 7 (Registered Nurse (RN) #1) nurses did not provide privacy during medication administration.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to report timely an allegation of abuse for 1 of 5 (Resident #237) Facility Reported Incidents reviewed.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure nail care was provided for 1 of 2 (Resident #3) sampled residents reviewed for activities of daily living (ADL) care.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide appropriate oxygen therapy for 1 of 1 (Resident #21) sampled residents reviewed for oxygen therapy.