Life Care Center of Federal Way

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate and complete pre/post Hemodialysis (HD- mechanical way of eliminating waste from the body when the kidneys no longer functioned) for 4 of 4 residents (Residents 55,11, 62, & 94) reviewed for Dialysis. This failure placed the residents at risk for unintended health consequences and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared and stored under sanitary conditions in accordance with professional standards of food safety requirements for 1 of 1 facility kitchens observed. The failure to prepare ready-to-eat foods using sanitary practices and inconsistently monitoring refrigerator and freezer temperatures as required placed residents at risk for ingesting unsafe and/or contaminated food and the development of foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure grievances and concerns communicated during Resident Council meetings were addressed timely, or to respond and provide a rationale for their response, for 1 of 1 Resident Council groups reviewed. This failure placed residents at risk for unmet needs, frustration, untimely resolution of grievances, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR or PASARR- a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) Level 2 referrals were coordinated timely for 2 of 3 residents (Residents 12 & 56) reviewed for PASRRs and 1 of 5 residents (Resident 38) reviewed for Unnecessary Medications. This failure placed residents at risk of 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 ensure residents who were dependent on staff for daily cares received the assistance they were assessed to require for 5 of 9 sample residents (Residents 5, 10, 12, 21, & 25) reviewed for Activities of Daily Living (ADL). The failure to provide nail care, oral care, bathing, and shaving assistance left residents at risk for embarrassment, poor personal hygiene, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative/functional maintenance services for 4 of 7 residents (Residents 56, 41, 21 & 48) reviewed for limited mobility and Restorative Nursing Program (RNP). This failure placed residents at risk for further decline in their Range Of Motion (ROM) and mobility, loss of function, and/or permanent immobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu set was followed, affecting 1 of 2 sample residents (Resident 21) reviewed for food concerns and 2 supplemental residents (Residents 72 & 54) observed during lunch service. This failure placed residents at risk for lack of food enjoyment, nutritional deficits from poor food intake, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear, and gowns used to prevent exposure to infectious materials) for 3 of 3 residents (Residents 91, 53, & 56) reviewed for Transmission Based Precautions (TBP - used to prevent the spread of transmissible infections), staff used PPE in accordance with Enhanced Barrier Precautions (EBP - infection control measure used to reduce the spread of multidrug-resistant organisms) for 1 of 3 supplemental residents (Residents 84) reviewed for skin conditions, and perform hand hygiene during wound care for 1 of 3 residents (Resident 91) reviewed for wounds. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Advance Directives (AD) for 2 of 3 residents (Residents 48 & 9) reviewed were in place in the event residents became incapacitated to make medically related healthcare decisions. The facility failed to follow up on guardianship status (Resident 48) and failed to ensure the AD was accessible to staff as required (Resident 9). These failures placed residents at risk of losing their right to have their stated preferences and decisions honored regarding medical treatment and/or end-of-life care.

Inspectors wroteBased on observation and interview, the facility failed to maintain comfortable sound levels in the environment for 1 of 4 units (100 hall). This failure placed residents at risk for diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to comprehensively assess and monitor the needs of physical restraints for 1 of 3 residents (Resident 12) reviewed for physical restraints. This failure placed residents at risk for harm and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide a discharge summary that included a recap of the residents stay and reconciliation of all medications for 1 of 3 residents (Residents 4) reviewed for discharge process and offer a bed hold for 1 of 2 residents (Resident 86) reviewed for hospitalizations. Failure to properly prepare residents for discharge placed residents at risk of rehospitalization, negative health outcomes, and a break in continuity of care. Failure to offer/provide a bed hold to the resident/resident representative placed residents at risk for not having an opportunity to make informed decisions about their transfer/discharge rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) of 1 of 20 residents (Resident 21) were completed accurately to reflect the resident's condition and health status. The facility failed to identify Resident 21's appropriate diet and Restorative Nursing Program (RNP) exercises. This failure placed Resident 21 and other 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 care conferences for residents and their representatives and the applicable Interdisciplinary Team (IDT) members for 2 of 3 sample residents (Residents 5 & 41) reviewed for care planning. These failures placed residents at risk for inconsistent and/or inadequate care and treatment, a diminished quality of care, unmet care needs, and other negative health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's orders were followed for 1 of 2 residents (Resident 8) reviewed for bowel care and 2 of 5 residents (Residents 83 & 12) reviewed for Unnecessary Medications. The failure to follow orders for oxygen administration, bowel protocols, and parameters for blood pressure (BP) medications placed residents at risk for medication errors, unmet care needs, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents' skin was assessed, documented, monitored, and treated as required for 2 of 5 residents (Residents 5 &11) reviewed for non-pressure skin issues. These failures placed all residents at risk for delay in treatment, worsening of condition, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective pain management was provided to residents, consistent with professional standards of practice, for 2 of 3 sampled residents (Residents 21 & 38) reviewed for pain management. The failure to offer non-pharmacological interventions to residents experiencing pain, investigate causes of pain, and notify the physician for appropriate pain management placed residents at risk for untreated pain, unnecessary discomfort, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were discarded timely for 1 of 2 medication storage rooms (North Medication Room) and to ensure medications were labeled appropriately in 1 of 4 medication carts (200 Hall Medication Cart) reviewed for medication storage. This failure placed residents at risk for receiving incorrect or expired medications, ineffective treatment, and diminished quality of life. <North Medication Room> Observation on 05/29/2026 at 8:00 AM in the North Medication room showed the following: Three inhalers (portable handheld devices that deliver medication via a fine mist, spray, or powder to be inhaled orally) that were opened with no open date. [...]

Inspectors wroteBased on interview and record review the facility failed to implement an Antibiotic Stewardship Program to promote appropriate use of antibiotics and reduce the risk of unnecessary antibiotic use for 1 of 5 residents (Resident 91) reviewed for unnecessary medications and 1 of 1 supplemental residents (Resident 53). This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics.

Inspectors wroteBased on interview and record review, the facility failed to implement a policy and procedures to assess and manage pain for 1 of 3 Residents (Resident 1) reviewed for pain management. The failure to thoroughly assess resident pain on admission, develop an individualized care plan (CP) in collaboration with the resident, their representative and practitioner, implement the CP, monitor for adverse consequences, notify the resident representative of medication changes, and document resident conditions, placed residents at risk for untreated pain, medication overdose, hospitalization, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents' Care Plans (CPs) were comprehensive and implemented for 6 of 18 (Residents 139, 63, 6, 8, 69, & 14) sample residents whose CPs were reviewed. This failure placed residents at risk for unmet care needs, frustration, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to facilitate quarterly care conferences for 5 of 8 residents (Resident 63, 77, 8, 14, & 64) reviewed for care planning, and failed to ensure Care Plans (CPs) were revised as required for 1 of 19 samples residents (Resident 80). Theses failures placed residents at risk for unmet care needs, unnecessary care, frustration, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician orders were clarified for 3 of 5 sampled residents (Residents 8, 14, & 13) reviewed for unnecessary medications, and failed to ensure residents with multiple as-needed (PRN) pain medications had parameters to their orders for 3 of 5 residents (Residents 13, 14, & 8) reviewed for pain. These failures placed residents at risk for ineffective treatments, unmet pain management needs, overmedication, medications errors, and delayed treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an environment free of accident hazards for 2 of 4 units (Units 100 & 200), ensure wheelchairs were assessed for safety prior to use for 1 of 9 residents (Resident 63) reviewed for positioning/mobility, and failed to ensure sharps and chemicals were stored safely for 1 of 4 shower rooms (100 Hall Shower Room) reviewed. The failure to ensure hot water was maintained within safe limits, wheelchairs were assessed for safety prior to use, and shower rooms were free of hazards placed residents at risk for burns, exposure to sharps and chemicals, wheelchair accidents, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Dietary Manager (Staff J) had the required qualifications to perform their duties for 1 of 1 facility kitchens. The failure to ensure a Dietary Manager without the required certification had fulltime support from a Registered Dietician (RD) placed all residents at risk of receiving a menu prepared by staff without the required competencies and skills to provide food and nutrition services.

Inspectors wroteBased on interview and record review, the facility failed to provide education for the influenza vaccination and administer a pneumococcal (pneumonia) vaccination within the recommended timeframe for 4 (Residents 8,14, 13, & 64) of 5 residents reviewed for vaccinations. This failure placed residents at risk of experiencing complications, not being able to make an informed decision, and contracting pneumonia, with its associated complications.

Inspectors wroteBased on record review and interview, the facility failed to provide education on the benefits and potential side effects of the Covid-19 (C19) vaccination for 4 of 5 sampled residents (Resident 8, 14, 13, & 64) and provide education on the benefits and potential side effects of the C19 vaccination for 1 of 1 sampled staff (Staff U - Restorative Aide) reviewed for vaccinations. This failure placed residents, their representatives, and staff at risk of not being given the opportunity to make an informed decision regarding their medical care, potential complications of a communicable disease, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement a system to ensure 1 of 1 (Staff CC) nursing aides reviewed for training received the required training for continued competency of no less than 12 hours per year. The failure to implement a system to provide mandatory training on dementia management, abuse prevention, and other specialized resident needs placed residents at risk for abuse, neglect, emotional distress, and physical injury.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate care in a manner that promoted dignity for 1 of 2 (Resident 31) residents reviewed for dignity, and 1 supplemental resident (Resident 16) reviewed for care conference choices. The failure to provide adequate notice prior to a care conference and honor resident's preferences left residents at risk for feelings of diminished self-worth and embarrassment.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain resident consent for the Covid-19 (C19) vaccination for 4 of 5 sampled residents (Residents 8, 14, 13, & 64) reviewed for vaccinations, obtain resident consent prior to administration of psychotropic medication for 1 of 5 residents (Resident 14) reviewed for unnecessary medications, and obtain consent prior to utilization of a tilt-in-space wheelchair for 1 of 9 residents (Resident 63) reviewed for positioning and mobility. This failure placed residents at risk for loss of autonomy, entrapment, injury, and loss of the opportunity for alternative treatment options.

Inspectors wroteBase on record review, and interview, the facility failed to implement a system to ensure Advanced Directives (AD) were in place for 3 (Residents 63, 14, & 77) of 7 residents reviewed for ADs. The facility failed to provide information indicating residents were informed, educated, or offered assistance to formulate an AD. This failure placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe, clean, and comfortable environment was provided to residents. Facility failure to keep rooms free of wall gouges, room furniture in good repair, and hot water at a comfortable temperature for 2 of 4 units (Units 400 & 100) left residents at risk for a less-than-homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents/representatives received required written notice at time of transfer/discharge, or as soon as soon as practicable and ensure a system by which the office of the State Long-Term Care Ombudsman (LTCO - an advocacy group for individuals residing in nursing homes) received required resident transfer/discharge information for 2 of 3 residents (Residents 8 & 69) reviewed for hospitalizations. Failure to ensure written transfer notifications were provided to residents and/or their representatives, in a language and manner they understood, placed residents at risk for not having an opportunity to make an informed decision about the transfer/discharge. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide the resident and/or the representative a written notice of the facility's bed hold policy, at the time of transfer or within 24 hours, for 3 of 3 residents (Residents 8, 69, & 64) reviewed for hospitalizations. This failure placed residents and their representatives at risk of not being informed of their right to, and the cost of, holding the residents bed while hospitalized that was necessary for decision making.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR - a mental health screening required prior to nursing home admission) evaluation was completed and/or incorporated into the Care Plan (CP) for 2 of 8 residents (Residents 26, 43) reviewed for PASRR. This failure placed residents at risk for unmet mental health care needs, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were completed for 2 of 6 residents (Resident 64 & 69) reviewed for PASRR screening. The failure to ensure PASRR screening was complete and accurate left residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary care and services for 1 of 1 resident (Resident 77) reviewed for communication. Failure to provide communication assistance for residents where English was a second language placed residents at risk of miscommunication, unmet care needs, and quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL - bathing etc.) to residents dependent on staff assistance for 1 (Resident 139) of 5 residents reviewed for ADL. The failure to provide bathing assistance to residents placed residents at risk for poor hygiene, skin breakdown, and feelings of diminished self-worth. <Facility Policy> According to the facility's 09/10/2024 ADL policy showed residents unable to perform their own ADL would receive the necessary assistance to maintain good grooming, and personal hygiene. <Resident 139> According to the 03/04/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 139 required substantial/maximal assistance with bathing and had a moderate memory impairment. The MDS showed Resident 139 admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a system to ensure Physician's Orders for Life Saving Treatments (POLSTs) were implemented for 2 of 22 sample residents (Residents 32 & 16) and one supplemental resident (Resident 60), related to lifesaving treatment orders. The failure to follow the POLST instructions for Cardiopulmonary Resuscitation (CPR) (Resident 32) or ensure the POLST was readily available (Residents 16 & 60) placed residents at risk for receiving unwanted CPR, avoidable trauma, and other negative health outcomes.

Inspectors wroteBased on record review and interview the facility failed to ensure 3 of 3 residents (Resident 8, 13, & 64) reviewed for Edema (fluid retention in the body) received the necessary care and services they required in accordance with professional standards of practice. The facility failure to assess and monitor residents with edema placed residents at risk for complications, worsening conditions, and a diminished quality of life.

Inspectors wroteBased on observation and interview the facility failed to ensure fresh water was offered for 5 of 5 residents (Residents 8, 14, 13, 69, & 64) reviewed for hydration. Failure to offer fresh water daily placed residents at risk of dehydration, potential risk for medical complications, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 4 residents (Resident 43) reviewed for respiratory care, were provided the care they required, consistent with professional standards of practice. Failure to ensure oxygen delivery was provided according to physician ordered flow rates and failure to monitor oxygen equipment, placed residents at risk of respiratory discomfort, oxygen-related accidents, and a decreased quality of life. Findings Included . <Facility Policy> According to the revised 10/11/2024 Oxygen Administration Policy, the facility must ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice and the person-centered care plan. Oxygen orders should be written for a specific flow rate required by the resident. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain consent prior to implementing bed rails/bed against the wall for 2 of 3 residents (Resident 8 & 69) and complete a safety assessment for the bed against the wall for 1 of 3 residents (Resident 69) reviewed for accident hazards. The failure to obtain consent and complete a safety assessment prior to implementing bed rails/bed against the wall placed residents at risk for injury, entrapment, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 4 sampled residents (Resident 80) reviewed for mood and behavior was evaluated for potential mental health services to address demonstrated ongoing behaviors and failed to notify the provider of changes in behavior. This failure placed Resident 80 at risk for untreated mental health issues and other negative health issues.

Inspectors wroteBased on observation, interview, and record review the facility failed to: ensure medication refrigerator temperatures were monitored for 1 of 2 medication rooms (100/200 Unit); ensure expired medications and biologicals were disposed of appropriately for 1 of 2 medication rooms (300/400 Unit); and ensure medications and biologicals were secured for 1 of 6 Residents (Resident 31) reviewed for medication storage. These failures placed residents at risk for receiving the wrong medications, expired medications, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure confidentiality of resident records was maintained for 1 of 4 medication carts (100 hall medication cart) reviewed. This failure placed residents at risk for a violation of their rights to privacy.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure effective coordination of care between the facility and hospice staff and failed to implement and develop a coordinated Care Plan (CP) for 1 of 2 residents (Resident 25) reviewed for hospice services. The failure to implement a system by which consistent communication between the facility and hospice staff occurred placed residents at risk for not for receiving necessary care and services, avoidable discomfort, and other negative health outcomes.

Inspectors wrote<TBP Implementation> <Resident 84> According to the 02/21/2025 admission MDS Resident 84 had a Multidrug-resistant Organism (MDRO - a difficult to treat infectious organism) infection and surgical wounds. The MDS showed Resident 84 used an antibiotic medication. According to a 02/17/2025 physician's order Resident 84 required contact precautions (a type of TBP requiring anyone who entered the room to utilize specified Person Protective Equipment (PPE) before entry) related to their MDRO infection. Observation on 03/12/25 at 12:28 PM showed Enhanced Barrier Precautions (a system of PPE usage required for certain conditions that only required facility staff to use PPE when close contact with the resident was anticipated) were in place instead of the contact precautions ordered. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure qualified nursing staff were provided training and specialized training for 4 of 5 staff members (Staff I [Infection Preventionist], Staff K [Licensed Practical Nurse], Staff CC [Certified Nursing Assistant - CNA] and Staff S [CNA] sampled for staff training. These failures 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 staff provided care according to the resident's care plan to prevent accidents for 1 of 3 residents (Resident 1) reviewed for falls. Resident 1 experienced harm when facility staff did not use two caregivers as planned when providing incontinence care, they rolled off an air mattress bed and sustained an inoperable leg fracture. Failure to follow resident's care plans placed all residents at risk for injury, falls, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide a written explanation to residents and/or their representative for a facility initiated room change for 4 of 7 residents (Residents 14, 13, 12, & 11) reviewed for room moves. The failure to discuss reasons for a room move, provide written notification, provide an opportunity for the resident to see the new location and meet the new roommate, or inform roommates of a new person moving into the room placed residents at risk for feeling frustrated, powerless, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a system to assess resident's need for the use of an air mattress, determine required settings of the air mattress, recognize or assess risk factors of the use of an air mattress, inform and educate residents or their representatives of the risks of using an air mattress including falls and/or injury, obtain informed consent from the resident or their representative for the use of an air mattress, implement a resident-directed care plan for the use of an air mattress, monitor the mattress function, condition, and individualized pump settings, re-evaluate the ongoing use of air mattresses for each resident to ensure necessity of use, and train staff to use the air mattress and assessed settings during care to ensure resident safety for 7 of 7 residents (Residents 1, 2, 3, 4, 5, 6, & 7) [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure incident reports were completely and thoroughly investigated for 2 of 3 residents (Residents 4 & 7) whose facility investigation reports were reviewed for injuries of unknown origin. The failure to initiate, conduct a thorough investigation, and correct alleged violations left residents at risk for unidentified abuse and/or neglect, repeated incidents, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 5 residents (Residents 1 & 2) reviewed for Pressure Ulcer/Pressure Injury (PU/PI) were provided the necessary treatment and services consistent with professional standards of practice, to promote healing and prevent the occurrence of a PU/PI. Resident 1 experienced harm when their Moisture Associated Skin Damage (MASD) developed into a Stage 4 PU (a full thickness wound with tissue loss and exposed bone, tendon, or muscle) on their buttock and acquired Osteomyelitis (a bone infection). This failed practice placed other residents at risk for skin breakdown and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide resident focused care through consistent monitoring, assessment, evaluation of the resident's condition, and to implement physician orders timely to identify a change in condition for a suspected urinary tract infection (UTI) for 1 of 5 residents (Resident 1) reviewed for quality of care. Resident 1 experienced harmed when they were hospitalized in the intensive care unit for a bladder and kidney infection which accelerated into a systemic blood infection. This failed practice placed other residents at risk for unmet needs, hospitalization, and diminished quality of life.

Inspectors wroteBased on observation, interviews and record review, the facility failed to protect 1 of 6 (Resident 2) sample residents' right to be free from physical abuse. The facility failed to protect Resident 2 from physical abuse when Resident 1 punched Resident 2 twice on the shoulder. The facility failed to supervise Resident 1, who had a history of verbal and physical aggressive behaviors towards residents, and failed to mitigate known triggers for Resident 1. Resident 2 experienced psychological harm, using the reasonable person concept, as a result of the physical abuse as there is an expectation that the resident would not be punched while in the facility. Theses failures placed all residents at risk for the potential of abuse, psychological harm, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure one of four abuse allegations reviewed were identified as such and reported to the State Survey Agency as required. The facility failed to report an allegation of abuse by Resident 4 towards Resident 3. Failure of the facility to report allegations of abuse placed residents at risk for additional abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure allegations of abuse were thoroughly investigated for two of four abuse allegations reviewed. The facility failed to investigate an allegation of abuse by Resident 4 towards Resident 3, failed to conduct a thorough investigation of abuse of Resident 2 by Resident 1 and failed to identify or implement preventative measures. Failure of the facility placed residents at risk of continued abuse and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper daily oral hygiene and failed to assist residents to obtain prompt dental services for 2 of 3 residents (Resident 34 & 10) reviewed for dental care. Resident 34 experienced harm when they had sharp pain and pressure with eating due to a lack of consistent oral hygiene assistance (severe heavy plaque build up over time, severe gum disease, and bleeding gums) prompt dental care services were not obtained when recommended. This failed practice placed other residents at risk for unmet dental needs and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement an effective infection control program with monitoring to demonstrate ongoing analysis and trending of infectious organisms resulting in staffs inability to identify trends and implement interventions, placing residents at risk for facility acquired infections.1) The facility failed to ensure: Accurate notification was provided to the Department of Health (DOH) for 2 of 9 (Residents 74 & 244). 2) Ensure residents were monitored for symptoms of infection for 3 of 9 (Residents 48, 494, & 11). 3) Ensure Personal Protective Equipment (PPE) was utilized correctly for 1 of 9 (Resident 14). 4) Ensure Transmission Based Precaution (TBP) recommendations were followed (Resident 14). 5) Ensure Hand Hygiene (HH) principles were followed for 3 of 9 (Residents 19, 47, & 6). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were implemented and revised as needed for 8 of 19 sample residents (Residents 73, 34, 19, 47, 244, 84, 14, & 75) whose CPs were reviewed. The failure to ensure CPs were implemented or revised when necessary left residents at risk for unmet care needs, frustration, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 5 of 20 sample residents (Residents 16, 20, 69, 10, & 73) received the necessary care and services in accordance with their comprehensive person-centered plan of care. The failure to follow physicians' orders (Residents 16, & 20), provide treatment to non-pressure skin (Residents 69), provide less frequent blood sugar checks (Resident 10), assess Range of Motion (ROM) issues (Resident 73) left residents at risk for unfollowed physician orders, unmanaged skin impairment, discomfort, ongoing infection, high blood sugar, reduced hand ROM function, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 4 of 5 sample residents (Residents 10, 41, 20, & 84) and 2 supplemental residents (Residents 13 & 12) reviewed for respiratory care were provided care and services consistent with professional standards of practice. The facility's failure to deliver oxygen therapy according to physician ordered flow rates (Resident 10 & 84), monitor respiratory status while receiving supplemental oxygen (Resident 10 & 84), and maintain oxygen equipment (Residents 10, 84, 41, 20, 13, & 12) placed residents at risk for potential negative outcomes such as over or under oxygenation, respiratory discomfort, infections, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 (Residents 73, 18, & 25) of 5 residents whose medication regimens were reviewed, and 2 supplemental residents (Residents 84 & 75) were free of unnecessary psychotropic medications. This failure left residents at risk for receiving unnecessary psychotropic medications, adverse side effects, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to inform residents of the risks and benefits associated with psychotropic medication therapy (medications that affected the mind, emotions, and behavior), and obtain their consent for prescribed psychotropic medications for 2 of 7 residents (Residents 69 & 75) reviewed for psychotropic medications. These failures detracted from the residents' ability to exercise their right to make informed treatment decisions and their right to decline treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care which upheld their right to dignity. Facility staff failed to provide a dignified existence for 2 of 20 residents (Resident 75 & 51) reviewed for dignity. These failures placed residents at risk for invasion of privacy and had the potential to negatively impact the residents' quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to honor residents' rights to make choices of bathing for 3 of 4 residents (Resident's 75, 18, & 57), and choices of hair length for 1 of 4 residents (Resident 75) reviewed for choices. Failure to honor resident choices placed residents at risk for impaired hygiene, lack of choice, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to obtain, renew as needed, and/or failed to provide assistance in the formulation of an Advanced Directive (AD - a document describing a resident's wishes for care if they became incapacitated) for 3 of 10 residents (Residents 19, 47, & 14) reviewed for ADs. This failure left residents at risk for losing the right to have their preferences and choices honored during emergent and end-of-life care.

Inspectors wroteBased on observation, interview, and record review the facility failed to timely complete, thoroughly investigate, and provide prompt resolutions for complaints brought forth by residents and their representatives for 3 of 19 sample residents (Residents 34, 57, & 14) reviewed for grievances. Failure to ensure concerns about missing property (Resident 34), room noise (Resident 57), and incontinent care (Resident 14) were addressed and resolved placed residents at risk for misappropriation, frustration, neglect, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to report allegations of abuse and/or neglect, including injury of unknown origin, within five working days of the incident for 1 of 1 closed records (Resident 93) reviewed for death in the facility. This failure placed residents at risk for repeated incidents and unidentified abuse and/or neglect.

Inspectors wroteBased on interviews and record review, the facility failed to initiate and thoroughly investigate the occurrences of events for 1 of 1 closed records (Resident 93) reviewed for death in the facility and for 1 of 4 residents (Resident 25) reviewed for falls. The failure to initiate, conduct a thorough investigation, and correct alleged violations left residents at risk for unidentified abuse and/or neglect, repeated incidents, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were comprehensively assessed using the Centers for Medicare and Medicaid (CMS) specified Resident Assessment Instrument (RAI - a guide directing staff on how to accurately assess the status of residents) process and/or complete a Significant Change Minimum Data Set (MDS - an assessment tool) for 1 of 1 residents (Resident 14) who experienced a significant change in their health status. Failure to identify a significant cognitive decline and an increased need for Activities of Daily Living (ADL) assistance placed Resident 14 and other residents at risk for delayed care planning, further ADL decline, unmet care needs, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected residents' mental health conditions at the time of admission or were revised to reflect mental health changes for 2 of 5 sample residents (Residents 73 & 25) whose PASRRs were reviewed. These failures placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: Physician's Orders (POs) were clarified for 2 (Residents 75 & 18) of 19 sample residents; Abnormal Involuntary Movement Scale (AIMS) assessments were completed as required for 1 (Resident 16) of 7 residents reviewed for behavior. These failures left residents at risk for unmet care needs, inappropriate treatment, abnormal movements, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure assistance for Activities of Daily Living (ADL - personal care such as bathing/showering, dressing, getting in and out of bed or a chair) were provided for 4 (Residents 87, 47, 34, & 19) of 14 sample residents assessed to require ADL assistance. The failure to ensure dressing and shaving (Resident 87), bathing (Resident 47 & 34), oral care (Resident 34), and nail care (Resident 19) was provided as needed left residents at risk for unmet ADL needs, odors, tooth decay, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were provided with a program of individualized activities for 3 of 5 sampled residents (Residents 19, 244, & 75) and 1 supplemental resident (Resident 51). The failure to consistently implement meaningful, individualized activity programs left residents at risk for boredom, frustration, isolation, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 of 4 residents (Residents 10 & 14) reviewed for communication and sensory needs received treatment and assistive devices (ADs) to maintain their vision and hearing abilities. Failure to ensure vision devices were repaired and out-of-facility eye consultations were obtained (Resident 10) placed residents at risk for unmet care needs. Failure to determine the presence of hearing aids (HAs) placed residents at risk for impaired communication and a decreased quality of life.

Inspectors wrote<Resident 69> According to the 11/02/2023 Significant Change MDS Resident 69 had no memory impairment and required moderate assistance with rolling side to side in bed, and maximal assistance with dressing and hygiene of their lower body. This assessment showed Resident 69 had diagnoses including Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), cerebral palsy (a brain disorder marked by muscle impairment with a loss or deficiency of motor control), heart failure with edema (swelling from fluid retention), generalized muscle weakness, malnutrition, and chronic peripheral venous insufficiency (poor blood circulation to lower extremities). The 10/23/2023 functional goal CP showed Resident 69 would receive restorative nursing services for both arms' and legs' ROM and an ambulation program three times a week. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 of 7 (Resident 10 & 6) residents reviewed were free from potential accidents and hazards. This failure placed residents at risk for accidents, injury, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 2 residents (Residents 295) reviewed for Tube Feeding (TF- tube to provide nutrition directly into stomach for people who cannot swallow safely) care during medication administration were provided with care according to the Physician Orders (POs) and the facility policy. The facility's failure to follow the directions to administer medications via TF, amount of water for flushing the TF, amount of water provided with medications, and the techniques to administer medications via syringe too fast, placed Resident 295 and other residents at risk for dehydration, discomfort, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were trauma survivors and diagnosed with Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event that was either experienced or witnessed) received culturally competent, trauma-informed care and services in accordance with professional standards of practice for 1 of 7 residents (Resident 14) reviewed for mood/behavior. The facility's failure to assess or involve collateral contacts to obtain trauma history placed Resident 14 and other residents at risk for unidentified triggers, re-traumatization, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide behavioral health services for 1 of 7 (Resident 34) residents reviewed for behavioral-emotional health. The failure to provide intervention to Resident 34s behavioral health concerns placed Resident 34 and other residents at risk for not receiving necessary services to meet their mental health needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure storage of drugs and biologicals on 2 (200 Wing and 400 Wing Cart) of 4 medication carts, and failed to ensure resident rooms were free of medications and treatments for 1 of 20 sample residents (Resident 73) reviewed. These failures placed residents at risk for receiving expired medications and non-assessed, self-administration of medications by residents, and other negative health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' medical records were complete, accurate, and readily accessible for 4 of 20 sample residents (Residents 73, 10, 14 & 84) whose resident records were reviewed. The failure to maintain complete, accurate, readily accessible records left residents at risk for incomplete medical records, unmet care needs, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to administer Influenza (Flu) and Pneumococcal (PNA) vaccinations within the recommended timeframe for 5 of 7 residents (Residents 69, 75, 18, 51 & 25) reviewed for immunization status. This failure placed residents at risk for contracting influenza or pneumonia, with its associated complications.