North Auburn Care

Inspectors wroteBased on interview and record review, the facility failed to conduct performance reviews for 5 of 5 Certified Nursing Assistants (CNA's) (Staff M, N, O, P, & Q) at least every 12 months, as required. This failure placed residents at risk of receiving care from staff whose performance did not meet expectations and required additional training.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents and their environment were kept safe for 2 of 4 units (Birch Hall and Cedar Hall) observed with accident hazards and for 5 of 13 residents (Residents 63, 67, 17, 94, & 28) reviewed for accidents. The facility failed to ensure their sharps containers were not overfilled (rooms & treatment carts), resident safety assessments regarding device use (Resident 6) and smoking (Resident 28) were completed, Care Plan (CP) interventions were developed and implemented to prevent falls (Resident 67), smoking materials were safekept properly (Resident 17), and residents assessed with elopement risk were provided adequate supervision (Residents 94 & 28). These failures placed residents at risk for bloodborne pathogen exposure, avoidable injury, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate treatment and services were provided to attain or maintain the highest practicable physical, mental and psychological well-being for 1 of 4 residents (Resident 94) reviewed for dementia care. The failure to assess and implement a person-centered dementia care plan based on the resident's behavioral needs placed residents at risk for injury, accidents, behavioral distress, and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement preventive measures to protect residents' feet from injury, monitor the feet of high-risk residents, identify changes in skin integrity, report changes in wounds, seek treatment from the physician, ensure foot care treatments were completed consistently and according to physician orders, and arrange timely appointments with a podiatrist or wound care specialist for 2 of 3 Residents (Resident 1 and 2) reviewed for foot care. These failures placed residents at risk for impaired skin integrity, wound infection, hospitalization, and diminished quality of life. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from abuse for 3 of 3 residents (Residents 4, 5, & 6) reviewed for resident-to-resident altercations. This failure placed the residents at risk of physical injury, fear, intimidation, mental anguish, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure 4 of 4 licensed nurse staff (Staff D -Registered Nurse, Staff E - LPN, Licensed Practical Nurse, & Staff F- LPN) and 3 of 6 nurse aide staff (Staff H, I & J) had the specified competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. This failure placed residents at risk infection, injury, inadequate care, and rehospitalization.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents right to be free from neglect when it failed to provide goods and services that were necessary to avoid physical harm, pain, mental anguish, and emotional distress for 1 of 5 residents (Resident 1) reviewed for admission and rehospitalization. The failure to identify Resident 1 required a wound vacuum (WV - specialized equipment for wound care that applies negative pressure to the wound to manage drainage and promote healing) to treat a surgical wound on admission, ensure nursing staff had the skill set and supplies to manage the WV, and implement monitoring of the operation of the WV, placed Resident 1 at risk for impaired wound healing, infection, and rehospitalization.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures to complete criminal background checks upon hire and every two years for 5 of 25 Staff (Staff D- Licensed Practical Nurse, Staff E - Certified Nursing Assistant [CNA], Staff F - CNA, Staff G - CNA, Staff H - CNA). The failure to ensure completion of criminal background checks placed residents at risk of abuse, neglect, exploitation and misappropriation of resident property.

Inspectors wroteBased on interview and record review the facility failed to implement a policy and procedure to ensure staff were trained and competent in hands-on Cardiopulmonary Resuscitation (CPR, an intervention to restore a resident's respiratory function and circulation after they stopped breathing and their heart stopped beating) for 8 of 22 staff (Staff F - Certified Nursing Assistant [CNA], I - CNA, J - Licensed Practical Nurse [LPN], K - CNA, L - CNA, M - CNA, N - Registered Nurse, & O - LPN). The failure to ensure staff had hands-on training and competency to provide CPR placed residents requiring CPR, according to their advanced directive, at risk of injury or death.

Inspectors wroteBased on interview and record review the facility failed to implement a policy and procedure to obtain verification from the Washington State Nurse Aide Registry and/or Multi-State Nurse Aide Registry to ensure nurse aide staff met competency evaluation requirements for 12 of 12 nurse aide staff (Staff E, F, I, K, L, M, Q, R, S, T, U, & V). The failure to verify nurse aide competency and maintain registry verification records prior to allowing nurse aide staff to care for residents, placed residents at risk for incompetent care, unmet needs, and possible injury during care.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received timely care and treatment prescribed by the Medical Provider (Physician, Nurse Practitioner or Physician Assistant) for a change in condition for 1 of 3 residents (Resident 1) reviewed for accidents and injury. This failure placed residents at risk for harm, worsening medical conditions, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately assess 5 (Resident 30, 36, 61, 62, & 69) of 20 residents' Minimum Data Sets (MDS - an assessment tool) reviewed. Failure to ensure accurate assessments regarding cognitive patterns (Resident 36) language (Resident 61), oral status ( Resident 61), vision status (Resident 30), behaviors (Resident 36), dental status (Resident 62), and discharge status (Resident 69) placed residents at risk for unidentified and/or unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the completion of a required Pre-admission Screening and Resident Review (PASRR) Level 2 evaluation (a person-centered evaluation that is completed for anyone identified as having or suspected of having a Serious Mental Illness (SMI), intellectual disability, developmental disability, or related condition) prior to admission for 3 of 5 sampled residents (Residents 17, 52, & 62), and 2 supplemental residents (30 & 36) reviewed for PASRRs. These failures placed the residents at risk for unmet mental health care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were accurately completed prior to or upon admission to the facility for 3 of 5 (Residents 52, 24 & 35) and 1 supplemental resident (Resident 30) reviewed for PASRR's . This failure 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, record review, and interview the facility failed to ensure Care Plans (CP) were updated and/or revised as needed to reflect person-centered care for 4 (Residents 17, 61, 36 & 62) of 20 sample residents whose CPs were reviewed, and failed to provide CP meetings for 4 (Residents 62, 23, 66, & 28) of 7 sample residents reviewed for CP meetings. The failure to update and/or revise CPs or provide CP meetings left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure services provided met professional standards of practice for 7 of 20 (Residents 36, 54, 30, 17, 7, 64, & 52) residents reviewed. Nursing staff failed to: follow or clarify physicians orders when indicated, document for only those tasks completed, monitor residents for significant medication dose changes, follow up on appointment recommendations from outside providers, and to monitor residents for side effects for the treatment received at appointments in outside clinics. These failures placed residents at risk for medication errors, delay in treatment, adverse outcomes, and diminished quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs) for 5 of 12 (Residents 61, 22, 62, 54, & 31) who were assessed to be dependent on staff for ADLs. The failure to provide ADL assistance including bathing, oral care, and nail care as required, left residents at risk for poor hygiene, soiled long nails, diminished feelings of self-worth, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide risks and benefits of bed rail use prior to installation, ensure proper installation of bed rails, and provide ongoing maintenance of bed rails for 5 of 5 residents (Resident 7, 24, 28, 35, & 17) reviewed for bed rails and 2 supplemental residents (Residents 30 & 22) reviewed. These failures 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 3 of 5 residents (Residents 52, 17, & 35) reviewed for unnecessary medications and 2 (Resident 36 & 54) supplemental residents were free from unnecessary psychotropic drugs related to the failure to: ensure clinical justification for dose increases, adequately monitor, and attempt Gradual Dose Reductions (GDR). These failures placed residents at risk to receive unnecessary medications and/or adverse side effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5%. Failure to properly administer 5 of 25 medications for 3 of 4 residents (Residents 2, 30, & 19) observed during medication pass resulted in a medication error rate of 20%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was served under sanitary conditions. Facility staff failed to: monitor and ensure adequate sanitation for the dishwasher and ensure staff reported when sanitation levels were inadequate. These failures placed residents at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain resident consent for vaccinations for 3 of 5 sampled residents (Residents 35, 7, & 24) and 1 supplemental resident (Resident 28) reviewed for vaccinations, obtain resident consent prior to administration of psychotropic medication for 2 of 5 residents (Resident 7 & 24) reviewed for unnecessary medications, and obtain consent prior to utilization of safety devices for 4 of 6 residents (Resident 7, 24, 28, & 35) reviewed for accident hazards. This failure placed residents at risk for loss of autonomy, entrapment, injury, and loss of the opportunity for alternative treatment options.

Inspectors wroteBased on observation, interview and record review, the facility failed to have a system in place which ensured grievances were thoroughly investigated and resolved in response to residents' concerns for two (Residents 52 &17) of three residents reviewed for grievances. Failure to ensure accurate resident inventories detracted from staff's ability to thoroughly investigate reported complaints of missing items and failure to follow up with residents about the grievances placed residents at risk of feeling frustration and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which the Office of the State Long-Term Care Ombudsman (LTCO) received required resident discharge information and provide required written notices at the time of transfer/discharge to the residents and/or their representatives for 3 (Residents 54, 31, & 7) of 4 residents reviewed for hospitalization. Failure to notify the LTCO and ensure written notification was provided to the resident/resident representative, in a language and manner they understood, placed residents at risk for not having an opportunity to make informed decisions about their transfer/discharge rights.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or the resident's representative with a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours for 3 (Resident 54, 31, & 7) of 4 residents reviewed for hospitalization. This failure placed residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized .

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe discharge including documenting the reason for leaving or explaining the risks of discharging for 1 of 1 (Resident 67) resident who chose to leave the facility Against Medical Advice (AMA). This failure placed the resident at increased risk of hospital readmission and diminished quality of life.

Inspectors wrote<Resident 30> Resident 30 admitted to the facility on [DATE] and according to the 03/05/2025 Significant Change MDS, the resident was cognitively intact and required care related to fractures and other multiple traumas. Resident 30 was assessed with multiple skin issues including pressure ulcers, functional limitations in range of motion to both lower extremities, and was dependant on staff for toileting, bathing, and dressing the lower extremities. Observations on 04/14/2025 at 1:27 PM revealed Resident 30 lying in bed and was noted with a moderate amount of crusty, reddish debris on the medial (inside) left great toe nail bed. The resident stated, I get ingrown toenails, I have to see a diabetic doctor to get my nails trimmed .No, I haven't seen a podiatrist since I've been here. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received proper treatment and assistive devices to maintain vision and hearing abilities for 1 (Resident 30) of 2 residents reviewed for vision services. Failure to ensure Resident 30 received assistance in obtaining vision devices placed this resident at risk for decline in Activities of Daily Living (ADLs) related to vision.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 of 3 sampled residents (Residents 6 & 7) reviewed for Pressure Ulcers (PUs), received appropriate pressure reducing measures and repositioning on a consistent basis. This failure placed all residents at risk for PU development, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary foot care and treatment in accordance with professional standards, including provision of nail care and Podiatry Services. Deficient practice was identified for 3 (Residents 30, 17, & 23) of four residents reviewed for nail care. Failure to provide timely toenail care placed the residents at risk for negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify, assess, and implement interventions to prevent accidents for 1 of 1 resident (Residents 62) reviewed for smoking. These failures left the resident at risk for injury and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure indwelling urinary catheters (device that drains urine from the bladder to an external bag) had a valid medical justification for the use of or a plan for discontinuation for one (Resident 36) of two residents reviewed for catheter use. These failures placed residents at risk for urinary tract infections and decline of normal bladder function.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 2 residents (Resident 17) reviewed for nutrition and staff offered and provided hydration services to 2 of 2 residents (Resident 7 & 35) reviewed for hydration. Failure to ensure consistent, timely weights, and act on the Registered Dietician (RD) recommendations, including reweighs, placed the residents at risk for delayed identification of interventions, and continued weight loss. Failure to offer and provide hydration services to residents placed all residents at risk for dehydration and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored in accordance with current accepted professional standards in 2 of 2 medication carts and 1 medication room reviewed. Additionally, the facility failed to ensure medications were stored in a secure manner for 1 (Resident 52) of 1 residents with medications at bedside. These failures placed residents at risk to receive expired and/or improperly administered medications and biologicals.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate records for 10 (Residents 17, 52, 61, 40, 47, 6, 7, 36, 62, & 35) of 20 current sampled residents reviewed and 15 supplemental residents (9, 2, 51, 19, 27, 32, 4, 5, 18, 15, 29, 49, 24, 33, & 21) reviewed. The facility failed to ensure: physician orders were clear/accurate, assessment documents accurately reflected resident condition, behaviors were monitored, personal inventories were accurate/updated/available, informed consents were signed/dated, and resident inventory lists were complete. Failure to ensure clinical records were complete and accurate placed residents at risk of not having their needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to: ensure staff performed hand hygiene before and after resident care for 3 of 3 staff observed, ensure proper labeling and containment of resident's personal care items observed in 2 resident rooms, administer medications while maintaining infection control measures, and wear facility required face masks appropriately to prevent the spread of infection. These failures placed residents at risk for the development of infectious diseases and living in an unclean environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure 21 of 24 residents (Residents 33, 31, 9, 21, 11, 19, 23, 15, 17, 1, 20, 7, 8, 2, 5, 42, 51, 12, 46, 4, 37, 41, 40, & 27) who had a Trust Account with the facility had their funds covered by a surety bond. This failure placed residents at risk to be unable to recover their money in the event of loss of funds from their account.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were informed and provided written information concerning their rights to accept, refuse, or formulate an Advance Directive (AD) for 6 of 21 residents (Residents 60, 44, 28, 30, 226, & 3) reviewed for ADs. This failure placed residents at risk for not having a surrogate decision maker when unable to make their own healthcare decisions. This failure placed the residents at risk of losing their rights to have their stated preferences/decisions regarding end-of-life care followed.

Inspectors wroteBased on observation and interview, the facility failed to ensure a clean, comfortable, and homelike environment for 4 of 4 halls. The failure to ensure resident rooms were free of wall scrapes, to provide an environment free of institutional-style overhead paging, to ensure resident bedroom windows had adequate coverings, and to ensure sufficiently warm water temperatures in resident bathrooms left residents at risk for a diminished quality of life, and a less than homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which the Office of the State Long-Term Care Ombudsman (LTCO) received required resident discharge information for 3 of 4 sampled residents (Residents 60, 49, & 42) reviewed for discharge to the hospital. Failure to ensure required notification was completed, prevented the Ombudsman's office the opportunity to educate residents and advocate for them regarding the discharge process.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed hold policy, at the time of transfer or within 24 hours, for 3 of 4 sampled resident's (Residents 60, 49, & 42) reviewed for discharge. This failure placed the residents and/or their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized .

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 8 of 24 residents' (Residents 55, 6, 7, 15, 27, 44, 60, & 42) Minimum Data Set (MDS - an assessment tool) were completed accurately to reflect the resident's condition. This failure placed residents at risk for unidentified and/or unmet needs.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure Care Plans (CP) were updated and/or revised as needed to reflect person-centered care for 3 of 21 (Residents 15, 276, & 226) sample residents whose CPs were reviewed, and failed to provide CP meetings for 3 of 5 sample residents (Residents 71, 28, & 44) reviewed for CP meetings. The failure to update and/or revise CPs or provide CP meetings left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes. Findings inlcuded . <Facility Policy> Review of the Care Planning Process facility policy revised 05/19/2023 showed the comprehensive CP was an interdisciplinary tool that must have measurable objectives with time frames and described the services to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs) for 3 of 5 (Residents 9, 30, & 46) who were assessed to be dependent on staff for ADLs, and 1 supplemental resident (Resident 27). The failure to provide ADL assistance as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure restorative nursing services were provided for 3 of 4 residents (Residents 7, 55, & 44) reviewed for rehab/restorative. This failure left residents at risk for diminished Range of Motion (ROM), loss of function, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing communication and collaboration about resident's health with the kidney center occured regarding dialysis (a procedure to clean and filter the body's waste products) treatment and services for 2 of 2 sampled residents (Resident 60 & 3) reviewed for dialysis care. These failures placed residents at risk for unmet care needs, unidentified medical complications, and adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide timely assistance with toileting and call light response in accordance with established clinical standards as evidenced by information provided from 8 (Resident 52, 3, 228, 276, 60, 178, 44, & 277 ) resident interviews, information provided by 2 (Resident 22 & 7) Resident Council residents, review of facility grievance forms for Residents 10, 8, 60, & 48, call light reports for Resident 277, 276, & 56, and staff interviews provided by Staff KK (Certified Nursing Assistant - CNA), Staff MM (Registered Nurse), and Staff N (Licensed Practical Nurse). The facility had insufficient staff to ensure Restorative Nursing Programs (RNPs) were provided to Residents 7, 55, & 44. These failures placed residents at risk for unmet care needs and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 4 sample residents (Residents 52) reviewed for food concerns received the diet prescribed to them, and 5 supplemental residents (Residents 227, 13, 37, 39, & 20). Failure to ensure residents received their diet as ordered, placed residents at risk for an inappropriate diet and related negative health outcomes.

Inspectors wroteBased on observation and interview the facility failed to store and prepare food under sanitary conditions for 1 of 1 kitchens. The failure to ensure food items in the dietary department were properly labeled and stored, adequate hand washing supplies were available to dietary staff, and food brought to residents from outside the facility was properly, placed residents at risk for consuming expired/spoiled foods and potential exposure to food-borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and services that ensured privacy in a manner that maintained and promoted resident rights and resident dignity for 2 of 3 sampled residents (Residents 46 & 276) reviewed for dignity concerns. Failure to dress residents, provide privacy, and assist with toileting placed residents at risk for diminished resident rights, feelings of institutionalization, embarrassment, frustration, disrespect, and diminished self-worth.

Inspectors wroteBased on interview and record review, the facility failed to provide the Skilled Nursing Facility Notice of Medicare Non-coverage (SNF-NOMNC - a required form notifying the resident that their skilled services coverage was ending and would no longer be covered by their Medicare A benefits) as required for 1 of 3 residents (Resident 68) reviewed for beneficiary notification. This failure placed Resident 68 and other residents at risk for not being fully informed and losing their right to an appeals process.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to initiate and complete a thorough grievance investigation for 2 of 2 residents (Residents 42 & 71) who were reviewed for grievances. The facility failed to ensure there was a resolution for lost property (Resident 42) and how the environmental noise affected their quality of life (Resident 71). These failures placed residents at risk for frustration and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify the need for and complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) for 1 of 21 sample residents (Resident 15). The failure to identify and complete a SCSA MDS left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes.

Inspectors wroteBased on record review and interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR - a mental health screening required before transfer to a nursing home) assessments were revised to reflect mental health changes for 2 of 5 residents (Residents 7 & 44) reviewed for PASRRs. This failure left residents at risk for 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 6 & 30) of 21 sample residents; blood pressure was measured as ordered for 2 (Residents 15 & 7) of 21 sample residents; and POs were followed for 2 (Residents 55 & 52) sample residents. These failures placed residents at risk for unmet care needs, inappropriate care, falling, weight loss, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and provide care and services in accordance with the resident's goals and professional standards of practice in the areas of skin care/treatment and self-medication administration for 3 of 21 residents (Resident 15, 30, & 52) reviewed for quality of care. These failures placed residents at risk for undiagnosed condition of the skin and soft tissues, skin breakdown, unsafe medication administration, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with vision deficits were assessed and provided Assistive Devices (ADs) to maintain vision abilities for 1 of 1 residents (Resident 42) reviewed for vision needs. These failures placed Resident 42 and other residents at risk for unmet care needs and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 5 residents (Resident 6) reviewed for Pressure Ulcers (PU) were provided ordered interventions they required for the prevention or worsening of PU. This failure to implement pressure reducing devices in accordance with physician's orders placed residents at risk for PU development, worsening of PU, pain, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify, assess, and implement interventions to prevent accidents for 3 of 6 residents (Residents 60, 71, & 72) reviewed for accidents. The facility failed to identify and assess 1 of 1 resident (Resident 60) for smoking, 1 of 1 resident (Resident 71) for a bolster air mattress (an air inflated mattress with propped up support to prevent accidental roll-outs), and 1 of 1 resident (Resident 72) for wander guard monitoring related to an elopement risk. These failures left residents at risk for injury, entrapment, and elopement.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 of 2 sampled residents (Residents 176 & 226) reviewed for respiratory care received care and services consistent with professional standards of practice. The facility's failure to deliver oxygen therapy according to the physician ordered flow rates (Resident 176 & 226) and to ensure correct equipment use (Resident 226) placed residents at risk for potential negative outcomes such as over or under oxygenation, respiratory discomfort, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically-related social service interventions that addressed refusal of care for 1 of 2 residents (Resident 226) reviewed for rehabilitation services and 1 of 5 residents (Resident 52) reviewed for unnecessary medications. Failure to have a process for resident refusals, identify, and find ways to support residents needs related to refusals placed residents at risk for early termination of skilled care benefits (Resident 226), unnecessary use of pain medications (Resident 52), unmet care needs, and a decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure expired medications were disposed of timely and controlled pain medications were properly secured for 1 of 1 medication room reviewed for medication storage. This failure placed residents at risk for receiving medications with decreased effectiveness and predisposes the staff to potentially diverting medications (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber).

Inspectors wroteBased on observation, interviews, and record review the facility failed to assess and ensure prompt dental care and services were provided for 2 of 9 residents (Residents 42 and 46) reviewed for oral/dental health. The facility's failure to assess and/or follow-up on dental exam recommendations placed resident at risk for oral pain, unmet dental needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the arbitration agreement was signed by the resident's Durable Power of Attorney (DPOA) for financial affairs as required for 1 of 1 residents (Resident 41) whose Arbitration Agreements (AA) were reviewed. This failure placed Resident 41 and residents at risk of forfeiture of their right to a jury or court trial and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a person-centered comprehensive Care Plan (CP) was developed and implemented for 3 of 21 residents (Residents 30, 226, & 71) whose CPs were reviewed for individualized care. The facility failed to implement CP interventions (Resident 30) and develop a discharge CP regarding discharge disposition, needs, and/or barriers (Residents 226 & 71). These failures placed residents at risk for inconsistent and unmet care needs, anxiety regarding discharge, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff performed Cardio-Pulmonary Resuscitation (CPR) to 1 of 1 resident (Resident 1) who was found unresponsive and had a physician order to initiate CPR and signed POLST (Physician Order for Life Sustaining Treatment- a form indicating the resident's wishes to have or not have CPR) for life-sustaining care and services. [...]

Inspectors wroteBased on observation, interview, and record review the facility administration failed to act swiftly and effectively to ensure the Emergency Exit (EE) doors were operable and in compliance with federal regulatory requirements. The failure to prioritize the life safety component of repairing the EE doors when found locked and inaccessible in emergent situations placed residents' health and safety at risk for serious harm including death and resulted in Immediate Jeopardy (IJ) on 12/01/2021. Administration failed to ensure supplies, including linens, wound care supplies, and over-the-counter medications were available to staff to provide care in a clean and comfortable manner and according to physician orders. This failure led to residents having inadequate linens on the beds, medication errors and alternate wound treatments. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was prepared according to the required menu for modified food textures and thickened liquid consistencies and as ordered by the physician for 3 of 3 (Residents 42, 40, & 66) residents. This failure placed 27 total residents assessed to require altered food textures and/or thickened liquid consistencies, for safe swallowing, at risk for choking while eating, aspiration (inhalation of food/fluids into the lungs), pneumonia, and/or death. CFR 483.60 (c)(3)(5)(6) F-803 Menus meet Resident Needs/Prep in Advance/Followed. On 12/08/2022 at 5:31 PM, an Immediate Jeopardy was identified, and the Administrator was informed. On 12/09/2022 the immediacy was removed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 18 residents (Resident 45) received necessary care and services in accordance with professional standards of practice related to hospitalization, significant change in condition, edema management, and medically related appointments. The facility's failure to recognize, accurately assess, and provide ongoing monitoring for worsening heart failure and kidney function; assess and adequately monitor progressively significant weight gain and edema; implement repeated physician orders for daily weights and multiple referral requests to Nephrology (kidney specialist); [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was stored, prepared and served in a sanitary manner and in accordance to professional standards for food service safety. The failure to ensure food: had cold storage temperature was maintained at or below 41 degrees; was stored in a clean refrigerator, was free of expired, unlabeled and undated food products for one of one unit refrigerators; failure to ensure staff performed adequate hand hygiene during food preparation and food service; and ensure food was prepared in a kitchen free of potential food contamination placed residents at risk for food-borne illness and unsavory food.

Inspectors wroteBased on interview, and record review the facility failed to ensure residents had the ability to exercise self-determination related to aspects of life in the facility that was significant to the resident including the frequency and type of bathing for 3 of 3 residents (Residents 51, 6, & 65) reviewed for choices. The facility's failure to identify and/or honor resident preferences related to bathing placed residents at risk for feelings of un-cleanliness, powerlessness, decreased self-worth and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure funds were reimbursed to the state Office of Financial Recovery (OFR), within 30 days of resident discharge or death, for 3 (Residents 221, 223, 222) of 3 discharged residents reviewed. This failure caused delay in reconciling resident accounts within 30 days as required. Additionally, the facility failed to notify 2 (Residents 38 & 2) of 28 residents reviewed, who were Medicaid recipients, when their personal fund account balances reached $1800 (i.e. within $200 of the $2,000 resource limit beneficiaries could possess, without their Medicaid coverage being impacted). This failure placed residents at risk for personal financial liability for their care.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were informed and provided written information concerning their rights to accept, refuse, or formulate an Advance Directive (AD) for 9 (Residents 6, 35, 45, 52, 20, 32, 65, 12, & 40) of 18 residents reviewed for ADs. This failure placed residents at risk for not having a surrogate decision maker when unable to make their own healthcare decisions. This failure placed the residents at risk of losing their rights to have their stated preferences/decisions regarding end-of-life care followed.

Inspectors wroteBased on interview and record review the facility failed to provide timely notice, in writing, of changes in payment status and potential charges for services not covered by Medicare/Medicaid for 2 of 3 (Residents 27 & 371)residents reviewed for Advanced Beneficiary Notices (ABN, a notification of costs when services provided may not be paid by Medicare) and assist residents or their representatives to understand these notices or assist with the appeal process placed residents at risk for insufficient information to make informed decisions about care and finances.

Inspectors wroteBased on observation and interview, the facility failed to ensure a clean, comfortable, homelike environment for 4 of 4 Wings (Wings A, B, C & D) reviewed. Facility failure to ensure a sufficient supply of linens in adequate condition, hallways were clean and homelike, resident rooms were free of wall gouges and damaged furniture, hand sanitizer dispensers were intact, call lights were within reach, clocks in resident rooms were accurate, and Blood Pressure cuffs were kept clean left residents at risk for a diminished quality of life and a less than homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to implement a system to ensure resident concerns were identified and addressed timely and the outcome communicated to residents, including concerns brought up during Resident Council meetings. Facility failure to identify, address timely, and provide residents with the outcome of the grievance investigation left residents at risk for unresolved concerns, feeling unheard, frustrated, diminished self-worth and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Minimum Data Sets (MDS - an assessment tool) were complete and accurate for 6 of 20 (Residents 35, 55, 51, 6, 27, & 49) sample residents reviewed. Facility failure to complete accurate MDS assessments prevented the facility from transmitting accurate information to the Centers for Medicare and Medicaid Services (CMS) for facility quality ratings, and left residents at risk for unidentified and/or unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level 2 comprehensive evaluations were obtained, and/or implemented and incorporated into the Care Plan (CP) for 2 of 5 (Residents 55 and 32) residents and 1 supplemental resident (Resident 18) reviewed for PASRR. This failure placed residents at risk for not receiving necessary mental health care and services.

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 for 3 of 5 (Resident 51, 34, and 49) residents and 1 supplemental (Resident 18) resident reviewed for PASRR. This failure placed residents at risk for inappropriate 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 Care Plans (CPs) were revised and implemented for 9 (Residents 35, 51, 34, 55, 42, 6, 52, 65, & 22) of 20 sample residents reviewed. The failure to include residents and/or their resident representatives participation in the CP process prevented residents from exercizing their rights in developing person-centered care plans and deterred the facility from providing individualized resident informaiton to staff caring for residents placing residents at risk for unmet needs, feeling institutionalized, depersonalization, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nursing services were provided within professional standards of nursing for 6 of 18 (Residents 45, 51, 34, 6, 40 & 41) residents reviewed. Nursing staff failed to follow physician orders (Resident 45, 51, & 34), clarify physician orders (Residents 45, 51, 6, & 40), and signed for tasks not performed (Residents 51), which placed the residents at risk for medication and treatment errors and adverse outcomes.

Inspectors wroteBased on interview and record review the facility failed to implement effective discharge planning processes to transition residents to post-discharge care for 2 of 3 (Residents 161 & 69) residents and 1 supplemental resident (Resident 51) reviewed for discharge planning. The failure to identify and plan for the individual discharge needs of each resident placed residents at risk for unmet needs after discharge, lack of medical equipment, distress about plans to go home, unsafe discharge location, and rehospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs) for 5 of 18 residents (Resident 12, 51, 6, 41, & 46) reviewed for ADL care to dependent residents. The failure to provide dependent residents with bathing, nail care, oral care, and overall grooming placed them at risk for poor hygiene, embarrassment, and diminished quality of life.

Inspectors wroteEmergency Exit Doors During a life safety inspection on 12/01/2022 from 8:45 AM to 9:50 AM, a Washington State Fire Marshal identified the two EE doors (door 2 and 3) on the east side of the building did not function as required. The Fire Marshal determined the EE doors were locked and could not be opened, which prevented residents and staff from exiting emergently. In an interview and observation on 12/01/2022 at 11:51 AM, Staff I (Maintenance Assistant) stated they took the door pins to their private home and needed to collect the pins before they could get the EE doors open. Staff I stated they removed pin from each of the push-bars for EE doors 2 and 3 after a resident wandered through the doors outside to the patio area, unsupervised. Staff I was unable to recall the name of the resident or the date they removed the pins from the door but stated that it was a while ago. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 4 (Residents 19, 66, 51, & 20) of 8 residents reviewed for nutrition maintained acceptable parameters of nutritional status. Failure to ensure consistent and timely weights, notify physicians of changes, and implement interdisciplinary interventions and physician ordered nutritional supplements, placed residents at risk for weight loss and/or delayed implementation of interventions to prevent continued weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assured timely acquiring, receiving, and administering of all drugs) to meet the needs of each resident for 8 of 10 residents (Resident 51, 23, 2, 42, 49, 4, 65, and 32) reviewed. The facility failed to implement a system of medication records that ensures accurate reconciliation and accounting of all controlled medications for 4 of 5 inventory of controlled substance books reviewed from 3 of 3 medication carts. This failure resulted in residents not receiving their medications as ordered, placed residents at risk for adverse effects from not receiving prescribed medications, at risk for misappropriation of property, and drug diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain infection control practices that provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to ensure the availability of hand sanitizer, and failed to ensure staff: performed hand hygiene during medication administration, and performed wound care without wearing gloves in accordance with the Centers for Disease Control (CDC) recommendations. These failures placed residents at risk for the development and transmission of communicable disease and infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure influenza and/or pneumococcal vaccines were offered and/or provided for 4 of 5 residents (Residents 32, 34, 51, and 49) reviewed for immunizations/unnecessary medications. These failures placed residents at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from influenza and pneumococcal disease.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and services that ensured privacy in a manner that maintained and promoted resident rights and resident dignity for 1 of 18 (Residents 50) sampled residents. Failure to communicate with residents in a dignified manner placed residents at risk for diminished resident rights, feelings of institutionalization, embarrassment, frustration, disrespect, and diminished self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide advanced written notice for room changes, to include the reason for the move, for 3 (Residents 2, 6 & 41) of 3 residents reviewed for room changes. These failures placed the residents at risk for feelings of powerlessness and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure 15 of 28 residents who had a Trust Account with the facility had their funds covered by a surety bond. This failure placed residents at risk to be unable to recover their money in the event of loss of funds from their account.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a Significant Change in Status Assessment (SCSA), including Care Area Assessments (CAAs), were completed within 14 days from the date of determination for 3 of 3 residents (Residents 27, 42, & 19) reviewed for significant changes in status. The failures to identify the need for a SCSA for: decline in cognition, eating abilities, new swallowing disorder, and repeated falls for Resident 42; decline in ability to feed self, decline in mood, and significant weight loss for Resident 19; and a terminal prognosis with initiating hospice services for Resident 27 placed the residents at risk for further decline, diminished quality of life/quality of care, and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and/or implement comprehensive, person-centered, and/or individualized care plans for 5 of 18 residents (Resident 12, 27, 45, 49, & 51) whose care plans were reviewed. Failure to establish care plans that were individualized and accurately reflected care needs, placed residents at risk of unmet care needs due to inaccurate or absent direction to staff. Resident 12 According to the 11/20/2022 Quarterly Minimum Data Set (MDS, an assessment tool) Resident 12 required total assistance during transfers from the bed to the chair and the support was provided by two staff during the assessment period. The MDS showed Resident 12 did not reject care from staff. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure weekly skin assessments, documenting and monitoring of wounds for infection, and wound treatment supplies were available for 1 of 3 (Resident 6) residents reviewed for Pressure Ulcers (PUs). Failure to complete weekly skin checks as ordered, assess and document wound progress, and/or ensure the availability of ordered skin care and treatment supplies placed residents at risk for deterioration in skin condition, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents that can eat enough orally is not fed by enteral (feeding by tube into body) methods for 1 of 1 resident (Resident 40) reviewed for tube feeding. The failure to complete on-going interdisciplinary team (IDT) assessments of the clinical indications and rationale to continue tube feeding and to identify the residents wishes and requests for oral intake placed Resident 40 at risk for possible unnecessary artificial tube feeding and diminished quality of life.

Inspectors wroteBased on observations, interview, and record review the attending physician failed to ensure and/or adequately supervise the complete medical care for 1 of 20 (Resident 45) residents reviewed. The failure to follow up on the status of repeated orders given to nursing staff for a referral to a kidney specialist, address the omission of daily weight monitoring, and facility failure to follow Physician orders (POs) resulted in Resident 45 not being evaluated for worsening fluid balance status by a kidney specialist for over 12 months, required a possibly avoidable hospitalization with the removal of a significant amount of water weight, experienced acute kidney injury and acute respiratory failure.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with dementia receive the appropriate treatment and services for 1 of 2 (Resident 20) residents reviewed for dementia care. The failure to assess residents individualized care needs through an interdisciplinary approach and implement a person-centered care plan prevented the facility from supporting residents to maintain their highest practicable physical, mental, and psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's drug regimens were free from unnecesary psychotropic medications for 2 (Residents 32 & 49) of 5 residents and one supplemental resident (Resident 66) reviewed for unncessary medications The failure to obtain consent and review the risks and benefits of psychotropic medicaitons and failure to monitor for Adverse Side Effects (ASEs) left residents at risk for use of unnecessary psychotropic medications, adverse side effects and 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 (%). Failure of 1 of 3 nurses (Staff Q) to properly administer 3 of 26 medications for 1 of 8 residents (Resident 23) observed during medication pass resulted in a medication error rate of 11.54%. This failure placed residents at risk for adverse side effects due to improper medication administration.

Inspectors wroteBased on observation and interview, the facility failed to ensure expired medications, liquid feeding supplement, and medical supplies were disposed of timely in accordance with current accepted professional standards of practice for 1 of 1 medication room, 1 of 3 medication carts, and 1 of 2 emergency crash carts reviewed. These failures placed residents at risk for receiving compromised supplies and medications with decreased or no potency.

Inspectors wroteBased on interview and record review, the facility failed to obtain timely laboratory services to meet the needs of 3 (Residents 51, 49, and 32) of 5 residents reviewed for unnecessary medications. Failure to obtain physician ordered blood tests for residents who were assessed to require this service, placed residents at risk for delayed treatment and services.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure 1 of 6 residents (Resident 45) reviewed for dental services was assisted in obtaining emergent dental care. The facility's failure to follow through with the resident's request for outside emergent dental care, failure to follow a hospital transfer order for dental services follow-up, failure to follow up on two separate dental exam recommendations for emergent dental care placed resident at risk for an oral infection, hospitalization, pain, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide foods according to the resident's preferences for 1 of 2 (Resident 52) residents reviewed for food preferences. The failure to accommodate a resident's religious dietary preferences placed residents at risk for inadequate nutrition and well-being.

Inspectors wroteBased on interview and record review, the facility failed to identify a designated interdisciplinary team member appointed as the responsible party for coordinating care and communication with hospice services, and to ensure the development of a coordinated plan of care for 1 of 1 residents (Resident 27) reviewed for hospice care services. These failures placed the resident at risk for not receiving necessary hospice services, lack of continuity of care, and unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to establish an infection prevention and control program that included developing an antibiotic (ABO) stewardship program to promote appropriate use of antibiotics; failed to analyze and complete monthly surveillance effectively for 4 of 4 months (July 2022 to October 2022) reviewed; failed to have an effective Infection Control Committee to meet regularly and analyze/review Antibiotic usage in the facility. These failures placed residents at risk for potential adverse outcomes associated with the inappropriate/unnecessary use of antibiotics and an increased risk for multi-drug resistant organisms (MDRO).

Inspectors wroteBased on interview and record review the facility failed to ensure 2 of 5 residents (Resident 51 and 49) were offered the COVID-19 (a highly transmissible infectious virus that causes respiratory illness, in severe cases can cause difficulty breathing and could result in impairment or death) vaccination and had education on the benefits and potential risk associated with COVID-19. These failed practices placed the residents at risk of COVID-19 infection and placed residents at risk for not having their medical records reflect complete and/or accurate information to be considered when making a medical decision.