North Cascades Health and Rehabilitation

Inspectors wroteBased on interview and record review the facility failed to identify and report a potential allegation of abuse and/or neglect for 1 of 3 residents (Resident 1) and failed to report results of abuse and/or neglect investigations within 5 days for 3 of 3 resident investigations (Residents 1, 2, and 3) reviewed for abuse. The facility failed to report unexplained bruises found on Resident 1's arms, legs and torso and failed to report the results of a resident to resident (Residents 2 and 3) abuse allegation. This failure placed the residents at risk of further abuse, psychological distress, and diminished quality of life.

Inspectors wroteBased on interviews, and record reviews, the facility failed to conduct thorough investigations for 1 of 3 resident investigations (Resident 1) reviewed for abuse, and/or neglect. The failure to conduct thorough investigation into unexplained bruises to a resident placed all residents at risk for repeat incidents, potential injury, and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold at the time of transfer to the hospital for 4 of 4 residents (Residents 10, 14, 33 and 52) reviewed for hospitalizations and bed holds. This failure placed the residents and/or representatives at risk of not having the necessary information to make an informed decision regarding their ability to return to the facility

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility assessment addressed the physical environment, equipment, services, and other physical plant considerations that are necessary to care for its identified resident smoking population. Failure to thoroughly assess all factors associated with resident smoking placed residents at risk for adverse events related to smoking safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure smoking policies were implemented in accordance with applicable Federal, state and local laws and regulations regarding smoking, smoking areas, and smoking safety. Failure to ensure smoking areas were in compliance with the Americans with Disabilities Act which prohibits blocking handicapped parking spaces, and Revised Codes of the State of [NAME] which prohibits smoking within 25 feet of facility entrances or windows that open, impacted parking accessibility and created the potential for smoke intrusion into the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure grievances were reviewed promptly and thoroughly resolved with supporting documentation to prevent reoccurrences for 9 of 15 Residents (Residents 30, 47, 57, 65, 79, 95, 105, 122 and 124) reviewed for grievance process. The failure to resolve grievance concerns caused the uncertainty of the resident and/or resident representative receiving necessary care and services, having a diminished quality of life, and not being able to voice concerns with some type of resolution.

Inspectors wroteBased on interview and record review, the facility failed to ensure 5 of 7 sampled residents (Residents 4, 6, 13, 18 and 104) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to monitor and document behaviors and symptoms, and failed to document non-pharmacological interventions, and effective use of medication. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure the level one Pre-admission Screening and Resident Review (PASRR- assessment/a federal requirement for Medicaid-certified nursing facilities to ensure individuals, especially those with mental illness, seeking admission are appropriately placed and receive necessary services) were referred and followed up on for 5 of 6 residents (Residents 11, 13, 73, 82 and 104) reviewed for PASRR. This failure placed residents at risk of unmet mental health services and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure care plans were revised as needed for 5 of 9 sampled residents, 2 of 6 (Resident 56 and 105) reviewed for accidents, 2 of 3 (Resident 41 and 84) reviewed for skin issues, and 1 of 6 (Resident 46) reviewed for activities of daily living. This failure placed residents at risk of unmet needs, decreased quality of care related to outdated or inaccurate care plans, and a diminished quality of life.<ACCIDENTS> <RESIDENT 56> Resident 56 was admitted to the facility on [DATE] with diagnoses to include convulsions (episodes of uncontrollable shaking, jerking, or stiffening of the muscles), Parkinson's disease (a slow, progressive brain disorder that impacts movement), polyneuropathy (dysfunction of multiple nerves often causing numbness, tingling, or weakness, typically starting in the hands and feet) and anxiety. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide sufficient qualified staff to provide care and services for 18 of 23 sampled residents (Residents 1,6, 9, 19, 28, 30, 35, 50, 58, 60, 65, 79, 83, 95, 105, 115, 121, 124) and 3 of 5 family members that had concerns related to staffing. The facility had insufficient staff to ensure residents received prompt call light response, medications delivered timely, assistance with activities of daily living including nail care, restorative care and to ensure care was completed in accordance with established clinical standards, the facility assessment, and resident's needs and preferences. These failures placed residents at risk of experiencing feelings of frustration, vulnerability, diminished quality of life, and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that drugs and biologicals were labeled and dated, expired medications were removed in the medication cart and medications were not left at bedside unattended. Failure to label and date 2 of 2 intravenous (IV) medications, not dating insulin vials after opened, keeping expired medications in 2 of 4 medication carts and 3 random observations of medications at bedside unattended, placed residents at risk for adverse effects for receiving expired medications, taking the wrong medications and a diminished quality of life.

Inspectors wroteBased on observation and interview the facility failed to provide a nourishing, palatable, well-balanced diet that met residents' daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 4 of 14 residents (Resident 19, 35, 119, and 121) reviewed for the facility meeting the dietary needs of each resident. This failure placed all residents at risk of unintended weight loss, malnutrition, depression, feelings of helplessness, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored under sanitary conditions in 2 of 4 snack/nourishment refrigerators. The failure to monitor and document refrigerator temperatures, label opened food/beverage items, discard expired food items in the unit refrigerators placed all residents at risk for their food to be contaminated, development of food borne illnesses, and consuming spoiled food.

Inspectors wroteBased on interview and record review, the facility failed to document and address issues raised by the Resident Council group for seven of seven months (September, October, November, December of 2025 and January, February and March 2026) meeting minutes reviewed. Failure of activity staff to document concerns and grievances filed by the resident council in the meeting minutes and failure to report back to the council group in writing with a response, rationale and action taken placed the residents at risk for having unresolved, ongoing care concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to comprehensively assess and monitor the need for physical restraints for 2 of 2 residents (Residents 41 and 55) reviewed for physical restraints. The facility failed to assess, obtain consent and physician order, care plan and document ongoing evaluation of the need for the restraint. These failures placed residents at risk for harm and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with grooming, including shaving and nail care for 3 of 4 residents (Residents 89, 104 and 121) reviewed who were unable to carry out their ADL's (activities of daily living) independently. The failure to provide residents, who were dependent on staff for assistance with grooming, placed the residents and others at risk for poor hygiene, injury, unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 4 of 5 residents (Residents 28, 72, 104, and 106) reviewed received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being. The facility failed to assess and document Resident's 72 and 106's for possible injury after abuse allegations. The facility failed to order mental health services as ordered for Resident 104. Additionally, the facility failed to ensure Resident 28 received care and treatment for their catheter. This placed the residents at increased risk for decline in conditions, unmet care needs, increased discomfort, psychosocial distress and less than optimal quality of care and life.

Inspectors wroteBased on observation, interview and record review, the facility failed to comprehensively assess and ensure timely and appropriate services/interventions were provided to maintain, increase and/or prevent a decrease in range of motion (ROM - was the extent that a joint can move within the expected [normal] range of values) for 1 of 4 sampled residents (Resident 3) reviewed for ROM and restorative nursing services. This placed residents at risk for developing new contractures (permanent, abnormal shortening of muscles, tendons, or skin) and/or worsening of existing contractures. Findings Included .Resident 3 was admitted to the facility on [DATE] with diagnoses to include history of stroke, which affected their dominant right side. On 04/08/2026 at 10:16 AM Resident 3 was observed in their bed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from accidents for 2 of 3 residents (Resident's 18 and 56) sampled for accidents and for 4 of 6 sampled residents (Resident 30, 50, 79, and 105) reviewed for smoking. Failure to ensure smoking materials (cigarettes and lighters) were secured for a safe environment to protect other residents from potential fire hazard and failed to ensure residents did not experience falls placed residents at risk for avoidable injuries and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate fluids to maintain hydration for 2 of 6 sampled residents (Resident 56 and 89) reviewed for hydration and 1 of 6 sampled residents (Residents 121) reviewed for nutrition. Failure to implement, monitor and accurately document fluids consumed to ensure fluid restrictions were implemented per provider's orders placed residents at risk for dehydration, fluid overload, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 3 residents (Resident 89) reviewed for respiratory care. The facility failed to follow physician orders, ensure that appropriate orders for oxygen administration were to include flow rate and to develop a comprehensive respiratory care plan. These failures placed residents at risk for unmet needs, potential negative outcomes and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure a system in which residents' records were complete and accurate for 2 of 5 residents (Resident 28 and 121). This failure placed residents at risk of not having their medical records accurate and incomplete information being considered when making medical decisions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices were followed for 1 of 2 residents (Resident 28) observed for would care and 1 of 6 staff (Staff R) observed for medication administration. These failures placed residents at risk of potential infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the daily nurse staffing information was being posted in a place readily accessible to residents/visitors and included the required information on 2 of 7 days of the recertification survey. This failure placed residents, family members, and visitors at risk of not being fully informed of current staffing levels and resident census information.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from sexual abuse by a staff member for 1 of 1 resident (Resident 1) reviewed for abuse. The facility failed to recognize and report the allegation immediately to protect the resident from the potential further abuse. This failure allowed the alleged perpetrator to continue to work with other residents and allowed them to still have access to Resident 1. Resident 1 who had a known history of domestic violence, was a victim of a home robbery by a past caregiver, experienced psychosocial harm when they experienced increased panic attacks, a change in their sleeping pattern and increased anxiety related to fear of the staff member. This failure placed residents at risk for potential sexual abuse, psychological harm, and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure timely reporting of a sexual abuse allegation to the State Agency for 1 of 1 resident (Resident 1), reviewed for abuse/neglect reporting. This failure placed all residents at risk for potential unidentified and ongoing abuse and lack of protection from abuse.

Inspectors wroteBased on interviews, and record reviews, the facility failed to conduct thorough investigations for 2 of 4 residents (Residents 1 and 2) reviewed for abuse, neglect and/or misappropriations. The failure to conduct thorough investigations placed all residents at risk for repeat incidents, potential injury, and unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure physician orders for medications were followed for 1 of 3 (Resident 3) sampled residents. This failure placed residents at risk for unmet needs, injury, and ineffective and/or delayed treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff immediately performed Cardio-Pulmonary Resuscitation (CPR) to 2 of 2 residents (Residents 1 & 2) who were found unresponsive (not breathing and without a pulse) and had a physician order to initiate CPR. Resident 1 had a 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, facility staff were unable to locate Resident 2's POLST after they became unresponsive. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure potential abuse/neglect allegations were thoroughly investigated for 1 of 2 residents (Resident 2), reviewed for unexpected death. This failure placed residents at risk for unidentified abuse and/or neglect and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment that was free from accident hazards over which the facility has control for 1 of 3 residents (Resident 1) reviewed for falls. Resident 1, who had a known history of falls experienced harm when the facility failed to safely administer medications which resulted in cumulative adverse effects contributing to a fall with a significant injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for falls were free from significant medication errors. Failure to follow physician ordered medication parameters for antihypertensive (blood pressure lowering) medications resulted in harm when Resident 1 experienced dizziness and a fall resulting in significant injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 2 residents sampled for legal representative, (Resident 3) had an accurate designation of legal representative on file in the facility, in case of decreased capacity. This failure placed the resident at risk of violation of resident rights to appoint a legal representative for decisions.

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-a document the resident completes to declare their wishes for Cardiopulmonary Resuscitation [CPR] or No CPR) were in place for immediate access to nurses and failed to ensure each resident's electronic medical record (EMR) accurately and consistently reflected the resident's code status for 1 of 1 resident (Resident 2) related to lifesaving treatment orders. The failure to access and follow the POLST instructions for CPR or ensure the POLST was readily available for Resident 2 placed residents at risk for receiving unwanted CPR against their known wishes, avoidable trauma, and other negative health outcomes.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure a system was in place in which residents' records were complete, accurate, accessible, and systematically organized for 2 of 3 residents (2 and 3) reviewed for accurate and complete medical records. The facility failed to ensure the medical records reflected an adverse event for Resident 2 and hospital visit report for Resident 3. These failures to not maintain complete and accurate medical records placed residents at risk for medical complications, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified social worker when reviewed for qualifications of a social worker for a facility licensed for more than 120 beds. This failure placed residents at risk of not having access to medically related social services, inability to coordinate care, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to have a system in place that ensured grievances were initiated, logged, addressed and resolved timely in response to residents' verbal conveyance of concerns for 1 of 1 resident (Resident 1), who verbalized complaints. The facility's failure to initiate, log, investigate verbalized concerns, inform residents of the facility's findings and the actions taken, if any, prevented the facility from identifying care trends and determining if actions taken to resolve grievances were effective. These failures led to the resident repeatedly reporting the same issues without resolution and placed them at risk for feeling frustrated, unimportant, with diminished self-worth and decreased quality of life.

Inspectors wroteBased on interviews, and record reviews, the facility failed to conduct thorough investigations for 5 of 6 residents (Resident 3, 4, 5, 6, and 7) reviewed for abuse and neglect. The failure to conduct thorough investigations placed all residents at risk for repeat incidents, potential injury, and unmet care needs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice and their person-centered plan of care for 1 of 1 resident (Resident 2) reviewed for pressure ulcers and 1 of 1 resident (Resident 1) reviewed for weights and respiratory care. The failure to obtain physician ordered laboratory testing, weekly weights and provide respiratory care in accordance with physicians' orders placed residents at risk for continued infection, delays in treatment, unmet care needs and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's received care and services in accordance with professional standards for one of one resident (Resident 2) reviewed for pressure ulcers. Failure to follow physician's orders for wound treatment and follow established standards of infection control procedures for wound care, placed residents at risk for adverse outcomes, wound deterioration, infection and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to conduct thorough investigations for 3 of 3 residents (Residents 1, 2, and 3) whose investigations were reviewed for thorough investigations, and failed to log 1 of 1 (COVID - Coronavirus Disease 2019) communicable disease outbreak. The failure to log, and conduct thorough investigations placed residents at risk for repeat incidents, injury, and for unmet care needs due to a lack of thorough investigations after incident occurred. These failures placed residents at risk for repeat incidents and injury.

Inspectors wroteBased on interview and record review the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form was completed prior to admission and according to the guidelines specified for 3 of 3 residents (Residents 4, 5, and 6) reviewed for PASRR. This failure placed residents at risk for not receiving timely and necessary mental health services, and decreased quality of life.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure residents were free from avoidable accidents when fall prevention care plans were not implemented for 1 of 3 residents (Resident 2) reviewed for accidents/incidents. These failures placed all residents at risk for lack of consistent interventions, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who engaged in smoking were assessed for adequate supervision to prevent injury from burns, provided a safe environment, necessary devices, and supplies to safely smoke, and to protect other residents from potential fire hazard for 2 of 2 residents (Residents 66 and 78) reviewed for smoking. These failures potentially placed all residents at risk for injury related to unsafe smoking practices and constituted an Immediate Jeopardy (IJ). The failed practice resulted in an IJ on 01/16/2025 when the facility failed to ensure residents, and the resident environment were safe from injury from burns and fire. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure annual Certified Nursing Assistant (CNA) performance reviews were completed for 6 of 11 CNAs (Staff F,G,H,I,J and K) who had been employed longer than one year. This failed practice had the potential to negatively affect the competency of those CNAs and the quality of care provided to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate less than 5 percent (%, unit of measure). During observation of 34 opportunities for error, 1 of 2 Licensed Nurses (LN, Staff P), made thirty-one errors, an error rate of 91 %. This placed residents at risk for side effects, unnecessary medications, and/or reduced medication effectiveness due to improper administration.

Inspectors wroteBased on interview and record review, the facility failed to provide the required notice of transfer/discharge at the time of discharge or transfer to the hospital for 1 of 2 sampled residents (Resident 50) reviewed for hospitalization. This failure placed residents at risk for lack of knowledge of their rights related to transfers and discharges.

Inspectors wroteBased on interview and record review, the facility failed to provide written bed hold notices at the time of transfer to the hospital for 2 of 2 sampled residents (Residents 50 and 72) reviewed for hospitalizations. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure assistance with bathing, nail care, grooming, and assist the residents out of bed for 3 of 4 dependent residents (Residents 20, 58 and 68) reviewed for activities of daily living (ADL's). Facility failure to provide the residents, who were dependent on staff for assistance with ADL's, placed the resident and others at risk for unmet care needs, poor hygiene, injury due to nail breakage, diminished dignity, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 2 of 5 resident's (Resident's 58 and 68) received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being. This placed the residents at increased risk of discomfort, unmet care needs, and medical complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing communication and collaboration with the hemodialysis (a mechanical way of removing waste from the body when the kidneys no longer function) center for 1 of 1 resident (Resident 335) reviewed for hemodialysis (HD) services. The failure to consistently and accurately complete resident's pre- and post-dialysis assessments and consistently ensure communication between the facility and dialysis center about what occurred during HD was completed, placed the resident at risk for unidentified medical complications and other potential/negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 5 residents (Resident 26, 68 and 72) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure appropriate indication for psychotropic medications and to obtain consent including a discussion of risks and benefits of the psychotropic medication, monitor and document behaviors and or symptom. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure 1 of 7 residents (Resident 46) observed during medication pass were free from significant medication errors. This placed the resident at risk for complications and decline in condition.

Inspectors wroteBased on observations and interview the facility failed to ensure drugs and biologicals were stored in accordance with state and federal laws appropriately for 2 of 2 (1st Floor and 2nd Floor) Medication Storage Rooms. The facility failed to ensure Schedule II-V (Substances with a high potential for abuse which may lead to severe psychological or physical dependence) controlled medications were in a separate locked permanently affixed compartment not accessible to others. These failures left controlled substances to be unintended with access to drugs that should have been securely stored.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff were complaint with Infection Prevention and Control Guidelines and standards of practice for 1 of 1 resident room (room [ROOM NUMBER]) that's on Transmission-Based Precaution (TBP), 1 of 4 residents' rooms (room [ROOM NUMBER]) that's on Enhanced-Barrier Precaution (EBP) and 1 of 1 resident during catheter care (Resident 45). The facility failed to ensure staff used appropriate hand hygiene practices in caring for a Clostridium Difficile [(C. diff) a highly contagious bacteria that can infect the gut and cause watery diarrhea] positive resident and when performing catheter care and wearing appropriate Personal Protective Equipment [(PPE) - specialized clothing clothing or gear worn to pretect for infection or illness] during high contact resident care activities. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to promptly refer, reimburse or document on 1 of 1 resident (Resident 1) who had their dentures dropped, broken and subsequently lost at the facility. This failed practice placed the resident at risk of diminished quality of life and financial impact.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the residents' rooms, shower room and hallways for 1 of 2 floors were clean and free of damaged walls. These failed practices placed the residents on the first floor at risk of diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 1 of 3 residents (Resident 6), reviewed for falls received the implementation of an intervention to reduce the risk of further falls. This placed Resident 6 and other residents at further risk of falls, potential injury and diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the direct care data of both contract and agency staff was accurately entered into the Payroll Based Journal (PBJ, a system for tracking staffing in nursing homes) for 1 of 1 quarter (Quarter 4) for the Fiscal Year (FY) 2023 reviewed for PBJ reporting. This failure caused the Centers for Medicare and Medicaid Services (CMS) to have inaccurate data related to nursing home staffing levels which had the potential to impact care and services provided to all the residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff monitored, assessed, and implemented interventions to prevent the occurrence of avoidable pressure ulcer/pressure injuries (PI) for 1 sampled resident (Resident 1) reviewed for PI. Resident 1 experienced harm when they developed an avoidable Stage 3 pressure PI to their rib area and two avoidable unstageable PI's to their sacrum. This failed practice placed all other residents at risk of the development of a PI.

Inspectors wroteBased on interview and record review, the facility failed to provide the required refund for 3 of 4 sampled residents and/or their resident representative (Resident 3, 4, and 6) within the required 30 days after the resident's discharge. This failed practice placed the resident and/or resident representative at risk of financial hardship.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure 1 of 1 sampled resident (Resident 2) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure person-centered behavioral interventions were in place, appropriate indications for use, and diagnoses were present for psychotropic medications. Resident 2 had a decline in their function, increase in falls, and a decline in their cognition after the start of psychotropic medications. These failures placed residents at risk of receiving unnecessary psychotropic medications and for medication-related complications.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident's Power of Attorney (POA) was notified timely for 1 of 2 sampled residents (Resident 1) reviewed for notification of change of condition. The facility failed to notify the POA timely of the start of an antibiotic for a respiratory tract infection and of a ground level fall. This failure placed all the residents' POA at risk of not being informed of residents' status.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 2 new hired Licensed Practical Nurses (LPN) nursing staff (Staff A) received their credentials (username and password) to document in the facility's electronic medical record prior to working independently. This facility failed practice recorded Staff A, LPN falsely documented nursing notes, medication administration record (MAR) and treatment administration record (TAR) as completed by Staff B, Registered Nurse (RN).

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently monitor a resident for significant weight loss, notify the physician/responsible party, provide nutritional supplements timely, assistance with meals, and meal alternatives when the meals were consumed at less than 50% for 1 of 6 sampled residents (Resident 39) reviewed for weight loss. The facility failed to recognize Resident 39 experienced harm when they had significant weight loss of 12.3% in 4 months (calculated from their weight on 11/05/2023 to their 03/07/2024 weight). These failures placed all other residents at risk for unrecognized weight loss and decline in their nutritional status.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the direct care data of both contract and agency staff was accurately entered into the Payroll Based Journal (PBJ, a system for tracking staffing in nursing homes) for 1 of 1 quarters (Quarter 3) for the Q3's Fiscal Year (FY) 2023 (which included July 2023 through September 2023) reviewed for PBJ reporting. This failure caused the Centers for Medicare and Medicaid Services (CMS) to have inaccurate data related to nursing home staffing levels which had the potential to impact care and services provided to all the residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that they had an individual who had Based on interview, and record review, the facility failed to ensure they had an individual who had completed specialized training in infection prevention and control as their designated Infection Preventionist. This failure placed all residents and staff at risk for unmet infection control issues and/or care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary care and services for 4 of 10 sampled residents (Resident 50, 71, 191, and 39) reviewed. The failure: 1) to provide wound care treatment recommendations made by the contracted wound care providers, 2) to offer ice for pain as ordered, 3) to obtain a food texture consult as ordered, 4) to obtain a physical therapy consult as ordered after a fall, 5) to administer oxygen as ordered, and 6) to monitor and assess a resident with an infection, placed the residents at risk for unmet care needs, pain, wounds that didn't heal, difficulty eating, more falls, and diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to complete required annual performance reviews for 3 of 3 sampled Certified Nursing Assistants (Staff H, J, and M) reviewed for annual review after one year of employment. Failure to complete annual performance evaluations and provide in-service education as needed based on performance evaluations placed all residents at risk for diminished quality of care.

Inspectors wroteBased on observation and interview, the facility failed to ensure two of two medication rooms had unexpired medications. In addition, the facility failed to ensure medications were secured and not accessible to residents. These failures placed the residents at risk of receiving expired medications and potential drug misuse.

Inspectors wroteBased on record review, and interview, the facility failed to ensure 3 of 5 employees, (Staff H, J, and M) reviewed for training, had the required 12 hours per year of in-services, abuse, and dementia training. This failure placed residents at risk of less than competent care and services from staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor residents' rights to have an opening and functioning dining room (1st floor dining room) for breakfast where residents could eat and socialize while they ate. The failure to open the dining room for breakfast resulted in residents having to eat in the hallways or in their rooms and placed them at risk for isolation and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs and preferences of 1 of 1 resident (Resident 50) reviewed for accommodation of needs. The facility failed to provide a chair for the resident to sit in so they could spend time out of bed, and to provide a wheelchair (w/c) that met the resident's needs. This failure placed residents at risk being confined to their bed with no option of anywhere to go outside of their bed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 of 6 residents (Residents 72 and 50) who were reviewed for abuse and neglect were free of abuse and neglect. Resident 72 was abused when staff forced them to receive care when they had refused. Resident 50 was neglected when they were confined to their bed for months, did not provide the resident an option of a chair or other furniture they could sit in so they could get out of bed, and to provide a wheelchair that met the resident's needs. These failures placed the residents at risk for abuse and neglect, unmet needs, and diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to conduct thorough investigations for 1 of 6 residents (Resident 72) reviewed for thorough investigations and had corrective action taken following an investigation where a staff to resident abuse allegation was verified. This failure placed all residents at risk for abuse, and diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to obtain the Level II Preadmission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability, or Related Condition, and a serious mental illness prior to admission to a Medicaid-certified nursing facility or a significant change of condition) and identify and refer for Level II (an in-depth evaluation to determine whether the resident requires specialized rehabilitation services) PASRR recommendations when the resident experienced a change in their psychiatric conditions for 1 of 5 resident's (Resident 65) reviewed for PASARR. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards were met for 1 of 2 residents (Resident 87) reviewed for wandering. The facility failed to ensure a licensed nurse completed the assessment of a wander guard device (worn device that alerts related to location) before they documented the task was completed. This failure placed the resident at risk for an inaccurate assessment, negative outcomes, and potential elopement risk.

Inspectors wroteBased on interview, and record review, the facility failed to consistently conduct and document pre and post dialysis assessments, ensure consistent ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 of 1 resident (Resident 61) reviewed for dialysis. This failure had the potential to place residents who receive dialysis at risk for unmet care needs and medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 5 residents (Resident 65 and 3) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure appropriate indication for psychotropic medications and to monitor and document behaviors and or symptom. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a system in which resident's records were complete, accurate, and accessible, for 1 of 1 resident (Resident 87) reviewed for accurate and complete medical records. The facility failed to ensure the medical record for Resident 87 reflected the lack of guardianship, and the authority limitations of the court appointed visitor. This failure by the facility to not maintain complete and accurate medical records placed residents at risk for medical complications, unmet care needs, and for diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control and transmission-based precautions (TBP) were being followed for 1 of 1 resident rooms (room [ROOM NUMBER]) on contact TBP. This failure placed residents and staff at risk for transmission of communicable diseases.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from neglect for 1 of 4 sampled residents (Resident 6) reviewed for abuse and/or neglect. The failure to provide incontinence care to a resident who was identified to be incontinent of bowel and bladder and required staff assistance for toileting assistance from the day shift staff (approximately for six hours and 23 minutes) prior to being discharged from the facility. This resulted in psychological harm for Resident 6 in the form of mental anguish and embarrassment, (applying the reasonable person approach), when they experienced urine incontinence on a paratransit bus and when they arrived home and placed other residents at risk for experiencing embarrassment and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services according to professional nursing standards for 1 of 3 residents (Resident 1) reviewed for unwitnessed falls. The facility failed to identify a possible neurological injury (injury to that effects the head, brain, and spine) when the resident presented with multiple episodes of elevated blood pressures beyond their base line, after an unwitnessed fall where the resident had head trauma. The facility failed to appropriately notify the provider after the resident had an unwitnessed fall that caused head trauma, and failed to notify the provider that there was a delay in treatment of a physician's order to obtain x-rays for the resident after they had three consecutive unwitnessed falls that resulted in head trauma, increased neck pain and a decline in the resident's condition. [...]

Inspectors wroteBased on observations and interview the facility failed to ensure drugs and biologicals were stored in accordance with state and federal laws, and expired medications were discarded appropriately for two of two (1st Floor and 2nd Floor) Medication Storage Rooms. These failures placed residents at risk to receive expired medications and to experience adverse side effects and other potential negative health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in accordance with food safety standards in the facility kitchen and in 2 of 2 resident nourishment refrigerators. The failure to maintain a sanitary nourishment refrigerator placed residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their personal food policy for foods brought in from the outside and stored in 2 of 2 resident (1st and 2nd floor) nourishment refrigerators/freezers. The failure to properly store residents' personal foods placed the residents at risk for foodborne illness.

Inspectors wroteBased on interview, and record review the facility failed to ensure abuse policies and procedures were implemented by failing to thoroughly investigate allegations of abuse and neglect, ensure investigations identified the root cause of the incident, completed timely, interview staff involved and protect the resident for 14 of 16 sampled resident incidents investigations (Residents 1, 2, 3, 4, 5, 6, 14, 15, 17, and 18) reviewed for allegations of abuse and neglect. These failures placed residents at risk for unidentified abuse and/or neglect and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to have sufficient nursing staff to provide nursing services to 6 of 14 sampled residents ( Residents 4, 7, 8, 9, 14 and 15), and failed to respond to call lights in a timely manner for 1 of 2 floors (1st Floor) reviewed for staffing. The facility failed to ensure there was sufficient nursing staff to provide services such as bathing, and toileting to the residents. Failure to timely respond to resident call lights, and have sufficient, competent Nursing Assistants Certified (NAC), resulted in missed bathing, and delayed toileting needs for the residents. This failure placed residents at risk for unmet care needs, discomfort, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 1 of 2 floors (2nd Floor). The facility failed to ensure oversight and implementation of their Infection Prevention and Control Program during a Coronavirus Disease 2019 (COVID-19, an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) outbreak. [...]

Inspectors wroteBased on interview, and record review, the facility failed to obtain the Level II Preadmission Screening and Resident Review (PASARR a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) and follow recommendations for 1 of 1 resident (Resident 18) reviewed for PASARR. Facility failure obtain the Level II (an in-depth evaluation to determine whether the resident requires specialized rehabilitation services) timely delayed the implementation of recommendations and left the resident at risk for unmet mental health needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive, person-centered care plan to meet the needs of 1 of 3 residents (Resident 3) reviewed for care planning. This failure placed residents at risk for injuries to their skin and a diminished quality of life. Findings Included . Resident 3 was admitted to the facility on [DATE] diagnoses included dementia and chronic lower extremity edema. Resident 3 was on hospice services in place. In a review of the facility's injury of unknown source incident report, dated 10/17/2023, showed Resident 3 was found to have a bruise to their left lower leg. The incident report concluded the resident was unable to provide how they obtained the injury. The facility linked the injury to Resident 3 bumping into their wheelchair (w/c) when it was parked next to their bed. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure 1 of 1 sampled resident (1) who was admitted with osteoarthritis and pain in both of their needs and legs were transferred in manner to prevent potential injury. This placed resident at risk for potential injury during transfers and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to conduct thorough investigations for 2 of 4 residents (Resident 1 and 2) reviewed for potential abuse or neglect. The failure to conduct complete and thorough investigations placed residents at risk for repeat incidents, injury, and lack of appropriate corrective action on the part of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans were reviewed and revised to accurately reflect resident needs and preferences for 1 of 4 residents (Resident 2) reviewed for allegations of abuse and neglect. This failure placed Resident 2 at risk for psychosocial harm when the care plan was not updated to reflect a preference for staff of a specific gender for toileting and personal care and the facility continued to schedule staff of the non-preferred gender to care for the resident.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 4 sampled residents (Resident 1) reviewed for quality of care. Failure to assess residents skin risk factors, identify a change in the residents skin, and implement care planned interventions for residents with non-pressure skin conditions accurately and thoroughly. This failure placed residents at risk for delayed wound healing, medical complication, increased pain, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety and mobility interventions were provided as directed in the care plan for 2 of 3 residents (Resident 1 and 2) reviewed for falls. This failure caused harm to Resident 1, who experienced a fall when assisted with a one-person transfer that resulted in a fracture, Resident 2 at risk for injury when a fall occurred during ambulation with a nursing assistant, and placed residents at risk for a fall with potential injury.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of neglect to the State Agency within 24 hours and to log the allegations in the facility's reporting log as required for 4 of 4 identified residents (Resident 3, 4, 5, and 6) reviewed for abuse/neglect. The failure to report, log and timely investigate allegations of neglect placed residents at risk for ongoing unaddressed neglect, and decreased quality of life and other negative healthcare outcomes.