Olympia Convalescent Hospital

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food preparation equipment in the kitchen was clean when one of one ice machines (Ice Machine 1) had yellowish-brown debris on the interior of the ice storage compartment according to the facility's policy and procedures (P&P) titled, Cleaning Schedule, last reviewed 1/1/2026 and the Food and Drug Administration's (FDA) Food Code, dated 2022. This failure had the potential to cause foodborne illness in 120 out of 121 residents who receive and consume food prepared from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two staffs (Housekeeping Supervisor - [HKS] and the Environmental Supervisor - [EVS]) understood the correct water temperatures and drying temperatures when washing and drying linen for residents in the facility according to the facility's policy and procedures (P&P) titled, Laundry - Sorting, Washing & Drying, last reviewed 1/1/2026, California Code of Regulations Title 22 Section 71629 - Laundry Service (CCR), undated, and the manufacturer's guidelines titled, Washer-Extractor Pocket Hardmount, dated December 2005. The facility has three linen Washing Machines (1, 2, and 3) and four linen Dryer Machines (1, 2, 3, and 4). This failure increased the potential for the spread of infections and diseases among the 121 residents residing in the facility.

Inspectors wroteBased on observation, interviews and record review, the facility failed to protect 19 of 19 residents' (Residents 7, 9, 13, 23, 26, 27, 33, 39, 45, 53, 55, 57, 60, 65, 82, 101, 106, 107 & 129) rights to privacy and confidentiality of records according to the facility's policies and procedures (P&P) titled Resident Rights with a review date of 1/01/2025 and titled Education Requirements-medical Records Manual-HIPAA (the Health Insurance Portability and Accountability Act of 1996 - a federal privacy rule which establishes national standards to protect individuals' medical records and other individually identifiable health information) with a review date of 1/01/2026, evidenced by when Licensed Vocational Nurse (LVN) 8 left the 9 aforementioned residents' medical records hidden under a laptop computer in the facility's hallway. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Residents 106, 117, and 129) were free from physical restraints (a physical method or device used to limit a person's movement or freedom) for staff convenience to treat the residents' medical symptoms without a physician's order, consent, and according the facility's policy and procedures (P&P) titled, Restraints, last revised 5/1/2026. The facility staff positioned Residents 106, 117, and 129 beds against the walls. This failure resulted in restricting the residents' free movement, increased the risk of physical function decline, and increased the risk of entrapment (when a resident becomes trapped in the gaps of a bed system) by their beds potentially leading to accidents, asphyxiation (when a person cannot breathe normally), and death for Residents 106, 117, and 129.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Residents 46, 113, and 117) received the treatment and services necessary to prevent or heal pressure ulcers (PU - localized damage to the skin and/or underlying tissue usually over a bony prominence) according to the manufacturer's undated guidelines for the Drive-branded LALM titled, Drive - Harmony - True Low Air Loss Tri-Therapy Mattress Replacement System, the facility's policy and procedures (P&P) titled, Support Surface Guidelines, last reviewed 5/1/2026, and undated manufacturer's guidelines for the Wellell-branded LALM titled, Wellell - Procare Elite - User Manual, undated when:1. [...]

Inspectors wroteBased on observation, interview, and record review, for one of five residents (Resident 15) who had a diagnosis of protein-calorie malnutrition (lack of proper nutrition)., the facility failed to:1. Ensure a resident with a gastrostomy tube (GT - a tube that is passed through the abdominal wall to the stomach used to provide nutrition) received the tube feeding as ordered by the physician.2. Restart the tube feeding pump once the enteral feeding was stopped for at least 26 minutes. This deficient practices resulted the tube feeding (is a medical method used to deliver liquid nutrition directly into a person's gastrointestinal (GI-[stomach/intestine] tract) not infusing into Resident 15 and the pump was alarming and had the potential to result in the resident to not receive the adequate nutrition .

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free sexual abuse (non-consensual sexual contact of any type with a resident) for one of one sampled resident (Resident 1) according to the facility's policy and procedures (P&P) titled, Abuse Prevention and Prohibition Program dated 6/25/2025. On 7/21/2026 at around 11PM, Resident 1 complained to Licensed Vocational Nurse (LVN) 1 that Certified Nursing Assistant (CNA) 1 sexually abused Resident 1. This deficient practice resulted in CNA 1 remaining in the facility and continued to provide care to residents on 7/21/2026 and 7/22/2026 for a total of 15 hours and 30 minutes increasing the potential risk for abuse for the residents in the facility. Findings; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to report allegation of sexual abuse within two hours to the Department of Public Health and Adult Protection Services (APS) for one of one sampled resident (Resident 1), according to the facility's policy and procedures (P&P) titled, Abuse Prevention and Prohibition Program dated 6/25/2025. This deficient practice had the potential for Resident 1 and other residents in the facility to experience/suffer abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and implement effective interventions to prevent elopement (when a resident leaves the facility grounds or a designated safe area without the staff knowing and/or without the supervision the resident needs) for one of three sampled residents (Resident 1) who was assessed at risk for wandering (walking around without a clear purpose) and elopement by failing to: 1. Accurately assess and identify elopement risk. The facility's Wandering & Elopement assessment dated [DATE] indicated a Low Probable Risk even though Resident 1 demonstrated repeated exit seeking, wandering, and attempts to elope on [DATE]. RN 2 stated the assessment was inaccurate and should have reflected a Moderate Actual Risk (is where a hazard is present and has a fair or intermediate likelihood of occurring). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their infection control policy and procedure (P&P) for two of three sampled residents (Resident 1 and 2), by failing to report the positive COVID cases to the State Agency (SA). This deficient practice had the potential to spread infection to the residents, visitors, and the community.

Inspectors wroteBased on interview, and record review, the facility failed to ensure:1) Licensed Vocational Nurse (LVN) 1 verified all medications, including controlled substance medications, received from pharmacy were checked and accounted for accuracy.2) LVN 2 and LVN 5 did not sign the narcotic count sheets ahead of time indicating that they (LVN 2 and LVN 5) actually counted and confirmed with the oncoming licensed nurse that the narcotics count was accurate/correct during shift change narcotics count. These deficient practices of not verifying medications received from pharmacy were accurate and not signing out on the narcotic sheets without counting/verifying with another licensed nurse present had the potential for diversion of narcotics.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and services to prevent an avoidable accident from occurring for one of three sampled residents (Resident 1) by failing to: 1. Ensure Restorative Nursing Assistant 1 (RNA 1-nursing aide program that helps residents maintain their function and joint mobility) implemented the Activities of Daily Living (ADL- include eating, dressing, getting into or out of a bed or chair) Care Plan to transfer Resident 1 from a shower chair (is an assistive device designed to help people who have limited mobility or physical strength when bathing) to the bed using a Hoyer lift (a mechanical device used to safely transfer individuals with limited mobility) on 7/26/2025 between 8 am to 9 am. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete annual performances evaluations (the review and evaluation of an individual's or organization's performance over a 12-month period), annual skills competencies (the measurable or observable knowledge, skills, abilities, and behaviors critical to successful job performance), and trainings for five out of five employees (Licensed Vocational Nurse 1 [LVN1], LVN2, Certified Nursing Assistant 2 [CNA2], Houskeeper, and Housekeeping Supervisor). These deficient practices had the potential for residents not to receive the appropriate level of care needed, affecting quality of care and potentially leading to resident harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen when: 1. Walk in refrigerator shelves were cracked and rusted. 2. Food stored on rusted shelves in the walk-in refrigerator. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of bacteria from one object to another) that could lead to foodborne illness medically compromised residents who receive and eat food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Maintain and ensure patient care bathrooms were in safe operating condition for 2 of 2 sampled bathrooms. 2. Maintain and ensure the kitchen ice machine was in safe operating condition, two of three food preparation tables, one of four food worming trays, four of four food storage racks, and the overhead light in the walk-in freezer, were in safe operating condition. These deficient practices had the potential to result in staff being unable to meet the needs of residents in a timely and safe manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced dignity and respect in full recognition of resident's individuality by failing to ensure that the urinary collection bag was covered with a privacy bag for two of two sampled residents (Residents 41 and 54) This deficient practice had the potential to affect Resident 41 and 54's self-esteem and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility's interdisciplinary team (IDT-- a group of health care professionals with various areas of expertise who work together toward the goals of their clients) failed to ensure one out of one sampled residents (Resident 44) was assessed determined capable to self-administer medication left at the bedside and, had a physician's order for self-administrations. This deficient practice had the potential for duplicity, overdose, and consumed by confused wandering resident which could lead to an adverse reactions, unnecessary hospitalization and possible poor health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to complete a change of condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) in accordance with the facility policy and procedures (P&P) titled Change of Condition Notification revised 1/24/2025 for one of three sampled residents (Resident 47). This deficient practice had the potential to result in the delay of necessary care for Resident 47.

Inspectors wroteBased on interview and record review, for one of four residents (Resident 45), the facility failed to: 1) Complete a Preadmission Screening and Resident Review (PASRR - a screening evaluation used to determine whether placement in a long-term care facility is appropriate for the resident) Level I (a tool that helps identify possible serious mental illness and/or intellectual/development disability) assessment when Resident 45 was readmitted on [DATE]. 2) Notify the mental health agency (A mental health agency that provides and is responsible for mental health services. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for one of four sampled residents (Resident 15) in accordance with the facility policy and procedures (P&P) titled Care Planning revised on 1/24/2025, by failing to initiate a care plan for Resident 15's gastrostomy (g-tube -a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). This deficient practice had the potential to negatively affect the delivery of necessary care and services needed for Resident 15.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measure) per resident in multiple resident bedrooms for 11 out of the 39 resident rooms (Rooms 100, 102, 104, 106, 108, 115, 117, 120, 123, 134, and 135). The 11 Resident rooms consisted of 3 beds in each room. This deficient practice had the potential to result in inadequate useable living space for the residents and working space for the health caregivers.

Inspectors wroteBased on interview and record review, the facility failed to implement its Unusual Occurrence Reporting policy for one of two sampled residents (Resident 1) by failing to report Resident 1's injury of unknown cause occurrence to the State Survey Agency (SSA) within 24 hours. Resident 1, who was confused sustained multiple left rib fractures and was unable to report how the injury occurred. This deficient practice had the potential to result in a delay of an onsite inspection by the SSA to ensure the residents' injury and accidents were investigated and had the potential to place residents at further risk for injuries.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents' (Resident 1), right to be free from physical abuse by Resident 2. Resident 2, had a history of attempting to strike other residents and staff. As a result, on 11/1/2024, Resident 2 hit Resident 1 several times on the left side of his the face/chin which resulted in bleeding. Resident 1's left chin was treated by staff for 13 days. Resident 2 was transferred to a general acute care hospital (GACH) on 11/1/2024 by non-emergency transportation for evaluation and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent elopement (when a resident leaves the facility unsupervised and unnoticed by staff) for one of three sampled residents (Resident 1). For Resident 1, who was assessed as high risk for elopement and had a wander guard bracelet (a monitoring device that would emit an audible alarm to warn staff when a resident leaves the facility), the facility failed to: 1. Respond immediately when the wander guard alarm was triggered and emitted an audible alarm when Resident 1 walked out the front door of the facility on 5/19/24 at 11:53 a.m. and out to the community. 2. Provide Resident 1 with adequate supervision. These deficient practices resulted in Resident 1 eloping from the facility on 5/19/24 at 11:53 a.m. and placed Resident 1 at risk for injuries and harm while out in the community.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure seven sampled residents (Residents 28, 61, 3, and 7) were treated with dignity and respect, and staff did not refer to the residents as feeders. This deficient practice had the potential for Residents 28, 61, 3, and 7 to suffer humiliation, embarrassment, shame, and lowered self-esteem when referred to a feeders.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Keep usage record of the emergency medication supplies. 2. Keep record of inventory discrepancies for their automated dispensing cabinet (STATSAFE, a computer-controlled system that stores and dispense medications). 3. Ensure the administration of a controlled substance was documented in the resident's electronic medication administration record for one of 32 sampled residents (Resident 70). These deficient practices had the potentials of medication errors and/or drug diversions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide effective dietetic service oversight when the dietary manager did not meet the state and federal requirements for the position and the registered dietitian worked on a consulting basis, as evidenced by lapses in the delivery of food services associated with staff competency (cross reference F802), safe and sanitary food storage and food preparation practices (F812) and therapeutic diet texture accuracy, wrong portion sizes and not following the menu (cross reference F805 and F803). This deficient practice could result in compromising the safety and nutritional status of residents through the potential for cross contamination, decreased nutrient intake and choking or aspiration risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency related to their duties when: 1. Dishwasher 1 (DW1) and Dietary Aide 1 (DA1) did not know the proper sanitizer test strip to use for dish machine sanitizer. Both DW1 and DA1 were testing the dish machine sanitizer using the wrong test strip. 2. Cook 1 did not follow the menu and the standardized recipes when preparing pureed diet and was not evaluated for competency related to pureed diet preparation. 3. Dietary Manager (DM) did not have documented routine staff competency evaluation to ensure all kitchen staff were competent in their job-related duties. These deficient practices had the potential: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the standardized recipes and portion sizes for lunch menu was followed on 4/29/24 when: 1.facility failed to ensure staff followed food production recipes for the puree diet (food that is blended to a pudding consistency, no chewing required) during lunch preparation and tray line observation. 15 Residents on puree diet did not receive the puree pork and kimchi stew and the zucchini, they received pureed tofu and pureed peas. 2. Cook used small scoop size to serve pork and kimchi for residents on regular and mechanical soft diet. 24 Residents on regular diet and 18 residents on mechanical soft diet received 3oz of pork and kimchi stew instead of 6 oz per menu and 15 residents on puree diet received 4 oz of pureed tofu instead of 6 ounces. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. 12 residents on finely chopped diet (modified diet with food prepared approximately 1/8-1/4-inch inches) and 14 residents on minced diet (modified diet with food prepared approximately 1/8-1/4-inch inches) received meat texture in the forms that meet their needs when cook served regular diet with inconsistent size and large size of meat instead of chopped and minced per resident diet orders. 2. 15 residents on pureed diet received the incorrect pureed diet texture (foods that do not require chewing and are easily swallowed. Food should be smooth .consistency of pudding) when the [NAME] served thin and soupy rice instead of pureed rice that was homogenous, cohesive and had a pudding like consistency. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. One small container of previously prepared rice and one small container of previously prepared minced meat with a use by date of 4/28/24 expired were stored in the reach in refrigerator. One gallon milk with open date 4/26/24 exceeding storage period for open container of milk was stored in the reach in refrigerator. Nutritional supplement (milk based high protein and calorie drinks) labeled store frozen with manufactures instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor signs (something found during a physical exam or as a result of a laboratory or imaging test that shows that a person may have a condition or disease) and symptoms (Something that a person feels or experiences that may indicate that they have a disease or condition) of urinary tract infection (UTI; an infection involving any part of the urinary system, including urethra, bladder, and kidney) and indwelling catheter (a flexible tube inserted in the bladder to drain out urine) was irrigated as per treatment administration record (TAR) for one of 6 residents (Resident 48). This deficient practice resulted in Resident 48 developing cloudy urine with sediment and a potential UTI and blocked indwelling catheter.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 64), had a documented date for the Isosource bag (a form of liquid nutrition) hung for the gastronomy tube feeding (G-tube, a tube that is inserted through the belly to deliver nutrition, medication, and or hydration directly to the stomach). The failure has the potential to cause the bag to be infused past the manufacture's 48-hour guidelines resulting in potential growth of food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 64), range of motion was documented. This deficient practice had the potential to negatively reflect Resident 64's range of motion treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy titled, Hand Hygiene, by failing to ensure: 1. Certified Nursing Assistant 1 (CNA 1) performed hand hygiene between care of Resident 25 and Resident 81. 2. Licensed Vocational Nurse 1 (LVN 1) performed hand hygiene between resident's room's 142 and 143. 3. A urinal was not found in Resident 82's room without being labeled. A review of Resident 25's admission Record indicated Resident 25 was admitted to the facility on [DATE] with medical diagnoses that includes dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities), depression (a constant feeling of sadness and loss of interest which stops you from doing normal activities), and hypertension (HTN -blood pumping with more force than normal through your arteries). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light for one of six sampled resident's (Resident 28) was within reach. This failure had the potential to result in Resident 28's not receiving assistance when needed from the facility staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measure) per resident in multiple resident bedrooms for 24 out of the 35 resident rooms (Rooms 107, 109, 116, 118, 120, 121, 122, 123, 124, 125, 126, 128, 129, 130, 131, 133, 134, 135, 136, 138, 142, 143, 144, and 145). The 24 Resident rooms consisted of 3 beds in each room. This deficient practice had the potential to result in inadequate useable living space for the residents and working space for the health caregivers.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the facility's cook (COOK 1) was competent on hand hygiene in accordance with facility's policy and procedures titled Dietary General revised 10/2022. This deficient practice resulted COOK 1 to not wear gloves while preparing gravy and with the potential to lead to food borne illnesses.

Inspectors wroteBased on observation, interview and record review,the facility's cook (COOK 1) failed to wear gloves while pouring flour into a pot of boiling water to make gravy. This deficient practice had the potential to lead to food borne illnesses.

Inspectors wroteBased on observations, interviews, and record review the facility ' s governing body (individuals such as facility owner(s), Chief Executive Officer(s), or other individuals who are legally responsible to establish and implement policies regarding the management and operations of the facility) failed to appoint an administrator responsible for managing and overseeing the implementation of policies and procedures. This deficient practice had the potential to affect the safety and over all well-being of the residents and could result in poor management of the facility.