Olympia Transitional Care and Rehabilitation

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate fluids, within reach of the residents, to maintain hydration for 1 of 4 hallways (Dementia Unit) reviewed for hydration. This failure placed residents at risk for dehydration, medical complications and a diminished quality of life.

Inspectors wroteBased on interviews and record review the facility failed to honor a resident's choice for a room change for 1 of 1 sampled resident (Resident 80) reviewed for resident rights. The facility's failure placed theses residents at risk of not exercising their resident rights, loss of autonomy, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure transfer and discharge notifications to the Office of the State Long-Term Care Ombudsman (patient advocate for all residents in the nursing home) were accurate and/or contained the required copy of the notice for the transfer/discharge provided to residents/representatives, and/or that the facility maintained documentation of the transfer with the required information to be communicated to the receiving health care institution/provider for 5 of 5 residents (Residents 9, 8, 4, 84 & 86) reviewed for hospitalization and discharge. This failure placed residents at risk of lack of advocacy and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice by ensuring nursing staff followed physicians orders, had accurate documentation, and/or by ensuring medications were observed to be taken by residents for 6 of 19 sampled residents (Resident 4, 2, 7, 3, 54 & 65) reviewed for nursing care. These failures placed residents at risk for medication errors, delay in treatment, and adverse outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy recommendations were either addressed or implemented for 3 of 5 sampled residents (Residents 3, 6 & 14) reviewed for unnecessary medications. These failures placed residents at risk for medication errors, adverse side effects, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to follow medication parameters (provider instructions of when to hold or give a medication) and/or ensure nonpharmacological (non-medication) interventions were in place/documented on/observed for 3 of 6 residents (Resident 85, 6, and 7) reviewed for unnecessary medications. These failures resulted in residents receiving unnecessary medications and placed them at risk of hypotension (low blood pressure), falls, injuries and other medical complications.

Inspectors wroteBased on observation, interview and record, the facility failed to obtain consent from residents and/or resident representatives prior to implementing medical devices that potentially restrained movement and/or before administering psychotropic (mind altering) medication for 3 of 6 residents (Resident 7, 4 & 14) reviewed for right to be informed about treatment decisions. The failure to explain the risks and benefits associated with proposed medical devices and psychotropic medications in advance, detracted from the ability to make informed decisions about the proposed medical care/treatment, and prevented residents/resident representatives from exercising their right to decline the proposed care before it was implemented.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 5 residents (Residents 7 and 14) reviewed for unnecessary medications, were free of chemical restraints. The failure to ensure residents receiving psychotropic medications (drugs that affect behavior, mood, thoughts and perception) had identified target behaviors that were monitored and documented when observed, non-drug interventions were attempted prior to administration of as needed (PRN) psychotropic medications, and PRN psychotropic medication orders did not exceed 14 days, unless a clinical rationale was documented in the residents record by the provider. These failures placed residents at risk of receiving unnecessary psychotropic medications, experiencing adverse side effects such as sedation, a decline in physical function, and other potential negative health outcomes.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 4 of 19 sample residents (Resident 4, 2, 7, & 40) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide bowel care in accordance with provider orders and the facility's bowel protocol for 2 of 7 residents (Resident 3 & 7) reviewed for bowel management. This failure placed residents at risk for abdominal pain/discomfort, decreased appetite and other potential health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 2 residents (Resident 40) reviewed for pressure ulcers (PU - injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time), was provided care and services consistent with professional standards of practice, to promote healing and prevent new pu formation. The failure to consistently implement preventative offloading measures residents were assessed to require placed residents at risk for further skin breakdown, prolonged wound healing and development of new avoidable PUs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure diabetic nail care was provided for 1 of 2 residents (Resident 4) reviewed for foot care. The failure to refer residents to a qualified specialist when staff were unable to meet a resident's diabetic foot/nail care needs, placed the resident at risk for ingrown toenails, foot ulcers, infection, pain/discomfort, and other medical complications associated with inadequate of diabetic foot care.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide adequate and ordered fluids, within reach of the resident and at mealtimes, to maintain hydration for 1 of 1 sampled resident (Resident 60) when reviewed for hydration. This failure placed residents at risk for dehydration, medical complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program, to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of adverse side effects and antibiotic resistance for 3 of 5 residents (Residents 9, 96, & 3) when reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor the functioning of window alarms to prevent elopement for 1 of 20 residents (Resident 1) in a secure dementia unit. This failure placed residents at risk for elopement from the facility, injury and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure laboratory tests were completed as ordered for 1 of 3 residents (Resident 4) reviewed for quality of care. This failure placed the resident at risk of medical complications from lack of monitoring of medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to provide the Ombudsman with transfer notification for 3 of 3 sampled residents (Resident 64, 71 & 16) reviewed for hospitalization. The failure to ensure required notifications were completed, prevented the Office of the State Long-Term Care Ombudsman (an advocacy group for individuals residing in nursing homes) the opportunity to educate residents and advocate for them regarding the discharge process.

Inspectors wroteBased on interview and record review, the facility failed to ensure routine assessment and monitoring of skin condition/injuries for 1 of 3 residents (Resident 331) reviewed for non-pressure skin, to provide bowel care in accordance with physicians' orders and facility protocol for 3 of 6 residents (Residents 67, 61 & 31) reviewed for bowel management, and to report dental pain for 1 of 2 residents (Resident 181) reviewed for dental care. These failures placed residents at risk for unidentified decline and/or delayed treatment of non-pressure skin conditions, abdominal pain, decreased appetite, other negative outcomes related to untreated constipation, and for untreated dental pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to fully operationalize an effective Infection Control and Prevention program when the facility failed to implement Infection Prevention and Surveillance Program (IPSP) to ensure line listings contained complete and accurate infection control data, with ongoing monitoring and analysis of infections and microorganisms for 2 of 2 months (January and February 2025) reviewed. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an antibiotic stewardship program that ensured complete and accurate information was collected (signs/symptoms, culture results etc.), evaluated to determine if McGeer's Criteria (tool for infection surveillance and antibiotic stewardship, criteria to show if antibiotics were indicated) was met, antibiotic use warranted, and providers were notified if criteria was not met or a microorganism was resistant to the current treatment for 3 of 3 residents (Residents 50, 31 & 335) reviewed for antibiotic use. These failures placed residents at risk for ineffective treatment of infections, development of multi-drug-resistant organisms, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident funds were transferred to the state office of financial recovery (OFR) within 30 days of death or discharge, for 1 of 1 discharged residents (Resident 332) reviewed for trust accounts. This failure resulted in delayed reconciliation of resident trusts.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans (CPs) were reviewed, revised, and accurately reflected resident care needs for 4 of 18 sample residents (Residents 331, 26, 67 & 71) whose CPs were reviewed. These failures placed residents at risk for unmet care needs, inappropriate care, and other negative health outcomes.

Inspectors wrote<Documentation of Oral Care> Resident 331 admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident had moderate cognitive impairment and was dependent on staff for oral care. On 03/26/2025 at 2:31 PM, Resident 331 reported they were provided oral care the previous evening for the first time since admission. Physicians' orders, dated 03/14/2025, showed Resident 331 was NPO (nothing by mouth) secondary to dysphagia (difficulty swallowing), and directed licensed nurses to provide Resident 331's oral care twice daily, once on day shift and once on evening shift. On 03/28/2025 at 10:29 AM, Resident 331 said they had not received oral care since the evening of 03/25/2025, as previously reported. The resident said staff informed them they had to wait for an order of toothettes to be delivered. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents anticipated for discharge were provided with a discharge summary, discharge plan, or discharge medications for 1 of 1 residents (Resident 79) reviewed for discharge. This failure placed residents at risk for an unsafe discharge, for complications related to not receiving medications, delay in treatment, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the provision of bathing and oral care for 1 of 2 dependent residents (Resident 331) reviewed for activities of daily living (ADLs). These failures placed residents at risk for poor hygiene, body odor, dental caries (cavities or tooth decay), a decreased self-worth and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed ensure timeliness of laboratory [NAME] to include the reporting of critical lab results to the provider immediately for 1 of 3 residents (Resident 71) reviewed for hospitalization. This failure placed residents at risk for medical complications, hospitalization, delayed treatment, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to complete wound care per physician's orders for 1 of 3 residents (Resident 2) reviewed for quality of care. This failure placed residents at risk for prolonged wound healing and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely laboratory (lab) services were provided for 2 of 3 residents (Resident 3 and 4) reviewed for lab services. This failure placed residents at risk for delayed identification and treatment of underlying health conditions, over or underdosing of medication and other potential negative outcomes.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents were free from avoidable accidents for 1 of 3 residents (Resident 1) reviewed for Activities of Daily Living (ADLs-such as bed mobility, toileting, eating, and transferring) and accidents. This failure placed residents at risk for injury and diminished quality of care. Resident 1 experienced harm when facility staff did not follow resident's individualized care plan (CP) and use two people for bed mobility during incontinence care, resulting in a fall from the bed and a broken leg.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide timely toileting assistance for 7 of 9 Residents (Residents 1, 2, 3, 6, 7, 8, & 9) and bathing services for 3 of 4 Residents (Residents 3, 4, & 11) reviewed for Activities of Daily Living (ADLs). These failures placed the residents at risk for skin breakdown, discomfort, urinary tract infections, undignified quality of care, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required colostomy (surgically created opening in the bowel) care received services and care consistent with professional standards of practice and per physician orders for 1 of 3 residents (Resident 1) reviewed for quality of care. This failure placed residents at risk of having unrelieved pain, worsening skin conditions, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 5 of 24 sampled residents (Residents 23, 177, 276, 128 and 129) reviewed. The failure to follow, obtain, and/or clarify incomplete or conflicting physicians' orders when indicated, placed residents at risk for medication errors and other potential negative outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the external catheter length of Peripherally Inserted Central Catheters (PICC/ a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) were measured upon admission and at least weekly thereafter, for 3 of 3 residents (Resident 128, 129 & 276) reviewed for intravenous (IV) therapy. These failures detracted from staffs' ability to determine if the PICC was in the same position or had migrated and placed residents at risk for loss of vascular access, infection, and other potential negative outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent when 2 of 2 nurses (Staff H & Staff G) did not correctly administer 3 of 31 medications in accordance with physician orders and/or manufacturer's guidelines for 2 of 3 residents (Residents 23 & 17) observed during medication pass. This resulted in a medication error rate of 9.68% percent. These failures placed residents at risk for ineffective treatment of underlying medical conditions and/or adverse side effects.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain and document refrigerator temperatures for 2 of 3 facility refrigerators (Reach In & 500 Hall) reviewed for food service; failed to document dishwasher temperatures, and failed to discard expired beverages for 1 out of 1 beverage carts observed. These failures placed residents at risk of food-borne illness, unsanitary conditions, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident medical records were complete and accurate for 6 of 6 residents (Residents 177, 20, 51, 18, 54, & 277) reviewed for bowel management. The failure to accurately record resident bowel movements placed residents at risk for unidentified and/or unmet bowel care needs.

Inspectors wroteBased on observation and interview, the facility failed to respect and value the residents' private space by not knocking and/or announcing themselves for 1 of 2 sampled residents (Resident 6) reviewed for resident rights for dignity. This failure placed residents at risk for being treated with lack of dignity and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure visibly dirty/soiled bed linen was removed and clean linen provided for 1 of 4 sampled residents (Resident 18) reviewed for environment. This failure placed the resident at risk of feeling unclean, undignified, and for potential infections.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of transfer/discharge which identified the reason for transfer, the transfer date, location transferred to or a statement of the resident's appeal rights for 1 of 2 residents (Resident 41) reviewed for hospitalization. This failure placed residents at risk for being inappropriately discharged and/or not understanding their rights regarding the discharge process.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident/resident representative at the time of transfer or within 24 hours of transfer, a written notice that specified the bed hold policy for 1 of 2 residents (Resident 41) reviewed for hospitalization. This failure placed the resident at risk of being unaware of the right to hold their bed while in the hospital.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident dental assessment was correct and accurately reflected resident care needs for 1 of 3 sampled residents (Resident 55) reviewed for dental care. This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure an environment free of accident hazards for 1 of 2 sampled residents (Resident 29) reviewed for accidents. The facility's failure to identify and enclose free hanging electrical wires, placed residents at risk for avoidable falls, other injuries, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure drugs and biologicals were labeled and/or dated when opened, in accordance with accepted professional standards of practice for 2 of 2 carts (400 & 500 Hall medication carts) and 2 of 2 medication rooms (300 & 500 Hall medication rooms) reviewed. These failures placed residents at risk to receive expired medications and negative health outcomes.