Puget Sound Transitional Care

Inspectors wroteBased on observation, interview and record review the facility failed to initiate and investigate an allegation of resident-to-resident abuse for 2 of 4 (Resident 1 & 2) residents reviewed for resident-to-resident incidents. The failure to initiate an investigation, document the incident and thoroughly investigate put all residents at risk for unidentified abuse or neglect, lack of protection, continued abuse, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect 1 of 1 sampled resident (Resident 1) reviewed for abuse and the right to be free from physical abuse by (Resident 2). The facility failed to assess, monitor and implement safety interventions to protect residents from residents with known behaviors. These failures placed residents at risk of physical and psychosocial harm, mental anguish, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with a Percutaneous Endoscopic Gastrostomy (PEG) tube (a soft, flexible plastic feeding tube inserted directly into the stomach through the abdominal wall) received the appropriate treatment and services according to professional standards of practice for 2 of 3 residents (Residents 1 & 2) reviewed for tube feeding management. The facility failed to follow and implement the physician's orders pertaining to tube feeding volume delivery to meet the resident's assessed nutritional requirements (Resident 1) and failed to ensure ongoing review and evaluation regarding the discontinuation of the PEG site after adequate oral nutrition was established and achieved by the resident (Resident 2). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's medical records were complete, accurate, and reflected the actual care provided for 1 of 7 sample residents (Resident 7) reviewed for resident records. The failure to ensure wound care completion was documented accurately in the Treatment Administration Record (TAR) placed residents at risk for inaccurate representation of wound condition and care, unnecessary repetition of dressing changes, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents received required written notices and Long Term Care Ombudsman (LTCO) notifications at the time of transfer/discharge for 6 of 7 residents (Residents 1, 7, 9, 3, 11, & 53) and report to receiving hospital for 2 of 7 residents (Residents 3 & 11) reviewed for hospitalization. Failure to ensure a written notification was provided to the resident and/or representative in a language and manner the resident and/or representative understood, notify the LTCO as required of the reasons for the discharge, and give a report to the receiving hospital on resident's condition placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care/preferences, and a break in communication and continuity of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were updated and revised periodically and as needed for 5 of 19 sample residents whose CPs were reviewed (Residents 57, 28, 2, & 11). This failure placed residents at risk for unmet care needs, unnecessary care, and frustration.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Dietary Manager met the minimum qualifications required in the absence of a full-time Registered Dietician for 1 of 1 facility kitchens. This failure placed residents at risk for unmet nutritional needs and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was stored under sanitary conditions for 2 of 2 unit refrigerators (200 & 300 unit refrigerators), and meal trays were distributed in a way that promoted food safety for 1 of 2 units (300 unit). These failures placed residents at risk for spoiled food, foodborne illness, injury, and infections.

Inspectors wroteBased on interview and record review the facility failed to educate and offer staff the Covid 19 (C19) vaccination for all staff when reviewed for vaccinations. This failure placed staff and residents at a higher risk of contracting C19 infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident 9) of five sampled residents reviewed for unnecessary medications had completed consents for psychoactive medications. Additionally, the facility failed to obtain consents for safety devices including bed against the wall and floor mats both sides of bed for 2 (Resident 2 & 3) of 7 residents reviewed for safety devices. These failures did not ensure residents were notified about their medications, safety devices, and facility policies.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide information and assistance to formulate an Advance Directive (a document describing a resident's wishes for care if they became incapacitated) for 2 of 4 residents (Resident 11 & 8) reviewed for advanced directives. This failure left residents at risk for losing the right to have their preferences and choices honored during emergent and end of life care.

Inspectors wroteBased on interview and record review, the facility failed to complete the comprehensive assessments within the regulatory timeframes for 1 of 2 (Residents 64) supplemental residents, and 2 of 3 resident (Resident 18 & 93) reviewed as closed records for assessments and timing. The failure to ensure comprehensive admission Minimum Data Set (MDS - an assessment tool) assessments were completed timely hindered the care planning process necessary to provide the appropriate resident care and services, and placed residents at risk for unidentified care needs, delayed services, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) accurately reflected the status of the resident for 2 of 19 sampled residents (Residents 53 and 71). This failure placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) level 2 comprehensive evaluation (a process to determine what mental health services residents required after a level 1 PASRR identified potential indicators of Serious Mental Illness - SMI) were obtained for 2 of 5 residents (Residents 1 & 3) whose PASRRs were reviewed. This failure placed residents at risk for not receiving the necessary mental health care and services they needed, frustration, and unmet mental health needs.

Inspectors wroteBased on observation, interview, and record review the facility: failed to ensure physician's orders were followed for 3 of 19 (Residents 11, 62, & 5) sampled residents; failed to ensure nurses only signed for treatment once provided for 1 of 19 (Resident 1) sampled residents; failed to ensure physician's orders were clarified as needed for 1 of 19 (Resident 1) sampled residents; ensure physician's orders were in place prior to care for 2 of 19 (Residents 1 & 53) sampled residents. These failures placed residents at risk for unmet needs, and ineffective and/or delayed treatments.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 (Resident 1) of 1 sample residents reviewed for communication was provided with a functional communication system. Failure to identify and provide services to maintain effective communication placed residents at risk for unmet care needs, social isolation, and a diminished sense of well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs - bathing, grooming, getting up, oral hygiene etc.) to residents dependent on staff assistance for ADL for 4 of 6 (Residents 10, 2, 11, & 13) residents reviewed for ADLs and 1 supplemental resident (Resident 53). The failure to provide assistance with showers, dressing, oral hygiene, and getting out of bed left residents at risk for frustration, poor hygiene, embarrassment, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to offer and provide individualized activities plans and to document the refusals for 2 of 3 residents (Resident 11 & 2) reviewed for activities. Failure to consistently offer and provide meaningful individual activity plans left residents at risk of boredom, frustration, isolation, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility: Failed to ensure residents' skin was assessed weekly as ordered, monitored, and treated as required for 2 (Residents 9 & 10) of 4 residents reviewed for non-pressure skin. These failures placed all residents at risk for delay in treatment, worsening condition, unmet care needs, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents admitted with Indwelling Catheters (I/C - a flexible tube inserted into the bladder) were assessed for the continued need for a I/C, attempted to remove the I/C as soon as possible for 1 (Resident 9) of 3 residents reviewed for the I/C. These failures placed residents at risk for urinary tract infections, decreased bladder tone (muscle strength), urethral erosion (gradual destruction of the tissues), and dignity issues.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete safety assessments for a bed against the wall and fall mats on the floor for 2 of 7 residents (Residents 3 & 2) and a tilt-in-space wheelchair for 1 of 8 residents (Resident 77) reviewed for accident hazards. This failure placed residents at risk for injury, entrapment, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 percent (%). Failure of 2 of 4 nurses (Staff U & V - Registered Nurses) to properly administer 2 of 32 medications for 1 (Resident 38) of 4 residents observed during medication pass resulted in a medication error rate of 6.25%. This failure placed residents at risk for adverse side effects and/or not receiving prescribed medications as ordered.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were returned or discarded when expired or when residents discharged for 1 of 1 medication rooms (200 Unit Medication Room) and 2 of 2 medication carts (200 North and 300 North medication carts) observed. The failure to ensure unneeded medications were returned to the pharmacy or destroyed upon resident discharge or expiration placed the residents at risk for receiving unauthorized, compromised, and/or ineffective medications.

Inspectors wroteBased on interview and record review the facility failed to complete Antibiotic (ABO) Stewardship to promote appropriate use of ABOs and reduce the risk of unnecessary ABO use for 2 of 4 residents (Residents 10 & 93) reviewed for unnecessary ABOs. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate/unnecessary use of ABOs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure toilets were functioning properly on 2 of 3 floors (Second and Third Floor) and failed to ensure call lights were functioning on 1 of 2 floors where residents lived (Third Floor). These failures placed residents at risk for a less-than-homelike environment, skin tears, the inability to call for help when needed, and frustration.

Inspectors wroteBased on interview and record review, the facility failed to ensure Basic Life Support (BLS) was initiated immediately, as directed in the facility policy, including Cardio-Pulmonary Resuscitation (CPR - an emergency procedure consisting of chest compressions combined with giving breaths of air) for 1 of 1 resident (Resident 1) reviewed for unexpected death in the facility. This failed practice placed 48 additional residents (Residents 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50 & 51), who had current physician orders to receive CPR, at serious risk for adverse outcome including death and constituted an Immediate Jeopardy (IJ). On [DATE] at 2:05 PM, the facility was notified of an IJ in F678. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 7 staff (Staff C, D, & E) reviewed and 1 supplemental staff (Staff F) had the appropriate knowledge, competencies, and skill sets to provide nursing and related services, including Cardio-Pulmonary Resuscitation (CPR - an emergency procedure consisting of chest compressions combined with giving breaths of air), to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as determined by resident assessments, individual plans of care, and the facility assessment. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse prohibition policy for 1 of 2 residents (Resident 1) reviewed for abuse and/or neglect. The failure to report to the appropriate agencies as required by State and Federal laws regarding Resident 1's unexpected death placed residents at risk for exposure to potential abuse/neglect, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse prohibition policy for 1 of 2 residents (Resident 1) reviewed for abuse and/or neglect. The facility failed to completely and thoroughly investigate Resident 1's unexpected death. The failure to initiate, conduct a thorough investigation, and correct actual or potential alleged violations left residents at risk for unidentified and/or repeated incidents of abuse/neglect and a decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to keep the kitchen environment clean and sanitary and failed to ensure food was stored, prepared, and served under sanitary conditions for 1 of 1 kitchen observed. Facility staff failed to: Label and date food; discard damaged/expired/spoiled food (including after thawing); and perform Hand Hygiene (HH) when handling raw eggs during food preparation. These failures contributed to an unsanitary and unsafe storage and preparation of food, and placed residents at risk for life-threatening food-borne illness and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain and/or offer assistance to residents and/or their representatives to formulate Advance Directives (AD) for 8 of 17 residents (Residents 11, 59, 65, 80, 24, 77, 48, & 62) reviewed for ADs. These failures placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were provided an opportunity for a Care Conference (CC) for 5 of 17 sampled residents (Resident 44, 46, 2, 37, & 48). Failure to ensure residents were given the opportunity to participate in care conferences left residents at risk for unmet care needs, lessened participation in care planning, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Physician's Orders (POs) for 5 of 17 residents (67, 64, 24. 44, 46) reviewed for acquiring, implementing, and documenting physician orders. These failures left residents at risk for not receiving care they required, potential for new skin issues, and negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL), related to cleanliness and grooming for 5 (Residents 15, 44, 2, 80, & 24) of 17 sample residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with bathing (Residents 15, 44, & 2), shaving (Residents 24 & 80), and nail care (Resident 24), placed the residents at risk for poor hygiene, long facial hair, embarrassment, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement ongoing communication and care coordination with the dialysis (a procedure to clean and filter the body's waste products) facility regarding treatment and services for 2 of 2 residents (Residents 24 & 11) reviewed for dialysis care. This failure placed residents at risk for unmet care needs, unidentified medical complications, adverse health outcomes, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to properly administer 16 of 26 medications for 2 of 4 residents (Residents 28 & 15) observed during medication pass resulted in a medication error rate of 61.54%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of Physician Ordered (PO) medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representatives were informed of the nature and implications of entering into a binding Arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) Agreement (AA) for 2 of 3 residents (Residents 37 & 67) reviewed for arbitration. The facility failed to explain the AA in a form or manner that the resident and/or their representative understood (Resident 37) and failed to ensure the Durable Power of Attorney for Financial (DPOA-F) was the signatory on the AA (Resident 67) on behalf of the resident as required. These failures placed Residents 37 and 67 and other residents at risk of lacking understanding of the legal document signed, forfeiture (loss or giving up of something) of the right to a jury or court, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, clean, and comfortable environment was provided to residents. Facility failure to maintain a homelike and odor-free environment left residents at risk for an unpleasant living situation, infectious diseases, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents and Long-Term Care Ombudsman Office (LTCO) received required written notices at the time of transfer/discharge, or as soon as practicable, for 3 of 4 residents (Residents 48, 64, & 59) reviewed for hospitalization. Failure to ensure a written notification was provided to the resident and/or representative of the reasons for the discharge and in a language and manner the resident and/or representative understood placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Failure to ensure a notification was provided to LTCO of the reason for transfer/discharge prevented the LTCO the opportunity to educate residents and advocate them regarding the discharge process.

Inspectors wroteBased on interview and record review the facility failed to encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe, for 2 of 2 residents (Residents 6 & 68) reviewed for timeliness in encoding and transmission of Minimum Data Set (MDS - an assessment tool). This failure affected federal health information data gathering and placed residents at risk for inaccurate monitoring of the residents' decline or progress over time, untimely comprehensive review of residents' health data/information, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) of 3 of 17 residents (Residents 80, 48, & 67) were completed accurately to reflect the resident's condition and overall health status. The facility failed to assess and identify the presence of loose dentures (Resident 80), a fall while in the facility (Resident 48), and a Range of Motion (ROM) limitation (Resident 67). These failures placed residents at risk for aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident), fall triggers, decreased mobility, contractures, unidentified and/or unmet care needs, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive Care Plans (CP) for 2 of 17 residents (Residents 37 & 65) whose comprehensive CPs were reviewed. Failure to develop and implement a CP to address a resident's pain (Resident 37), provided care instructions regarding leg immobilizer device use (Resident 65), and establish individualized CPs with identified goals that accurately reflected the resident's condition placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure activity programs met the needs of each resident for 1 of 1 resident's (Residents 2) reviewed for activities. Failure to provide residents with meaningful activities left residents at risk for boredom, frustration, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 4 residents (Residents 64 & 59) reviewed for non-pressure skin alterations and 1 of 4 residents (Resident 2) reviewed for constipation were provided quality care and services. The failure to ensure resident skin issues were assessed, treated, and/or monitored, and the failure to initiate facility bowel care protocol left residents at risk for unmet care needs, pain/discomfort from constipation, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 3 of 6 sampled residents (Residents 44, 46, & 67) reviewed for Restorative Nursing Program (RNP) services received the care and services they were assessed to require. These failures placed residents at risk for a decline in Range of Motion (ROM), increased dependence on staff, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fall prevention interventions were in place for 1 of 4 sampled residents (Resident 37) reviewed for falls. This failure placed residents at risk for potential injuries that could affect the resident's quality of life and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe environment to prevent placing residents at risk for facility acquired infections. The facility staff failed to follow Transmission Based Precautions (TBP) recommendations for 2 (room [ROOM NUMBER] & 325) of 2 rooms on contact precautions reviewed, and ensure indwelling catheter (tubing to facilitate urinary drainage) bags were secured. These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed processes designed to prevent contamination in food storage and preparation areas for 3 of 4 staff (Staff N- Dishwasher/Tray Prep, Staff M- Dishwasher/Tray Prep and Staff L- Dishwasher/Tray Prep). The failure of staff to 1) always wear a hair restraint, 2) keep personal belongings and personal drinks out of the kitchen, 3) perform hand hygiene, use gloves correctly, dispose soiled paper towels appropriately, 4) use unclean thermometers when checking food temperatures, increased the risk of cross contamination of foodborne pathogens and placed all residents, who consumed food prepared in the facility's kitchen, at risk of food-borne illness and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility administration failed to manage the facility in a way to ensure substantial compliance with federal regulatory requirements. The Administration failed to ensure there was active and engaged oversight and monitoring of systems related to social services, infection control and prevention, Nutrition/Hydration, Quality of care in showers, edema and bowel management, care planning, resident rights, medication services. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 of 6 residents and 1 supplemental resident (Residents 16, 48, 35, and 61) reviewed for Care Plans (CP). The failure to include residents and/or their representatives in development or revising their person-centered CP prevented residents from exercising their right to participate in the development of, being informed of, and request changes in, their individual CP.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the accuracy of Minimum Data Set (MDS, an assessment tool) assessments for 3 of 20 (Residents 2, 19, and 14) sampled residents. The facility failed to accurately assess physical restraints, active diagnoses, and psychotropic medications which placed residents at risk of having unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR, a screening process for residents who have indicators of intellectual disability or serious mental illness) assessments accurately reflected residents' mental health conditions for 3 of 7 residents (Residents 6, 33, & 61) reviewed for PASRR. The failure to review and revise PASRR assessments on admission and with a change of mental health condition placed residents at risk for not receiving the appropriate and timely mental health services, not receiving a Level II evaluation if indicated, potential for inappropriate placement, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure a baseline care plan was completed within 48 hours of admission for 1 of 1 resident (Residents 61) reviewed for care plans and two supplemental residents (Residents 14 & 62). The failure to complete a baseline care plan and discuss care goals and interventions with residents on admission placed the residents at risk for being uninformed of care provision, complaints regarding care and unmet care needs.

Inspectors wroteBased on interviews, the facility failed to employ a qualified social worker on a full-time basis. This failure placed residents at risk of having unmet psychosocial needs.

Inspectors wroteBased on interview and record review the facility failed to ensure that the transfer of trust funds in a resident trust fund occurred within 30 days following death or discharge for 2 of 5 residents (Residents 117 & 118) reviewed for trust fund. The failure to reconcile resident accounts and provide reimbursement to the resident or the State Office of Financial Recovery (OFR), placed resident's funds at risk of misuse and the state department at risk for loss of funds and the interest accumulated.

Inspectors wroteBased on interview and record review, the facility failed to provide Skilled Nursing Facility Advance Beneficiary Notices (SNF-ABN) to 2 of 3 residents (Resident 1 & 57) reviewed for beneficiary notifications. The failure to provide residents the information regarding changes in their Medicare services, including potential financial liability and appeal rights, deterred residents from exercising their right to decide on continuation of skilled services and costs associated, as required by the Medicare Program.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) for 2 of 3 (Residents 47 & 54) residents. Failure to provide help with bathing to residents who are dependent on staff for assistance, placed residents at risk for poor hygiene, diminished self-image, embarrassment, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were monitored and received the treatment they were assessed to require for 2 of 2 (Residents 37 & 54) residents reviewed for constipation and diarrhea and 3 of 4 (Residents 54, 6, & 19) residents reviewed edema (swelling) management. The failure to monitor and implement interventions for bowel and edema management placed residents at risk for pain, decline in medical status, unmet care needs and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a system by which staff would routinely offer/supply water for 2 of 2 residents (Residents 59 &31). The facility staff's failure to offer residents water routinely placed residents at risk for dehydration and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with behavioral health needs maintained the highest practicable mental and psychological well-being. The facility's failure to recognize and monitor individualized behavior triggers, implement, assess, and document non-pharmacological (non-medication) interventions to minimize behaviors, develop an individualized behavior Care Plan (CP) based on individual resident needs, and monitor psychotropic medication use with required diagnoses and consent for use, for 2 of 4 residents (Residents 14 & 61) reviewed for behaviors. These failures placed residents, with behavioral needs, at risk for unidentified behavior triggers, unmet behavioral needs, refusal of care, lack of behavioral services and support, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement a system to manage drug regimen reviews by the facility pharmacist for 1 of 5 residents (Resident 14) reviewed for unnecessary medications. The failure of the physician to respond timely and implement recommendations by the pharmacist or provide a clinical rationale for not implementing the recommendations, and the failure of the facility to follow up on pharmacist and/or practitioner recommendations, placed residents at risk for unnecessary medications, adverse side effects and diminished quality of life.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure that 1 of 2 (Resident 35) sampled residents reviewed for insulin administration was free of a significant medication error. The failure to follow the manufacturer's instructions and prime the insulin pen is considered a significant error, as it may result in the resident receiving the incorrect dose of insulin, placing the resident at risk for blood glucose complications.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff performed hand hygiene between glove changes, before, after and during wound care for 1 of 3 (Resident 48) sampled residents reviewed for wound care. This failure placed the resident at risk for the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotics for 1 of 4 (Resident 315) sampled residents reviewed for urinary tract infections. This failure placed the resident at risk for potentially adverse outcomes.