Puyallup Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure 4 of 4 residents (Residents 1, 2, 3 & 4) reviewed for insurance disenrollment were informed of the risks/benefits, options, and alternative changes in their insurance, in ways that were easy for the residents and/or the residents' representative to understand. The facility failed to develop written policies and procedures regarding the process of assisting beneficiaries with changing their health care coverage, including the need to obtain a document signed by the beneficiary or representative that acknowledges that the specific information regarding the impact of a change in coverage was provided to them orally and in writing, and that they understood the information. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to protect 4 of 4 residents' rights to Medicare benefits. The facility disenrolled three (Residents 1, 2 & 3), and attempted to disenroll one (Resident 4) beneficiaries from Medicare Managed Health Plans without their request, consent, knowledge and/or complete understanding. The facility failed to develop written policies and procedures regarding the process of assisting beneficiaries with changing their health care coverage, including the circumstances under which the facility could assist a beneficiary with a plan change, and the need to obtain an attestation signed by the facility staff member that assisted with the change in enrollment, attesting that the beneficiary or representative requested the change. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promptly resolve grievances for 2 of 3 residents (Resident 1 & 2) reviewed for grievances and missing property. Failure to initiate, investigate, and resolve grievances timely placed residents at risk for frustration and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was no discrimination against Medicaid funded residents and failed to ensure Medicaid residents were not being discharged because of payment source. These failures caused residents to not have the right to stay in the facility or to be discharged to a facility that they did not want to live in.

Inspectors wroteBased on observation, interview and record review the facility failed to permit each resident to remain in the facility and involuntarily discharged 8 of 9 residents (Resident 1, 2, 3, 4, 5, 6, 7 & 8 ) reviewed for Nursing Home transfers without documentation of the basis for the transfer, and provision of sufficient time and orientation prior to discharge. In addition, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals and was reflected in the plan of care. This failure placed residents at risk of displacement, discrimination based on ability to pay for services, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide a written transfer notification to the resident/resident representative and notify the Office of the State Long Term Care Ombudsman (LTCO - resident advocates) for 9 of 16 sample residents (Residents 1, 2, 4, 5, 6, 7, 8, 11 & 13) reviewed for Nursing Home Transfers. Failure to notify the LTCO and ensure written notification was provided to the resident/resident representative, in a language and manner they understood, placed residents at risk of a lack of advocacy for not having an opportunity to make informed decisions about their transfer/discharge rights.

Inspectors wroteBased on interview and record review, the facility failed to have a system in place to address grievances/concerns raised by the Resident Council group for 4 of 8 months (January, March, April and September 2025) when reviewed for resident council. Failure of the grievance official to report back to the resident or council in writing with a response, rationale and action taken on grievances, placed residents at risk for continued concerns, unmet needs and a diminished quality of life.

Inspectors wroteBased on record review and interview, the facility failed to provide written bed hold notice at the time of transfer to the hospital for 4 of 4 sampled residents (Residents 1,11,39 and 52) when reviewed for hospitalization. This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to promptly screen residents for additional mental health supports through the Preadmission and Resident Review (PASARR, a mental health screening tool) for 4 of 7 sampled residents (Residents 2, 5, 3, and 9) when reviewed for PASARR. This failure placed residents at risk of lack of mental health support, increasing behaviors, decrease in mental health, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to implement non-pharmacological interventions (NPI) prior to providing as needed (PRN) pain medications for 4 of 5 residents (Residents 5, 39, 30 and 3) and failed to implement parameters for use of pain medications for 1 of 5 residents (Resident 30) when reviewed for unnecessary medications. This failure placed the residents at risk of receiving unnecessary pain medications, and a decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure a resident's bed fit them for 1 of 1 sampled resident (Resident 84) when reviewed for accommodation of need. This failure placed residents at risk of inability to sleep, decreased condition, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to thoroughly investigate and notify law enforcement for a physical abuse allegation with injuries for 1 of 3 sampled residents (Resident 45) reviewed for abuse and neglect. This failure placed residents at risk of physical and emotional harm, feelings of rejection and impaired quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide quality of care related to the following: medication parameters, non-pressure skin management, bowel management and anticoagulation management for 5 of 22 sampled residents (Residents 30,3, 9, 45 and 5) when reviewed for quality of care. These failures placed the residents at risk for poor clinical outcomes and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen services per provider's orders for 1 of 3 sampled residents (Resident 48) when reviewed for respiratory services. This failure placed residents at risk of oxygen poisoning, decline in condition, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental services to increase residents' ability to eat for 1 of 3 sampled residents (Resident 4) when reviewed for dental services. This failure placed the resident at risk of decreased nutritional intake, oral discomfort, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment in 2 of 2 halls (East and [NAME] Halls) when reviewed for environment. This failure placed residents at risk of decreased mood, feelings of worthlessness, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain laboratory services according to professional standards of practice for 6 of 18 Residents (Residents 3, 9, 10, 11, 12 & 13 ) reviewed for COVID-19 testing. The facility failure to obtain Physician Orders to conduct COVID-19 testing placed residents at risk of delayed identification/diagnosis of COVID-19.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases, including COVID-19 and other infections for 18 of 32 Residents, (1, 2, 3, 4, 5, 6, 7, 8, 9. 10, 11, 12, 13, 14, 15, 16, 17 & 18) reviewed for infection control. COVID-19 is an infectious disease by a virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death. The facility failed to do contact tracing, to identify those who may have been exposed to COVID-19. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the required care planned supervision to prevent accidents/falls for 3 of 4 sample residents (Resident 1, 3 & 4) reviewed for two person assists with transfers. This failure placed residents at risk for falls, injury and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to properly notify the Office of State Long-Term Care Ombudsmen (an advocacy group for residents in a nursing home) of discharges for 3 of 3 sampled residents (Residents 54, 76 and 36) reviewed for hospitalization. This failure placed residents at risk for an inappropriate discharge and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide or thoroughly complete a bed hold notice in writing at the time of transfer to the hospital or within 24 hours of transfer to the hospital for 2 of 3 sampled residents (Residents 54 and 36) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding the right to hold their bed while they were at the hospital and diminished quality of life.

Inspectors wroteResident 54 Review of Resident 54's electronic health record (EHR) showed the resident was transferred to the hospital on [DATE] and readmitted to the facility on [DATE] with diagnoses to include heart failure, diabetes, and had a surgical wound located on the right lower leg. Resident 54 was able to make needs known. During an interview on 08/12/2024 at 11:08 AM, Resident 54 stated they had just returned from the hospital after having surgery on their right lower leg. Review of Resident 54's provider order dated 08/09/2024 showed a wound treatment for the right lower leg/shin to be provided every morning. Review of Resident 54's current care plan showed no actual skin impairment and/or surgical wound documented in the resident's care plan. [...]

Inspectors wroteResident 44 Review of Resident 44's electronic health record (EHR) showed Resident 44 readmitted to the facility on [DATE] with diagnoses to include anxiety disorder, depression, and psychotic disorder (a mental illness that can cause a person to lose touch with reality and have abnormal thinking and perceptions). The resident was able to make needs known. Review of Resident 44's care plan showed no diagnosis of anxiety disorder addressed. The focused care plan initiated on 06/16/2023 showed that Resident 44 took a psychotropic medication for the diagnosis of dementia with behaviors as evidenced by: and did not show documentation of what behaviors or adverse side effects to monitor for related to the antipsychotic medication use. During an interview on 08/14/2024 at 9:27 AM, Staff D, LPN/RCM, stated that Resident 44 had a diagnosis of an anxiety disorder; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure freedom from unnecessary pain medication for 2 of 5 sampled residents (Resident 44, and 36) reviewed for unnecessary medications and 1 of 1 sampled resident (Resident 379) reviewed for pain management. These failures placed the residents at risk for side-effects related to the medications, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure monitoring of potential side effects related to the use of psychoactive medications for four of five residents (Resident's 9, 44, 36 and 26) reviewed for unnecessary medication use. The facility's failure to monitor behavioral monitoring and side effects related to use of an antipsychotic medications placed the residents at risk for adverse side effects, medical complications and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable disease and infections by ensuring the proper application of transmission-based precautions (TBP, precautions used with known or suspected infectious diseases/illnesses) for 1 of 2 sampled residents (Resident 23) reviewed for infections. The facility failed to follow recommendations for Enhanced Barrier Precautions (EBP, the use of gowns and gloves for high contact procedures) for 2 of 2 sampled residents (Residents 1 and 54) reviewed for infection control. The facility also failed to maintain sanitary conditions in 1 of 2 medication carts (East Long Hall medication cart) reviewed for medication storage. [...]

Inspectors wroteBased on interview and record review the facility failed to have psychotropic medication (medications that affect a person's mental state) consents signed and in place prior to residents receiving medications for 2 of 5 sampled residents (Residents 9 and 44) reviewed for psychotropic medication use. This failure placed the residents at risk for adverse side effects and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide written explanation of reason the facility initiated a room change or provide opportunity for the resident to see the new location and meet new roommates for 1 of 1 sampled resident (Resident 14) reviewed for resident rights. This failure placed the resident at risk for psychosocial distress and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify a significant change of condition for 1 of 2 sampled residents (Resident 55) reviewed for Hospice (end of life care) services. Failure to identify the need for significant change in condition assessment Minimum Data Set (MDS, a required assessment tool) placed the resident at risk for unidentified/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) assessment was accurately completed for 1 of 5 residents (Residents 44) reviewed for PASRRs and unnecessary medications. This failure placed the residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet mental health care needs.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the plan of care after a change of condition for 1 of 2 sampled residents (Resident 55) reviewed for Hospice (end of life care) services. This failure placed the resident at risk of unmet care needs 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 2 of 21 sampled residents (Residents 19 and 26) when reviewed for quality of care. The facility failed to ensure the initiation of Resident 19's provider order for Physical and Occupational therapy (PT/OT) and failed to monitor pain/evaluate the effectiveness of pain management for Resident 26 per providers orders. These failures placed the residents at risk of medical complications, unmet needs, and a poor quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently monitor and document bowel movements and implement the bowel program when needed for 1 of 2 sampled residents (Resident 3 and 9) reviewed for bowel protocol. Additionally, the facility failed to initiate proper positioning, and re-start Physical and Occupational Therapy (PT/OT) for 1 of 3 sampled residents (Resident 19) when reviewed for limited range of motion. These failures placed the residents at risk for worsening condition, discomfort, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to have an accurate and current smoking assessment for 1 of 3 sampled residents (Resident 4) reviewed for accidents. This failure placed the resident at risk for avoidable accidents and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ostomy (a surgical procedure creating an opening in the body for the discharge of body wastes into a collection bag) care and treatment instructions were provided in the plan of care for 1 of 1 sampled resident (Resident 129) reviewed for ostomy care. This failure placed the resident at risk for unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor and accurately document fluid restrictions (a diet which limits the amount of daily fluid intake) for 1 of 1 sampled residents (Resident 36) reviewed for hydration. This failure placed the resident at risk for medical complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide ongoing collaboration and communication with a dialysis provider for 1 of 1 sampled resident (Resident 28) reviewed for dialysis (a procedure to remove waste from the blood). This failure placed the resident at risk of a decline in condition, lack of coordinated dialysis care, and a diminished 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 for 2 of 6 sampled residents (Residents 1 and 8) reviewed for medication administration. During 25 medication administration observations, four medication errors were identified resulting in an error rate of 16 percent. This failure placed residents at risk of not receiving the full therapeutic effect of their medications, possible adverse side effects, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were provided a complete and accurate discharge summary that included a recapitulation (overview) of the residents' stay, a final summary of the resident's status (including skin condition), a reconciliation of all pre-discharge medications with the resident's post-discharge medications (prescriptions, over-the-counter medications, and treatments), scheduled appointments and contact information for Primary Care Provider (PCP), medical specialists, blood thinner clinic follow ups, and a post-discharge plan of care that included Physician Ordered (PO) Home Health (HH) services for 6 of 6 residents (Residents 3, 9, 8, 7, 10, & 11) reviewed for discharge summary. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary care and services to prevent the occurrence and/or worsening of avoidable pressure ulcer/pressure injury (PU/PIs) for 4 of 5 residents (Residents 3, 1, 4, & 6) reviewed for PU/PIs. The failure to develop a system to timely and accurately evaluate newly identified PU/PIs and perform weekly wound evaluations placed the residents at risk for worsening PU/PIs, unmet care needs, and diminished quality of care/quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the reason for transfer/discharge to the resident or responsible party and/or to properly notify the Office of State Long-Term Care Ombudsmen (Ombuds, an advocacy group for residents in a nursing home) of discharges to the hospital for 3 of 3 residents (Residents 7, 47, and 57) reviewed for Hospitalization. These failures denied the resident or responsible party knowledge of their rights regarding transfer/discharge from the facility, placed residents at risk for diminished protection from being inappropriately discharged , lack of access to an advocate who could inform them of their options and rights, and ensure that the Offices of the State Long-Term Care Ombudsmen was aware of the facility practices and activities related to transfers and discharges.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed-hold notice in writing at the time of transfer/discharge to the hospital and/or within 24 hours of transfer/discharge to the hospital for 3 of 3 residents (Residents 7, 47 and 57) reviewed for Hospitalization. This failure placed the residents at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized .

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to prevent contractures (a shortening of tissues which leads to rigidity of the joints) for 2 of 4 residents (Residents 22 and 5) reviewed for Positioning/Mobility. This failure placed residents at risk of developing/worsening contractures, inability to complete activities of daily living, a diminished quality of life.

Inspectors wroteBased on interview, observation and record review, the facility failed to identify significant weight loss in a timely manner and ensure interventions were in place to prevent continued weight loss for 2 of 6 residents (Residents 57 and 54) reviewed for nutrition. These failures placed the residents at risk for unmet nutritional needs and continued weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain medications were necessary prior to administration for 3 of 6 residents (Residents 22, 53, and 8) reviewed for Unnecessary Medications/Pain. Failure to ensure pain medications were necessary placed residents at risk of overmedication, unnecessary medication side effects, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to maintain sanitary food storage in 2 of 2 resident refrigerators (West and Activities) when reviewed for Kitchen. This failure placed residents at risk of ingesting contaminated food, foodborne illness, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the transmission of a communicable disease by ensuring the proper application of transmission-based precautions (TBP) for 5 of 5 residents (Residents 48, 46, 269, 270, and 66) and to ensure the proper use and fit of personal protective equipment (PPE) by staff during an outbreak of a respiratory virus when reviewed for TBP. The facility also failed to notify the residents or representatives of a COVID-19 (an infectious virus causing respiratory illness that may cause difficulty breathing and could lead to severe impairment or death) outbreak when reviewed for infection control. Additionally, the facility failed to provide sanitary environment for 1 of 4 hallways (East Short Hall) reviewed for environment. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide COVID-19 (a highly infectious respiratory illness caused by a virus) vaccinations and education regarding the benefits and potential side effects of the COVID-19 vaccine for 2 of 5 residents (Residents 15, and 48) reviewed for COVID-19 vaccinations. These failures denied the resident/representative of the right to make informed decisions and placed residents at risk for adverse health effects of a communicable disease.

Inspectors wroteased on interview and record review the facility failed to ensure Pre-admission Screening and Resident Review (PASRR, a mental health screening tool) assessments were accurately completed for one of five residents (Resident 12) reviewed for PASRRs and unnecessary medications. This failure placed the residents at risk for unidentified mental health care needs.

Inspectors wroteBased on interview and record review the facility failed to develop a collaborative, comprehensive care plan involving Hospice services (care that focuses comfort and quality of life for persons with a serious illness who is approaching the end of life) for 1 of 1 Resident (Resident 47) reviewed for Hospice. This failure placed resident at potential risk for unmet needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide showers as scheduled for 1 of 4 residents (Resident 165) reviewed for activities of daily living (ADLs). This failure placed the resident at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection and to document as needed dressing changes and skin assessments for 1 of 2 residents (Resident 266) reviewed for pressure injuries. These failures placed residents at risk for complications, impaired healing, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory services were provided according to professional standards of practice for 1 of 2 residents (Resident 166) reviewed for respiratory care. Failure to ensure oxygen delivery was provided according to the physician order, placed the resident at risk for discomfort, a potential negative outcome, and unmet needs.