Regency Olympia Rehabilitation and Nursing Center

Inspectors wroteBased on interviews and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 3 sampled residents (Resident 1) reviewed for quality of life. This failure placed residents at risk for compromised health outcomes and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in a manner that promoted dignity related to uncovered indwelling urinary catheter (a tube inserted into the bladder that drains urine into a bag outside of the body) bags for 1 of 2 sampled residents (Resident 21) reviewed for dignity. This failure placed residents at risk for embarrassment, diminished self-worth, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or resident representatives were informed and provided consent before administering psychotropic medications (a medication capable of affecting the mind, emotions, and/or behaviors) for 2 of 6 sampled residents (Residents 5 & 4) reviewed for unnecessary medications and/or medication consent. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to monitor for adverse side effects (ASE) of antianxiety medication (a class of drugs used to treat anxiety [a mental health condition that causes fear, a constant feeling of being overwhelmed, and excessive worry about everyday things]) and/or failed to complete an AIMS (Abnormal Involuntary Movement Scale) test (a rating scale used to assess the severity of involuntary movements that sometimes develop as a side effect of treatment with antipsychotic medications [a class of drugs primarily used to treat mental health conditions such as hallucinations and delusions]) and/or failed to place a stop date order of 14 days for PRN (as needed) psychotropic medication (a medication capable of affecting the mind, emotions, and/or behaviors), and failed to ensure resident specific target behaviors were monitored prior to administering [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I, a screening tool used to identify mental health needs, was requested upon a significant change of condition for 1 of 6 residents (Resident 7) reviewed for PASRR. This failure placed the residents at risk of unidentified mental health needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to fully address lab results as reported by laboratory services for 1 of 1 resident (Resident 31) reviewed for death. This failure placed residents at risk for adverse side effects and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to adequately monitor residents' heart rate (HR) for 1 of 5 residents (Resident 3) reviewed for unnecessary medications. This failure placed residents at risk for adverse side effects and a diminished quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that pressure ulcers were appropriately identified, and physician orders were obtained for 1 of 4 (Resident 1) residents reviewed for quality of care. This failure resulted in Resident 1 developing pressure wounds and not receiving appropriate medical interventions.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that allegations of abuse were reported timely for 1 of 2 [Resident 1] sampled residents reviewed for abuse/neglect. This failure placed residents at risk for potential verbal and physical abuse, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate Personal Protective Equipment (PPE) use was implemented during linen sorting and washing machine cleaning in 1 of 1 facility laundry areas, failed to ensure PPE was used during personal care for 1 of 1 sampled resident (Resident 14), failed to ensure safe hand hygiene practices were implemented during dressing changes for 2 of 3 sampled residents (Residents 12 and 124), failed to develop a complete Water Management Program to reduce the risk of Legionella (a family of micro-organisms which are naturally found in water bodies) growth and spread in the facility, and failed to create an Infection Prevention and Control Program based on a facility and community-based infection control (IC) risk assessment. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify and report potential allegations of abuse and/or neglect to the State Survey Agency as required for 2 of 3 sampled residents (Resident 5 and X). This failure placed residents at risk for further abuse and/or neglect and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a trauma trigger (a psychological stimulus that prompts recall of a previous traumatic event) assessment for 2 of 2 sampled residents (Residents 17 and 12) reviewed trauma informed care. This failure placed residents at risk for unidentified trauma triggers, behaviors, re-traumatization and a diminished quality of life.

Inspectors wroteBased on observations and interviews, the facility failed to ensure treatment carts were locked for 1 of 1 treatment carts (Treatment Cart 1), and failed to ensure medication dosages were accurately labeled for 1 of 6 sampled residents (Resident 14) reviewed for medication storage. This failure placed residents at risk for having access to treatment supplies not prescribed and receiving incorrect doses of medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure urinary tract infection related antibiotic initiation practices were based on Center for Disease Control and Prevention (CDC) approved criteria. This failure placed residents at risk of receiving or not receiving necessary antibiotics and a diminished quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess the dental status on the Minimum Data Set (MDS) assessment for 1 of 3 sampled residents (Resident 17) reviewed for assessment accuracy. This failure placed residents at risk for unmet dental and nutritional needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness (SMI), Intellectual Disabilities (ID), and related conditions are not inappropriately placed in nursing homes for long-term care) Level I form was completed accurately and Level II PASARR referrals were made for 2 of 5 sampled residents (Residents 8 & 9) reviewed PASARR screening. These failures placed residents at risk of not receiving specialized mental health services and a diminished quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure person centered care plans were completed to address all aspects of care including individualized goals and approaches for eating and for assistance with turning and repositioning for 2 of 14 sampled residents (Resident 4 & 14) reviewed for care plans addressing resident needs. These failures placed residents at risk for inconsistent and/or inadequate care and treatment and diminished quality of care.

Inspectors wroteBased on observation, record review and interview, the facility failed to implement physician's orders for a heart and a breathing medication during medication administration for 1 of 6 sampled residents (Resident 11) reviewed for services provided meet professional standards. This failure placed residents at risk for adverse outcomes for a heart rate below 60, mouth irritation, and a diminished quality of care.

Inspectors wroteBased on interview and record review, the facility failed to provide restorative nursing services including a restorative stretching program for 1 of 2 sampled residents (Resident 10) reviewed for maintaining activities of daily living. This failure placed residents at risk for avoidable decline in function and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide toileting, repositioning, and pressure relieving devices for 1 of 4 sampled residents (Resident 14) reviewed for activities of daily living for dependent residents. This failure placed residents at risk for skin impairment including developing a pressure injury (PI) and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing activity program of meaningful engagement to meet individual resident needs for 1 of 2 sampled residents (Resident 14) reviewed for activities. This failure placed residents at risk of boredom and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pressure reducing measures and repositioning to prevent and/or contribute to the development of a pressure injury for 1 of 3 sampled residents (Resident 14) reviewed for pressure injury (areas of damaged skin and tissue caused by sustained pressure). This failure placed residents at risk for developing pressure ulcers, pain and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure electronic smoking (involves using battery-powered devices called e-cigarettes or vapes) materials for 1 of 1 sampled resident (Resident 8); and failed to implement a system for securing and storing potentially toxic chemicals in 1 of 1 shower room (shower room [ROOM NUMBER]) reviewed for accident hazards. These failures placed residents at risk for accidents, injury and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate indication for medication was provided for 1 of 5 sampled residents (Resident 223) reviewed for unnecessary medications. This failure placed residents at risk for adverse side effects and a diminished quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely action was taken when a resident's indwelling urinary catheter (a small flexible tube inserted into the bladder to drain urine) showed abnormal urine characteristics indicating an infection for 1 of 1 sampled resident (Resident 1) reviewed for catheter care. This resulted in Resident 1 experiencing harm when the potential infection was not treated/evaluated timely and the resident required a transfer to the hospital where she was diagnosed with a kidney infection. This failure placed residents at risk of acquiring catheter associated infections, delay in care, pain and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the State Agency was notified and a entry on their Accident/Incident Log was completed when a tree uprooted and fell on the building causing a puncture in the apex of the roof. This failure placed residents at risk for an unsafe living environment and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide at least eight hours of Registered Nurse (RN) supervision for 9 of 30 days reviewed for RN coverage. This failure placed residents at risk for not receiving needed care and supervision of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure equipment was provided to prevent further avoidable reduction of range of motion (ROM) and mobility for 1 of 2 sampled residents (1) reviewed for ROM/mobility. This failure placed residents at risk for increased contractures and decrease quality of life.