Renton Health & Rehabilitation

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a homelike environment for 3 of 4 units (Unit B, Unit, C, & Unit D) reviewed for environment. The failure to ensure walls, flooring, and windows were in good repair left residents at risk of an unsafe environment, and a less than homelike environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care in a manner that promoted dignity for 2 (Residents 11 & 2) of 18 sample residents. The failure to provide privacy during assessment and treatment placed residents at risk for feelings of diminished self-worth and embarrassment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure person-centered Care Plans (CPs) were revised as needed to address all aspects of resident care for 4 of 18 residents (Residents 4, 5, 6, & 7) reviewed for comprehensive CPs. These failures placed residents at risk for inconsistent and/or inadequate care and treatment and a diminished quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident's skin was assessed, monitored, and treated as required for 1 (Resident 4) of 1 residents reviewed for non-pressure skin and 1 (Resident 6) supplemental resident. These failures placed residents at risk for new or worsening skin impairment, infection, and other negative health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide ongoing assessment, documentation, and prevention interventions consistent with professional standards of practice for 2 of 4 residents (Residents 5 & 2) reviewed for Pressure Ulcers (PU). Failure to assess and monitor PUs and implement preventative measures including repositioning placed residents at risk for deterioration in their skin condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 (Residents 5 & 11) of 5 sample residents reviewed for Restorative Nursing Program (RNP) received the services as they were assessed to require. These failures placed residents at risk for further decline in Range of Motion (ROM), a reduction in mobility, increased dependence on staff, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sharps and chemicals were stored safely for 1 of 1 Maintenance Offices and 1 of 2 Nurses station's (West Nurse's Station) reviewed. This failure to ensure sharps and chemicals were secured placed residents at risk of injury, an unsafe environment, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper storage and labeling of medications in 2 of 4 medication carts (Medication Cart A & C) reviewed for medication storage. This failure placed residents at risk for receiving expired medications, ineffective treatment, accidental ingestion of medication, and a diminished quality of life.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure food was stored in accordance with professional standards of safety. The failure to ensure foods stored in the facility's main kitchen and [NAME] Unit fridges were labeled, covered, dated, and/or disposed of upon expiration placed residents at risk of ingesting expired and/or contaminated foods and the development of food-borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure confidentiality of resident records was maintained for 1 of 4 units (Unit A) and services provided were appropriately documented in resident records for 1 of 18 residents (Resident 17) reviewed. This failure placed residents at risk for a violation of their rights to privacy and their right to receive care and services as ordered.

Inspectors wroteBased on observation, interview, and record review the facility failed to: ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear, and gowns used to prevent exposure to infectious materials) for 1 of 6 residents (Resident 5) reviewed for Infection Control; and ensure visitors used gloves while pouring ice from a communal ice bucket to avoid cross contamination. These failures placed residents and staff at risk for exposure to and development of contagious, communicable infectious diseases.

Inspectors wroteBased on interview and record review, the facility failed to notify 5 (Resident 1, 6, 25, 219, & 119) of 23 residents reviewed, who were Medicaid recipients, when their personal fund account balances reached $1800 (i.e. within $200 of the $2,000 resource limit beneficiaries could possess, without their Medicaid coverage being impacted). This failure placed residents at risk for personal financial liability for their care. The facility failed to ensure funds were reimbursed to the state Office of Financial Recovery (OFR), within 30 days of resident discharge or death, for 1 (Resident 219) of 3 discharged residents reviewed. This failure caused a delay in reconciling resident accounts within 30 days as required.

Inspectors wroteBased on observation and interview, the facility failed to ensure walls in resident rooms were maintained in a homelike condition for 9 of 18 rooms sampled (Rooms 22, 26, 32, 34, 50, 42, 47, 48, & 49). The failure to ensure rooms were free from gouges (Rooms 22, 32, 50, 48), resident televisions were mounted (room [ROOM NUMBER]), fans in resident rooms were clean (room [ROOM NUMBER]), and sinks, toilets, and bathroom fixtures in resident rooms were free from rust and maintained in clean, sanitary conditions (Rooms 22, 32, 34, 42, 47, & 49). These failures left residents at risk for a diminished quality of life and a less than homelike environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the environment was free of accident hazards for 1 of 1 laundry room and failed to ensure resident rooms were free of fall hazards for 1 of 3 (Resident 11) residents reviewed for falls. These failures placed residents at risk for elopement, ingestion of chemicals, and falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were stored, labeled, dated when opened, and discarded when expired for 1 of 2 medication carts (Garden Wing Cart), 1 of 1 medication rooms (West Hall Medication Room Refrigerator), and for 1 of 19 residents (Resident 60) observed. The facility failed to ensure 2 of 4 medication carts were locked when left unsupervised by staff. The failure to ensure medication refrigerators were double locked, medications were discarded when expired, eye drop medications were dated upon opening, medication carts were locked, and medications were not left at bedside, placed residents at risk for ineffective treatment, expired medications, and contaminated medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in 1 of 1 facility kitchens and for one unit refrigerator reviewed for food services. The failure to clean the facility's kitchen ice machine, cover food during transport, perform hand hygiene between glove use, and maintain sanitary unit refrigerators placed the residents at risk for food borne illness (illness caused by ingesting contaminated food or beverages), cross contamination, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure informed consent (a process explaining the risks and benefits of a treatment prior to use) was obtained prior to administration of psychotropic (affecting mental state) medications for 2 of 5 (Residents 20 & 34) reviewed for unnecessary medications and for bed rails for 1 of 2 residents (Resident 60) reviewed for accident hazards. This placed residents at risk for unwanted treatment.

Inspectors wroteBased on interview and record review, the facility failed to provide the Skilled Nursing Facility Notice of Medicare Non-coverage (SNF-NOMNC - a required form notifying the resident that their skilled services coverage was ending and would no longer be covered by their Medicare A benefits) as required for 2 of 4 residents (Resident 219 and 119) reviewed for beneficiary notification. This failure placed Residents 219, 119, and other residents at risk for not being fully informed and losing their right to an appeals process.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS -an assessment tool) accurately reflected the status for 3 (Resident 37, 51, & 61) of 19 residents reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the residents' mental health conditions for 1 of 5 (Resident 51) residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.

Inspectors wrote<Resident 58> According to the 07/30/2024 Quarterly MDS Resident 58 had diagnoses including a history of stroke and difficulty swallowing. The MDS showed Resident 58 received over half their daily calorie intake via a feeding tube (tubing that allows liquid nutrition to pass directly into the stomach for people with swallowing difficulties). According to the revised 05/13/2024 resident requires tube feeding . CP Resident 58 still received nutrition by feeding tube. Review of the physician's orders showed a 05/23/2024 order for a bolus (using gravity rather than a pump) feeding four times a day for Resident 34. This order was discontinued on 07/04/2024. In an interview on 09/16/2024 at 11:02 AM Staff AA (Dietician) stated Resident 20 successfully graduated from the tube feeding and was now able to meet their nutritional needs with oral intake. [...]

Inspectors wroteBased on interview and record review the facility failed to provide nursing care within professional standards. The failure to follow physician's orders for 2 of 19 sample residents reviewed (Residents 34 & 20), clarify physician's orders when required, and sign for physician orders not completed for 2 of 19 sample residents (Residents 25 & 52) placed residents at risk for unmet care needs, medication errors, and ineffective treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Activities of Daily Living (ADL) assistance was provided for dependent residents for 3 (Residents 52, 60, & 1) of 6 residents reviewed for ADLs and one supplementary resident (Resident 58). Facility failure to provide ADL assistance as needed placed residents at risk for poor hygiene and feelings of diminished self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary care and services to maintain residents' highest practicable level of well-being for 2 of 2 sampled residents (Resident 1 & 7) reviewed for hospice care. This failure placed residents at risk for not receiving necessary end- of- life care and services, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a restorative program was provided for 1 of 2 (Resident 37) sample residents identified by staff with mobility limitations and reviewed for Range of Motion (ROM). These failures placed residents at risk for declines in ROM, reduction in mobility, increased dependence on staff, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure weights were adequately monitored for 1 of 1 (Resident 58) residents reviewed for hydration/weights. The failure to monitor weights as ordered placed residents at risk for weight loss, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure prompt dental services were provided for 2 (Residents 52 & 37) of 5 residents reviewed for dental services. This failure placed residents at risk for oral discomfort and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain infection control practices that provided a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to 1) ensure staff used personal protective equipment for residents reviewed for Transmission Based Precautions (TBP); 2) perform hand hygiene during resident care and during dining service; and 3) provide catheter care with professional standards. These failures placed residents at risk for the development and transmission of communicable diseases and related complications.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Antibiotic (ABO) Stewardship Program, to promote appropriate use of ABO's, reduce the risk of unnecessary ABO use, and decrease the development of an ABO resistance for 3 of 5 sampled residents (Resident 223, 224, & 38) reviewed. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of ABO's.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the level of supervision necessary to prevent accidents for resident-to-resident altercations for 2 (Residents 1, 2) of 5 residents reviewed for supervision and accidents. The facility failed to provide supervision and placed residents at risk for potential verbal and physical abuse, serious injury, pain, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a system in place that ensured basic life support 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) when 2 of 3 residents (Residents 1 & 2) were reviewed for unexpected death in the facility. This failed practice placed 35 additional residents (Residents 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), 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 3:58 PM, the facility was notified of an IJ in F678. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement and maintain an in-service training program that ensured 3 of 3 Nursing Assistants (Staff's L, M, & N) reviewed for training and competency, had the required 12 hours per year of in-service training and education. This failure placed residents at risk of less than competent care and services from staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Physician Order for Life Sustaining Treatment (POLST - a form indicating the resident's wishes when found not breathing and without a pulse) to initiate Cardio-Pulmonary Resuscitation (CPR - an emergency procedure consisting of chest compressions combined with giving breaths of air/Full Code) or not during medical emergency for 2 of 8 residents (Residents 3 & 4) reviewed for Advance Directives. The failure to ensure a copy of the POLST form was available in the medical records and accessible to staff (Resident 3) and to fully complete the POLST form (Resident 4) placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care, not receiving CPR when indicated, and potentially death.

Inspectors wroteBased on interview, and record review the facility failed to ensure 4 (Residents 1, 3, 4 & 5 ) of 6 residents reviewed for unnecessary medications were free from unnecessary psychotropic medications. Facility staff failed to adequately monitor the effectiveness of medications ordered to treat insomnia (difficulty sleeping). Failure of the facility placed residents at risk to receive unnecessary medications and/or experience adverse side effects.

Inspectors wroteBased on interview and record review, the facility failed conduct thorough investigations and implement preventative measures to ensure the safety of 2 (Resident 1 & 2) of 2 residents reviewed for accidents. Failure of the facility placed residents at risk of injury.

Inspectors wroteBased on interview and record review, the facility failed to provide meals that accommodated resident food allergies and preferences for 2 (Resident 1 & 6) of 4 residents reviewed for food allergies/preferences. This failure placed the resident at risk for allergic reaction, dissatisfaction with food, weight loss, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify allegations of abuse, ensure alleged abuse, neglect and/or unexpected deaths were reported, and thoroughly investigated for 8 of 9 residents (Residents 2, 3, 4, 5, 6, 7, 8 & 1) reviewed for abuse. Residents expresed fear of staff, not feeling safe, crying, nervous from the fear and not calling for assistance due to fear of being yelled at or pushed and pulled by staff. Although the facility was aware of these concerns, they were not identified, reported, or investigated as potential allegations of abuse, but were considered grievances. In addition, residents were not proteted when the facility allowed the alleged perpetrator(s) to have continued access to residents prior to determining if abuse or neglect occurred. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to schedule sufficient staff to provide care and services to ensure resident's needs were met on one of three shifts (night shift) reviewed for sufficient staffing. This failure placed resident's at risk for unmet care needs, accidents/injuries, and diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the facility was administered in a manner that used its resources effectively and efficiently so residents could attain or maintain their highest practical physical, mental, and psychosocial well-being and to ensure the facility maintained substantial compliance with state and federal regulations. The Administration failed to provide administrative oversight and monitoring of facility personnel, systems, practices, and policies related to Abuse/Neglect; to provide sufficiently trained and supervised nursing staff to meet resident needs; and failed to ensure staff were trained on facility identified training and required mandatory training, including, but not limited to Abuse, Neglect, and Exploitation. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure fall prevention strategies were implemented for 1 of 3 residents (Resident 1) reviewed for accidents. This failure placed residents at risk for falls with injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consider and act promptly to address concerns raised by residents at the Resident Council. Facility failure to ensure resident concerns were considered, acted upon, or a rationale provided for why action could not be taken left residents at risk for frustration, and a less-than-homelike environment.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, comfortable, and homelike environment on 2 of 4 units, 1 of 1 therapy gyms, 1 of 1 dining/activity rooms, and 1 of 1 patio areas. Facility failure to maintain a home with adequate space for residents to congregate freely and comfortably outside their rooms, and maintain resident rooms and halls in a safe and homelike environment, left residents at risk for an unsafe and less-than-homelike environment.

Inspectors wrote<Resident 67> According to the 02/23/2023 Quarterly MDS Resident 67 had medically complex diagnoses including metabolic encephalopathy (a brain disease that can cause delirium, lethargy, and dementia) and history of stroke. The MDS showed Resident 67 required extensive assistance with eating and a mechanically altered diet (the resident's food and/or drinks needed to be altered in order to allow the resident to safely swallow). According to an 04/12/2023 progress note, Resident 67 choked while eating green beans and their diet texture was downgraded to an easier to chew and swallow texture. A 04/20/2023 progress note showed Resident 67 had a new order for an antibiotic medication to treat aspiration pneumonia (a lung infection caused by inhaled food particles). Another 04/21/2023 progress note showed Resident 67 was transported to hospital on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were updated and implemented for 10 of 18 sample residents (Residents 67, 4, 5, 20, 70, 63, 73, 25, 45 & 42). These failures left residents at risk for unmet care needs and negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Activities of Daily Living (ADL) assistance to dependent residents for 8 of 9 residents (Residents 4, 5, 63, 73, 25, 45, 42, & 11) reviewed for ADLs. Facility failure to provide ADL assistance as needed placed residents at risk for poor hygiene, and feelings of diminished self-worth.

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. The facility failed to consistently perform hand hygiene before and after resident care/contact and staff failed to ensure equipment was cleaned and disinfected after each use and between resident use. These failures placed the residents and staff at risk for development of contagious, communicable infections and disease.

Inspectors wroteBased on observation, interview, and record review the facility failed to honor preferences for bathing for 2 of 8 residents reviewed for choices for Activities of Daily Living (ADLs) (Residents 85 & 10). The facility's failure to accommodate resident choices regarding bathing preferences placed residents at risk for a frustration, embarrassment, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to notify 7 (Resident 13, 51, 47, 28, 1, 42, & 55) of 25 residents reviewed, who were Medicaid recipients, when their personal fund account balances reached $1800 (i.e. within $200 of the $2,000 resource limit beneficiaries could possess, without their Medicaid coverage being impacted). This failure placed residents at risk for personal financial liability for their care. The facility failed to ensure funds were reimbursed to the state Office of Financial Recovery (OFR), within 30 days of resident discharge or death, for 1 (Resident 339) of 6 discharged residents reviewed. This failure caused delay in reconciling resident accounts within 30 days as required.

Inspectors wroteBased on interview and record review, the facility failed to ensure 18 of 25 residents who had a Trust Account with the facility had their funds covered by a surety bond. This failure placed residents at risk to be unable to recover their money in the event of loss of funds from their account.

Inspectors wroteBased on interview and record review, the facility failed to ensure Advanced Directives (ADs - legal documents reflecting resident wishes for end-of-life care) were available in the resident record for 5 of 12 sample residents (Residents 5, 4, 3, 10 & 46) reviewed for ADs. These failures placed residents at risk for unnecessary care, and their end-of-life wishes not being honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who experienced a significant change in health status were comprehensively assessed using the Centers for Medicare and Medicaid (CMS) specified Resident Assessment Instrument (RAI) process. The facility failed to: (1) complete a Significant Change Minimum Data Set (MDS - an assessment tool) for 1 of 1 (Resident 338) residents, and (2) timely complete the Significant Change MDS for 1 of 1 (Resident 67) residents reviewed for hospice (supportive care focusing on comfort and quality of life) services. Failure to identify the need for a Significant Change MDS and timely complete the assessment placed residents at risk for unmet care needs, delayed care planning, and a decreased quality of life.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure 6 (Residents 20, 55, 63, 45, 42, & 10) of 18 residents Minimum Data Set (MDS- an assessment tool) were completed accurately to reflect the resident's condition. This failure placed residents at risk for unidentified and/or unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level 2 comprehensive evaluations (the process to determine what types of mental health services are required after a Level 1 PASRR determined services were necessary) were obtained and/or implemented and incorporated into the Care Plan (CP) for 1 of 6 (Residents 55) residents whose PASRRs were reviewed. This failure placed residents at risk for not receiving necessary mental health care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop comprehensive Care Plans (CPs) for 3 of 18 residents (Residents 4, 20 & 70) whose CPs were reviewed. Facility failure to develop individualized, comprehensive CPs left residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: follow Physician's Orders (POs) for 4 of 22 sample residents (Residents 73, 63, 44 & 41); clarify POs (Residents 67 & 70); sign only for tasks performed (Resident 20). These failures placed residents at risk for unmet care needs, medication and treatment errors, and negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure activity programs met the needs of each resident for 4 of 6 residents (Residents 4, 73, 63, & 42) reviewed for Activities. The failure to provide meaningful activities left residents at risk for boredom, frustration, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide assistive devices and/or proper treatment to maintain hearing for 1 of 1 resident (Resident 20) reviewed for hearing. This failure placed the resident at risk for frustration, decline in the ability to hear, and diminished quality of life.

Inspectors wroteBased on observations, interview and record review, the facility failed to follow the Care Plans (CP) with interventions todevelop new skin issues and to promote wound healing for 1 (Resident 25) of 2 residents reviewed for Pressure Ulcers (PU). Failure to follow the CP such as positioning resident in bed, getting the resident out of bed, and provide pressure relieving devices placed residents at risk for deterioration in skin condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 of 5 (Residents 59 & 2) residents reviewed for Restorative Nursing Services received the services as they were assessed to require. These failures placed residents at risk for decline in Range of Motion (ROM - move a joint in different directions), dependence on staff, and a decreased quality of life.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure 3 (Residents 77, 63, & 41) of 5 residents reviewed for unnecessary medications were free from unnecessary psychotropic medications. Facility staff failed to adequately monitor behaviors and adverse side effects of psychotropic medications, and failed to individualize target behaviors. These failures placed residents at risk to receive unnecessary medications and/or experience adverse side effects. <Resident 77> Review of a 04/21/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 77 had diagnoses of memory impairment and an anxiety disorder. This assessment showed Resident 77 received a psychotropic medication daily, during the assessment period. According to this MDS, Resident 77 did not have any physical or verbal behavioral symptoms. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were dated when opened, and expired medications and biologicals were disposed of timely for 2 of 4 medication carts reviewed. These failures placed residents at risk for receiving expired medications or experiencing medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prompt dental services were provided for 2 (Resident 20 & 70) of 6 sample residents and 1 supplemental resident (Resident 55) reviewed for dental services. This failure placed the residents at risk for unmet dental needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 1 (Resident 38) residents reviewed for altered texture diet received food in the texture prescribed by a physician, and as assessed by the interdisciplinary team to support the resident's treatment and care. Failure to ensure Resident 38 received the correct diet texture as ordered placed residents at risk for aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident), choking, and other serious medical complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was prepared, stored, and served under sanitary conditions in accordance with professional standards for food service safety. Facility staff failed to: (1) conduct proper testing of sanitizing bucket solutions, (2) use hair covering in food preparation areas, (3) use disposable gloves for food handling during tray line service, (4) thoroughly clean and sanitize the food thermometer before use, and (5) prepare Resident 67's beverage according to the prescribed altered liquid consistency. These failures placed residents at risk for food contamination, bare-hand contact, foodborne illnesses, aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident), and other serious medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure specialized rehabilitative services were provided as determined by the physician's order for 2 of 3 (Residents 70 & 63) residents reviewed for therapy services. This failure prevented residents from attaining, maintaining, or restoring their highest practicable level of physical, mental, functional, and psycho-social well-being.