Rockwood South Hill

Inspectors wroteBased on observation and interview, the facility failed to date, cover and discard expired food in the dry storage areas and 1 of 3 refrigerators (refrigerator 1), dishwasher final rinse temperatures were not maintained as required for the dishwasher, and refrigerator and freezer temperatures were not maintained at the required ranges for 2 of 2 dining room refrigerators (DR refrigerator 1 and DR refrigerator 2). The facility further failed to complete hand hygiene when indicated during 2 meal services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive infection prevention program designed to reduce the risk of infections for 1 of 1 residents (Resident 40). These failures placed residents, staff and students at risk of acquiring infections and unintended health consequences.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement bowel protocols for 3 of 3 sampled residents (Residents 3, 4 and 13) reviewed for constipation. This failure put the residents at risk of discomfort and more serious health consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain a system of records for receipt and disposal of all controlled drugs (substances or medications that have a high potential for abuse, misuse and addiction) in sufficient detail to enable an accurate reconciliation for 3 of 3 controlled medication emergency kits (e-kit) (e-kit 309, e-kit 314 & e-kit 315) reviewed for medication storage. This failure placed the residents at risk by the facility being unable to identify potential drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy recommendations were addressed timely for 4 of 5 sampled residents (Residents 4, 13, 17 and 27) reviewed for pharmacy monthly medication reviews. This failure placed the residents at risk for medication side effects or unintended health consequences.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain informed consent for 1 of 1 sampled residents (Resident 27) reviewed for resident rights. This failure resulted in position change alarms (a sensor pad the resident sits on that emits an audible alarm when the resident moves in certain ways) being implemented without consent from the resident and/or the resident representative.

Inspectors wroteBased on observation, interview and record review the facility failed to provide assistance with activities of daily living (ADL) as care planned and needed for 2 of 3 sampled residents (Residents 17 and 29), reviewed for ADLs. This failure contributed to Resident 17 not being provided with adaptive equipment and assistance at meals and Resident 29 not being provided basic hygiene. This failure placed residents at risk of hunger, lack of dignity and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions, develop treatment goals and notify the appropriate parties after a resident developed a pressure ulcer for 1 of 1 sampled residents (Resident 25) reviewed for pressure ulcers. This failure placed the resident at risk for further deterioration of their skin, unintended health consequences and decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to maintain oxygen equipment in a clean and sanitary manner for 2 of 3 sampled residents (Residents13 and 30) and failed to administer oxygen per provider orders for 1 of 3 sample residents (Resident 30), reviewed for respiratory care. This failure placed residents at risk of potential medical complications, potential respiratory infections, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to transcribe provider orders correctly and administer medications as intended by the provider for 1 of 6 sampled residents (Resident 31), reviewed for unnecessary medications. This failure placed residents at risk of adverse side effects and unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to follow the requirements to protect resident rights in an arbitration agreement for 2 of 4 sample residents (Residents 13 and 14) reviewed for arbitration. This failure placed residents at risk of losing legal protection, forfeiture (loss or giving up of something) of the right to a jury or court, lack of understanding of the legal document signed, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to maintain a resident's call light system in a functional manner for 1 of 3 sampled residents (Resident 25) reviewed for environmental concerns. This failure placed all facility residents at risk of potentially avoidable accidents, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure wheelchairs were maintained in a clean manner for 2 of 3 sampled residents (Residents 25 and 29) reviewed for physical environment. This failure placed residents at risk of potentially avoidable accidents, lack of dignity and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the staff performed the required hand hygiene and wore hair coverings during food preparation and meal service for 2 of 2 dining rooms observed. Additionally, the facility failed to ensure the staff discarded expired foods, labeled food items, monitored the temperatures of foods being served, and were competent on preparation of thickened liquids. This failure placed the residents at risk for foodborne illnesses and aspiration (accidental inhalation of liquid into the lungs).

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate records for 2 of 5 sampled residents (Resident 15 and 19) reviewed for unnecessary medications and 1 supplemental resident (Resident 17). Failure to ensure complete informed consents for psychotropics (drugs that affect a person's mental state), placed the residents at risk of not having their needs met.

Inspectors wroteBased on interview and record review, the facility failed to follow an established Antibiotic Stewardship Program (ASP) to promote the appropriate use of antibiotics (ABX) and reduce the risk of unnecessary ABX use for 2 of 2 months of infection control records reviewed. This failure increased resident risk for development of multidrug organisms (germs that are resistant to many ABX) and adverse outcomes associated with the inappropriate/unnecessary use of ABX.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and the resident representative of a change in condition experienced by 1 of 5 sampled residents (Resident 15) reviewed for unnecessary medications. This failure placed the resident at risk for delayed decisions for treatment by the legal representative and the physician/practitioner.

Inspectors wroteBased on interview and record review, the facility failed to provide the required beneficiary notices for 2 of 3 sampled residents (Resident 1 and 83) reviewed for required notices and associated choices related to Medicare services ending. This failure placed the residents at risk of not being fully informed of the potential cost of continued services.

Inspectors wroteBased on interview and record review, the facility failed to implement their Abuse and Neglect Prohibition Policies and Procedures to include, not reporting or investigating elopement episodes and the discovery of a skin injury for 1 of 2 sampled residents (Resident 30) reviewed for accident hazards. This failure placed the resident at risk for repeated elopement and precluded the state agency (SA) from being aware of and investigating the circumstances surrounding the resident's elopements and skin injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's medical record contained documentation of a transfer to the hospital, or that the receiving hospital had received information of the resident's condition, for 2 of 2 sampled residents (Residents 24 and 22), reviewed for hospitalization. This failure placed the resident at risk for a delay in treatment and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Office of the State Long-Term Care Ombudsman received written notification of a hospital transfer, for 2 of 2 sampled residents (Resident 24 and 22), reviewed for hospitalization/discharge. This failure placed the resident at risk of not having access to additional advocacy services from the State Long-Term Care Ombudsman.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed-hold notice, a notice that informed the resident of their right to pay the facility to hold their room/bed while they were hospitalized , to the resident and/or their representative at the time of discharge, or within 24 hours of transfer to the hospital, for 2 of 2 sampled residents (Resident 24 and 22), 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 develop comprehensive person-centered care plans to address all aspects of care for 4 of 16 sampled residents (Resident 15, 19, 24 and 8) whose care plans were reviewed. Failure to address the individualized needs of each resident placed them at risk for inadequate care and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement a physician order for the treatment of elevated blood pressures for 1 of 5 sampled residents (Resident 15) reviewed for unnecessary medications. This failure placed the resident at risk for a negative outcome from a high blood pressure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide grooming for 1 of 2 sampled residents (Resident 25), reviewed for activities of daily living (ADL's). This failure placed the resident at risk for not being groomed according to their preferences, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to follow up on a resident's request to change their code status (level of intervention a resident chooses if their heart or breathing stops) for 1 of 1 sampled resident (Resident 17) reviewed for Cardiopulmonary Resuscitation (CPR, the act of performing chest compressions and providing breaths to mimic heartbeat and breathing). This failure placed Resident 17 at risk to have CPR initiated when their legal representative requested to change their code status to No CPR.

Inspectors wroteBased on interview and record review, the facility failed to ensure the staff implemented the bowel protocol for the management of constipation for 3 of 5 sampled residents (Resident 14, 28, and 30) reviewed for unnecessary medications and monitor non-pressure injury and a fall with injury for 1 of 2 sampled residents (Resident 30) reviewed for accidents. These failures placed the residents at risk for unmet needs and complications from constipation and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the need for restorative services (a program available in nursing homes that helps residents maintain any progress they've made during therapy treatments or enables them to function at their highest capacity), for 1 of 1 sampled residents (Resident 7), reviewed for range of motion. This failure placed the resident at risk for a further decline in range of motion, due to limitations in their lower extremities and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision during a coughing episode for 1 of 2 residents (Resident 183) reviewed for supervision. This failure placed Resident 183 at risk for choking and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to establish a system to ensure the availability of a physician to timely coordinate the procurement of controlled substances during afterhours for 1 of 3 sampled residents (Resident 31) reviewed for closed records. This failure placed the resident at risk for unmet needs at end of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure sleep medications were consistently monitored for 1 of 5 sampled resident (Resident 183) reviewed for unnecessary medications. This failure placed the residents at risk for potential adverse side effects and medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain temperatures to ensure medications were properly stored. This failure placed residents at risk for receiving compromised or ineffective medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff had the required qualifications (current Washington State Food Worker Cards) for 3 nursing staff (Staff N, AA, BB). This failed practice had the potential risk for unsafe food handling practices and placed all residents at risk for developing foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 5 sampled residents (Resident 183) reviewed for unnecessary medications, received information on and were offered the recommended vaccinations for pneumonia based on the current recommendations from the Centers for Disease and Control Prevention. This failure placed the resident at risk for contracting pneumonia with its associated complications of infection.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure an allegation of neglect was reported to the State Survey Agency, as required, for residents residing on the South Hall (Resident 1, 2, 3, 4, 5). Failure to report an allegation of neglect placed all residents at risk for mistreatment and poor quality of life.

Inspectors wroteBased on observation and interview, the facility failed to store food in accordance with professional standards for food service safety for 1 of 1 kitchen and 1 of 2 dining rooms (South dining room). Failure to securely close opened bags of food to protect from exposure to contaminants, label foods with dates they were opened or discard dates, and discard expired food, placed all residents at risk for food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure monitoring of potential side effects related to the use of psychotropic medication (drug taken to exert an effect on the chemical makeup of the brain and nervous system) for 7 of 7 sampled residents (Residents 22, 31, 29, 15, 12, 18, and 1) reviewed for unnecessary medication use. The facility's failure to monitor side effects related to use of psychotropic medication placed the residents at risk for adverse side effects and medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean, comfortable, homelike environment for 1 of 2 sampled residents (Reisdent 23), reviewed for environment. This failure placed Resident 23 at risk for possible illness from unclean equipment, a lack of dignity, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive assessment for a significant change in condition within 14 days as required for 1 of 2 sampled residents (Resident 1), reviewed for Hospice Services. This failure placed the resident at risk for decreased quality of care and implementing standard disease-related clinical interventions.

Inspectors wroteAMENDED Based on observations, interview, and record review, the facility failed to provide the necessary care and services for 1 of 2 Sampled residents (Resident 34) reviewed for urinary tract care. This failure placed the resident at risk for delayed identification and interventions for changes in the medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents consistently received interventions to prevent further falls for 1 of 3 sample residents (Resident 22), reviewed for falls. These failures placed the residents at risk for injury from falling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dialysis services consistent with professional standards related to not monitoring fluid restriction, bruit and thrill (bruit is a sound which indicates flow of blood through the vessels, thrill is felt on the overlying skin as a vibration and also indicates blood flow) and no direction to staff on which arm was needed to obtain a blood pressure for 1 of 1 sampled residents (Resident 5), reviewed for dialysis (a procedure that removes waste products and excess fluid from the blood when the kidneys stopped working properly) services. This failure placed the residents for risk of medical condition complications and diminsihed quality of care.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a physician personally approved, in writing, a recommendation that an individual be admitted to the facility, for 2 of 3 (Residents 34 and 22) sampled residents reviewed for physician services. This failure placed the resident at risk for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure an initial comprehensive visit was done by physician after admission as required, for 1 of 3 sampled residents (Resident 34), reviewed for physician visits. This failure placed the resident at risk for delayed identification and treatment of medical needs.

Inspectors wroteBased on observation, the facility failed to ensure 1 of 1 medication rooms had the narcotic box affixed that was placed in the refrigerator, as required. This failure placed unintended access by others to drugs because they were not locked up and/or unmovable.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene and glove changes were performed when providing care, for 1 of 2 (Resident 15) sampled residents for infection prevention and control. These failures placed the residents at risk for infections and a diminished quality of life.