Seattle Medical Post Acute Care

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with impaired cognition and who had been identified as an elopement (a resident who is unsafe to be alone leaves the facility without supervision) risk, remained safely within the facility premises under adequate supervision for 1 of 3 residents (Resident 1), reviewed for accident prevention. This failure placed the resident at risk of significant hazards, including environmental exposure, potential medical complications, and the risk of being struck by a motor vehicle. A past noncompliance was initiated on 06/29/2026 related to F689 Free of Accident Hazards/Supervision/Devices, for failure to protect Resident 1 from an avoidable elopement. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide/administer medication for 1 of 7 residents (Resident 1), reviewed for significant medication error. Resident 1 experienced harm when they did not receive their steroid medication (used to reduce swelling), had a sudden change in condition and was transported/admitted to the hospital where they were diagnosed with adrenal crisis (a serious medical condition caused by a sudden stoppage of steroid medication). This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure pharmacy services were provided to meet the needs of 5 of 7 residents (Residents 2, 3, 4, 6 and 7), reviewed for medication administration. The failure to administer and/or document medication administration in accordance with professional standards of practice placed the residents at risk for negative outcomes and a diminished quality of lifeFindings included .Review of the facility policy titled, Medication Administration General Guidelines, dated 01/26 [January 2026] showed, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified when the facility's pharmacy could not provide medication for 1 of 7 residents (Resident 1), reviewed for significant medication error. The failure to notify the physician when the pharmacy could not provide a steroid medication (used to reduce swelling) placed the resident 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 resident was protected from misappropriation of controlled (narcotic or opioid) pain medication for 1 of 3 residents (Resident 1), reviewed for misappropriation of controlled medications. This failure placed the resident at risk in unmet care needs, ongoing misappropriation of medications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from misappropriation of controlled (narcotic or opioid) medication for 4 of 5 residents (Residents, 1, 2, 3 & 4), reviewed for misappropriation of controlled medications. This failure placed the residents at risk for pain, unmet care needs, ongoing misappropriation of medications, and a diminished quality of life. A past noncompliance was initiated on 02/20/2026 related to F602-Free from Misappropriation/Exploitation, for failure to protect Residents 1,2,3 and 4 from misappropriation of medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that two-person assistance was provided for bed mobility for 1 of 3 residents (Resident 1), reviewed for accident prevention. This failure to provide adequate supervision during repositioning in bed resulted in harm to Resident 1, who experienced an avoidable accident that caused a head injury requiring hospitalization and was found to have a new Left Frontal Intraparenchymal Hemorrhage (L F IPH - bleeding inside the left front part of the brain), leading to unintended health complications and a reduced quality of life. A past noncompliance was initiated on 01/18/2026 related to F689 Free of Accident Hazards/Supervision/Devices, for failure to protect Resident 1 from an avoidable accident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident environment were maintained for 3 of 6 rooms (Rooms 111, 314 & 317), for 2 of 3 floors (Third Floor & First Floor Hallway Ceiling), for 1 of 1 resident bed linen (Resident 30), for 3 of 3 elevator jambs (First Floor, Second Floor & Third Floor), and for 1 of 1 bed (Resident 1), reviewed for environment. The failure to ensure resident rooms were maintained, wall fans were properly mounted, condensation from ceiling pipes were prevented, elevator jambs were repaired, bed linens were changed, and/or bed were in good repair placed the residents at risk for a less than homelike environment and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess 4 of 24 residents (Residents 8, 86, 32 & 45), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding prognosis, Pressure Ulcer (PU)/Pressure Injury (PI-bed sore), and mechanical ventilation (a medical procedure that uses a machine to assist or replace spontaneous breathing) placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary assistance with Activities of Daily Living (ADL) for 4 of 10 residents (Residents 4, 33, 7 & 23) reviewed for ADLs. The failure to provide residents who were dependent on staff for assistance with personal hygiene placed the residents at risk for unmet needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical supplies were dated and discarded when expired and/or failed to maintain the required temperatures range for 2 of 2 medication refrigerators (First Floor Medication Refrigerator & Third Floor Refrigerator) and failed to ensure medications were properly stored and secured for 3 of 4 residents (Residents 37, 3 &11), reviewed for medication storage. These failures placed the residents at risk of receiving compromised medications/supplies and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired food items were discarded for 2 of 4 refrigerators (Kitchen Walk-In Refrigerator & Second Floor Refrigerator) and 1 of 1 dry storage (Kitchen Dry Storage Room), reviewed for food service safety. These failures placed the residents at risk of food-borne illness (caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP-precaution to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections]) practices were followed for 1 of 1 resident (Resident 77), failed to ensure sharps were disposed of properly for 1 of 3 shower rooms (Second Floor Shower Room) and for 1 of 2 clean utility rooms (First Floor Clean Utility Room), reviewed for infection control. In addition, the facility failed to ensure proper hand hygiene/glove use practices were followed for 1 of 3 residents (Resident 2) and for 1 of 3 staff (Staff Q). These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in a manner that maintains and promotes dignity and respect for 2 of 4 residents (Residents 23 & 55), reviewed for dignity. The failure to knock on the door and introduce themselves before entering, ensure oxygen concentrator (a machine that generates oxygen) was correctly labeled, and provide adequate covering was provided to maintain privacy during transfer placed the residents at risk for lack of privacy, decreased self-worth, potential embarrassment, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide written notices of transfer/discharge to the resident and/or their representative and failed to notify the Office of the State Long Term Care Ombudsman (an advocacy group for residents), describing the reason for transfers/discharge for 2 or 3 residents (Residents 101 & 8), reviewed for hospitalization and discharge. These failures placed the residents at risk for not having the opportunities to make informed decisions about transfers/discharges.

Inspectors wroteBased on interview and record review, the facility failed to ensure Level II Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or Related Conditions are not inappropriately placed in nursing homes for long-term care) referral was made for 1 of 7 residents (Resident 77), reviewed for PASARR screening. This failure placed the resident at risk of not receiving the care and services appropriate for their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow hospice (specialized care for people who are nearing the end of their life) physician orders and effectively communicate/coordinate hospice plan of care for 1 of 1 resident (Resident 8), reviewed for hospice services. This failure placed the resident at risk for delayed treatment, unidentified decline, and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed safe transfer practices when using a mechanical lift (a medical device used to safely and efficiently move residents with limited mobility) for 1 of 4 residents (Resident 55), reviewed for accident prevention. This failure placed the resident at risk of falls, injury, and compromised safety.

Inspectors wroteBased on interview and record review, the facility failed to obtain registry verification to ensure staff met competency evaluation requirements before allowing to serve as a nurse aide for 1 of 5 nurse aides (Staff M), reviewed for nursing aide registry. This failure placed the residents at risk for potential abuse, neglect, and unmet care needs.

Inspectors wroteBased on record review and interview, the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 5 residents (Residents 9), reviewed for unnecessary medications. The failure to administer and/or document medication administration in accordance with professional standards of practice placed the residents at risk for negative outcomes and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring was conducted before administering Blood Pressure (BP- the force of blood flowing through blood vessels) medication with parameters for 1 of 5 residents (Resident 77), reviewed for unnecessary medications. This failure placed the resident at risk for complications related to untreated or uncontrolled BP and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pneumococcal vaccine (used to prevent pneumonia [a lung infection]) was provided for 2 of 5 residents (Residents 9 & 77), reviewed for immunizations and infection control. This failure placed residents at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from pneumococcal disease.

Inspectors wroteBased on interview and record review, the facility failed to ensure the COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) vaccine was offered to 1 of 5 residents (Resident 3), reviewed for immunizations. The failure to educate and offer the COVID-19 vaccination placed the resident at risk for contracting the COVID-19 virus and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, comfortable, homelike, and safe environment for 1 of 2 rooms (room [ROOM NUMBER]), reviewed for safe and sanitary environment. The failure to ensure rooms were free from odors and maintained in safe and sanitary conditions placed the residents at risk of infection, poor living conditions, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to timely provide necessary care and services to prevent the worsening of pressure ulcer/pressure injury (PU/PI-an injury to skin and underlying tissue resulting from prolonged pressure on the skin) and ensure nutritional supplements and recommendations were followed for 1 of 2 residents (Resident 1), reviewed for pressure ulcers. Resident 1 experienced harm when their sacrum (the triangular bone at the base of the spine that connects the lower back to the pelvis [bony structure inside hip]) and left lower leg pressure ulcers worsened/deteriorated due to the delayed implementation of recommended treatments and nutritional supplements. These failures placed the residents at risk for further skin breakdown, worsening pressure ulcers, infection, medical complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure acceptable parameters of nutrition were maintained, provide nutrition per physician order, maintain accurate documentation of nutritional intake, and recognize significant weight loss for 1 of 2 residents (Resident 1), reviewed for nutrition/weight loss. Resident 1 experienced harm when they had a significant weight loss of 24.1 percent (%) in two months. This failure placed the residents at risk for further decline in their weight, unintended consequences of poor nutrition, unmet care needs and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician and resident representative were notified for 1 of 2 residents (Resident 1), reviewed for notification of changes. The failure to notify the physician and the resident's representative when Resident 1 had significant weight loss placed the resident at risk for a delay in medical/nutritional treatment, and not having their representative involved in the health care decision making process for timely care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed for 1 of 2 residents (Resident 1), reviewed for SCSA. This failure placed the residents at risk for delayed care planning, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide the required specialized rehabilitative services for 1 of 3 residents (Resident 1), reviewed for rehabilitation services. This failure placed the residents at risk for the decline in function, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement and/or develop discharge comprehensive care plans for 3 of 5 residents (Residents 1, 2 & 3), reviewed for care planning. 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 protect a resident's right to be free from sexual abuse for 1 of 2 residents (Resident 1), reviewed for sexual abuse investigations. Resident 1 experienced harm, applying the reasonable person concept (how a reasonable person would respond under the same circumstances, a reasonable person in this same situation would be upset, angry, and feel violated), when Resident 2 was observed performing nonconsensual sexual act on Resident 1. This failed practice placed all residents at risk for sexual abuse, psychological harm, and a diminished quality of life. A past noncompliance was initiated on 04/12/2025 related to F600 Free from Abuse and Neglect for failure to protect Resident 1 from sexual abuse. The facility implemented the following interventions that were initiated 04/12/2025 and corrected by 04/14/2025: [...]

Inspectors wroteBased on interview and record review, the facility failed to act timely and ensure resident received the necessary care and services for examination and/or treatment after a sexual assault in accordance with professional standards of practice for 1 of 2 residents (Resident 1), reviewed for sexual abuse investigations. The failure to send resident to the emergency room (ER) after sexual assault placed the residents at risk for delay in care and services, unintended health consequences, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received necessary assistance with toileting care for 2 of 3 residents (Resident 3 & 4), reviewed for bowel and bladder. This failure placed the residents at an increased risk of incontinence, loss of dignity, diminished quality of life, feelings of frustration and embarrassment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the primary care physician was timely notified when medications were not administered for 1 of 4 residents (Resident 1), reviewed for notification of change. The failure to notify the primary care physician when the medication (clozapine-used to treat Schizophrenia [a chronic mental illness characterized by a combination of symptoms that significantly impair a person's thinking, feeling, and behavior]) were not administered caused harm for Resident 1 who had increased anxiety, behaviors, and suicidal ideation requiring hospitalization. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an ordered medication, significant to the health of 1 of 4 residents (Resident 1), reviewed for medication administration. This failure caused harm to Resident 1 when their medication (clozapine-used to treat Schizophrenia [a chronic mental illness characterized by a combination of symptoms that significantly impair a person's thinking, feeling, and behavior]) were not administered resulting in increased anxiety, behaviors, and suicidal ideation requiring hospitalization. A past noncompliance was initiated on 02/26/2025 related to F760 Residents Are Free of Significant Medication Errors for failure to provide a medication significant to the health of the resident. The facility implemented the following interventions that were initiated 02/26/2025 and corrected by 02/28/2025: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to take timely action and ensure a urology (a surgical specialty that focuses on the urinary tract) referral, and urine analysis (UA- test for UTI [Urinary Tract Infection or bladder infection]) were conducted for 1 of 1 resident (Resident 1), reviewed for urinary care management. These failures placed the resident at risk for urinary associated infections, other health related complications, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure responsible parties were notified for 1 of 1 (Resident 1), reviewed for notification of changes. The failure to notify the resident's representative when Resident 1 went missing placed the resident at risk of not having their representative make decisions for timely care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a tube feeding [TF) directly into the stomach or small intestine) was administered in accordance with physician's orders and professional standards of practice for 1 of 2 residents (Resident 2), reviewed for tube feeding management. The failure to clarify enteral nutrition orders to include route of administration and/or follow physician's orders on the amount of formula to administer placed the resident at risk for adverse health outcomes, related complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from misappropriation of property for 1 of 7 residents (Resident 1), reviewed for abuse investigations. This failure placed the residents at risk for pain, unmet care needs, on-going misappropriation of medication, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure survey results were posted in a place readily accessible to residents and residents' legal representatives. In addition, the facility failed to ensure the survey result binder included the results for 8 of 9 (04/26/2021, 06/15/2021, 07/27/2021, 09/07/2021, 01/24/2022, 04/12/2022, 10/19/2023 & 12/06/2023) complaint surveys that resulted in citations. These failures prevented residents, residents' representatives and visitors from exercising their right to review past survey results and the facility's plan of correction.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident rooms were maintained for 4 of 6 rooms (Rooms 301, 303, 223 and 215) and 1 of 3 halls (Second floor hall), reviewed for environment. The failure to ensure resident rooms were free of wall scrapes, loose baseboards, holes in the walls, and the failure to ensure hall handrails were in good condition placed residents at risk for a less than homelike environment and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide written notices of transfer/discharge to the residents and/or their representatives and failed to notify the Office of the State Long Term Care (LTC) Ombudsman (an advocacy group for residents), describing the reason for transfers/discharge for 4 of 4 residents (Resident 9, 75, 52 & 15), reviewed for hospitalization and discharge. These failures placed the residents at risk for not having opportunities to make informed decisions about transfers/discharges.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 3 licensed staff (Staff GG) followed professional standards for proper medication administration via a gastrostomy tube (G-tube - a medical device used to provide nutrients through a tube directly into the stomach) and follow insulin (a hormone to lower blood sugar) order for 2 of 9 residents (Resident 54 & 36), reviewed for medication administration. In addition, the facility failed to ensure a urine specimen was properly labeled/stored in accordance with standard of practice for 1 of 1 specimen refrigerator (second floor specimen refrigerator), reviewed for environment. These failures placed the residents at risk for potential adverse effects and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were consistently provided to increase Range of Motion (ROM) and/or to prevent decrease in ROM for 6 of 6 residents (Residents 14, 59, 37, 28, 35 & 10), reviewed for restorative services. This failure placed the residents at risk for a decline in ROM, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure the daily nurse staffing form was posted 2 of 9 days and failed to post daily nurse staffing in prominent locations for 3 of 4 floors (First floor, Second floor & Third floor). This failure placed the residents, the residents' representatives, and visitors at risk of not being fully informed of the current staffing levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately label and store drugs or biologicals (diverse group of medicines made from natural sources) and/or failed to ensure expired medications were disposed of timely in accordance with current accepted professional standards for 2 of 3 medication carts (Second Floor Cart 2 & Third Floor Cart 1) and for 1 of 2 Medication Storage Room (Second Floor Medication Storage Room), reviewed for medication storage and labeling. These failures placed the residents at risk for receiving compromised and ineffective medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 1 of 1 kitchen and 2 of 2 resident personal refrigerators (Resident 6's two personal refrigerators), reviewed for food services. The failure to appropriately thaw food in a manner to provide food safety and failure to check temperature and maintain personal refrigerators, placed the residents at risk for food borne illness (caused by the ingestion of 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 Contact Precautions (measures put in place to prevent spread of infection by direct or indirect contact with the resident or environment by staff wearing gown and gloves before entering a resident's room or environment) practices were followed for 2 of 5 staff (Staff MM & LL) and failed to implement Enhanced Barrier Precautions (EBP- precaution to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections]) for 1 of 4 residents (Resident 6) reviewed for infection control. In addition, the facility failed to ensure hand hygiene practices and/or proper use of gloves were followed before, during, and after resident care for 2 of 2 staff (Staff BB & GG) and failed to disinfect medical equipment for 1 of 2 staff (Staff R) reviewed for infection control. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light (an alerting device for staff to assist residents in need) was within reach for 1 of 4 residents (Resident 35), reviewed for accommodation of needs. This failure placed the resident at risk for delayed care, accidents/falls, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy and procedure by not ensuring reference checks were conducted prior to hire for 1 of 5 staff (Staff W), reviewed for reference checks. This failure placed the residents at risk for abuse, neglect, exploitation, and misappropriation of property.

Inspectors wroteBased on interview and record review, the facility failed to ensure admission Minimum Data Set (MDS-an assessment tool) was completed within 14 days of admission for 1 of 21 residents (Resident 26), reviewed for comprehensive assessment. This failure placed the resident at risk for delayed and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS- an assessment tool) was completed timely for 1 of 3 residents (Resident 61), reviewed for significant change in condition. The failure to complete a SCSA within 14 days placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 3 of 21 residents (Residents 84, 82 & 26), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding hospice care, pressure ulcer (injury to the skin and the tissue below the skin that are due to pressure on the skin for a long time) care, and comatose status (deep sleep-like state where a person is unconscious, unresponsive, and unable to be awakened) placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to revise comprehensive care plan for 1 of 21 residents (Resident 28), reviewed for care plan revision. The failure to revise the care plan to include current and specific restorative nursing program services placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary assistance with Activities of Daily Living (ADL) for 1 of 4 residents (Resident 14), reviewed for ADLs. The failure to provide residents who were dependent on staff for assistance with getting out of bed placed the resident at risk for unmet needs, pressure related complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and services related to enteral tube feeding (TF-the delivery of nutrients through a tube directly into the stomach) were followed for 2 of 3 residents (Residents 54 & 36), reviewed for TF management. The failure to check TF placement or check the gastric residual volumes (GRV - fluid/contents that remain undigested in the stomach) prior to TF and medication administration placed the residents at risk for medical complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete required annual performance evaluation for 2 of 3 staff (Staff T & MM), whose personnel files were reviewed for Certified Nursing Assistant (CNA) performance evaluations. The failure to complete a performance review of every nurse aid at least once every 12 months placed residents at risk for receiving care from underqualified care staff, unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and services related to enteral tube feeding (the delivery of nutrients through a tube directly into the stomach) were followed for 2 of 3 residents (Residents 54 & 36), reviewed for tube feeding management. The failure to check tube feeding placement for gastric residual volumes (GRV - fluid/contents that remain undigested in the stomach) prior to tube feeding and medication administration placed the residents at risk for medical complications and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident meal preferences for meal services was provided for 1 of 2 residents (Resident 76). This failure placed the resident at risk for not having their food choices honored, dissatisfaction with food served, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to provide necessary/adequate supervision for 1 of 1 resident (Resident 1) reviewed for elopement. The resident was allowed to exit the facility unnoticed and was placed at risk for serious injury and a diminished quality of life. A past noncompliance was initiated on 08/28/2024 related to F689 Free of Accident Hazards/Supervision/Devices for failure to provide necessary supervision for a resident at risk for elopement. The facility implemented the following interventions that were initiated 08/28/2024 and corrected by 09/03/2024: - Assisted Resident 1 with returning to the facility from the kidney center [which was located across the street from the facility]. - Audits were completed for current residents for risk for wandering and elopement. - Elopement Risk evaluations were updated/completed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident room doors with COVID-19 (an infectious virus causing respiratory illness that may cause difficulty breathing and could lead to severe impairment or death) were kept closed for 4 of 5 Residents (Residents 1, 2, 3, and 4) in accordance with the Centers for Disease Control (CDC) guidelines. In addition, the facility failed to ensure 3 of 3 staff members (Staff D, E, and F) used personal protective equipment (PPE - use of gowns, gloves, eye protection, and N95 or higher-level respirator) in accordance with the CDC guidelines when caring for residents with known COVID-19 infections. These failures placed the residents, staff, and visitors at risk for COVID-19 infection and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enteral nutrition/tube feeding (the delivery of nutrients through a feeding tube [a device that delivers liquid nutrition] directly into the stomach) was provided per physician's order at the prescribed rate for 1 of 3 residents (Resident 1), reviewed for tube feeding. This failure placed the resident at risk for inadequate nutrition/hydration, weight loss, and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a wound vac (a machine using a suction pump, tubing, and a dressing to remove excess fluids and promote healing of wounds) was not removed prior to a follow-up appointment with a burn clinic for 1 of 1 Resident (Resident 1), reviewed for a skin graft wound (a surgical procedure in which a piece of skin is transplanted from one area to another). Resident 1 experienced harm when their wound vac was removed by the facility and a skin graft was compromised resulting in hospitalization and repeat skin graft surgery.

Inspectors wroteBased on interview and record review, the facility failed to assess and monitor before, during, and after hypodermoclysis (clysis - introduction of large amounts of fluid into the body between skin and muscle) procedure, ensure proper supervision during the procedure, and promptly intervene to address bleeding, in accordance with professional standards of practice for 1 of 1 resident (Resident 1). Resident 1 experienced harm when they were hospitalized to evaluate and treat a critically low blood pressure and an acute kidney injury (sudden and rapid loss of kidney [two bean-shaped organs that filter your blood] function) related to acute blood loss. This failed practice placed other residents at risk for unmet care needs, decline in medical status, and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident windows in good condition for 2 of 6 resident rooms (Rooms 217 & 205), reviewed for comfortable homelike environment. This failure placed the residents at risk for injury and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure a Significant Change in Status Assessment (SCSA) was completed for 1 of 1 resident (Resident 1), reviewed for significant change in condition. This failure placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegations of sexual aggression for 1 of 2 residents (Resident 1) reviewed for abuse investigations. This failure placed the resident at risk for unrecognized abuse, inappropriate corrective actions, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written notification of room changes including the reason for the move and failed to ensure monitoring for acclimation to the new environment for 2 of 5 residents (Residents 1 & 2) reviewed for room changes. This failure placed the residents at risk for not being informed, feelings of powerlessness, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure tube feedings (inserted through the belly that brings nutrition directly to the stomach) and tube feeding pumps (used to deliver nutrition via feeding tubes) were clean and sanitary for 4 of 4 residents (Residents 36, 2, 1 and 14) reviewed for safe and clean environment. This failure placed the residents at risk for potential infection control issues and a diminished quality of life.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and/or the residents' responsible party of a transfer/discharge in writing for 6 of 6 residents (Residents 26, 42, 47, 36, 2 and 44) reviewed for hospitalization. The failure to provide the written notice disallowed the resident and/or their representative an opportunity to fully understand the reason for transfer/discharge and their rights associated with the resident discharge appeal process.

Inspectors wroteBased on record review, interview, the facility failed ensure 6 of 6 residents (Residents 26, 42, 47, 36, 2 and 44) reviewed for hospital transfers were given a written copy of a bed hold notice prior to or within 24-hours of emergency transfer to the hospital. This failure created the potential for residents and/or responsible parties to not have the information needed to safeguard their return to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner and/or in accordance with professional standards of food safety. The failure to use the correct test strip to check the kitchen sanitizing solution, ensure food was dated when first opened/refrigerated, soiled sheet pans/manual can opener were cleaned after use, and food were stored with tight fitting covers or lids, placed the residents at risk for food contamination and food borne illness (caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper hand hygiene practices were followed for 3 of 3 residents (Residents 296, 41 & 246) reviewed during wound care and medication administration. In addition, the facility failed to ensure urinary drainage bag was off the floor for Resident 296 and failed to ensure enhanced barrier precautions (require gown and glove use) were followed for Resident 41. These failures placed the 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 provide care and services in a manner that maintained and promoted dignity for 2 of 2 residents (Residents 296 and 14) reviewed for resident rights. The failure to provide dignity bags to cover Resident 296's urinary drainage bag and the failure to cover Resident 14's disposable briefs while being transported to and from the shower room placed the residents at risk for lack of privacy, a decreased self-worth, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise and implement measures to prevent a subsequent verbal and physical altercation for 1 of 2 residents (Resident 82) reviewed for abuse. The failure to monitor and provide additional interventions placed the resident at potential risk for harm, injury, and intimidation.

Inspectors wroteBased on interviews and record review, the facility failed to report an allegation of financial exploitation/misappropriation of resident property (money) to the state agency within 24 hours for 1 of 1 (Resident 296) reviewed for reporting. This failure placed the residents at risk for abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 2 of 26 residents (Residents 10 and 14) reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding tube feeding (a device that delivers liquid nutrition via tube through the stomach) and injections placed the residents at risks for unidentified or unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure bathing/shower were consistently provided for 2 of 2 residents (Residents 296 and 2) reviewed for Activities of Daily Living (ADL). This failure placed the residents at risk for poor hygiene, decrease self-esteem, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a properly fitted wheelchair for 1 of 19 residents (Resident 346) reviewed for care and services. The failure to allow the resident mobility without discomfort placed the resident at risks for increased leg pain and discomfort, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube [a device that delivers liquid nutrition] directly into the stomach) was administered in accordance with physician's orders and accurately provide the ordered amount of enteral formula administered for 1 of 2 residents (Resident 10) reviewed for enteral nutrition. This failure placed the resident at risk for inadequate nutrition/hydration, weight loss, and potential adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent (%). Two medication errors were identified for 2 of 8 residents (Residents 10 and 296) observed during 26 medication opportunities resulted in an error rate of 7.69%. This failure placed the residents at risk for not receiving the full therapeutic effect of the medications and/or possible adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure eye drop medication was discarded within 60 days as required for 1 of 8 residents (Resident 10) reviewed for medication administration. This failure placed the resident at risk of receiving compromised/expired medications and potential for medication error and possibly experience adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu for the soft and bite sized diet and the minced and moist texture diet were followed for 3 of 3 residents (Residents 26, 65 and 86) reviewed for food and nutrition services. This failure placed the residents at risk for unmet nutritional needs, weight loss, and a diminished quality of life.