Shaw Mountain of Cascadia

Inspectors wroteBased on interview, record review, and review of the facility policy, the facility failed to protect the residents' right to be free from sexual abuse by a resident for two residents (Resident (R) 70) and R110) of three residents reviewed for abuse out of a total sample of 26. R10 touched R70's breast and R10 touched R110's breast. This failure had the potential to negatively affect R70 and R110's overall physical and mental health.

Inspectors wroteBased on interview, record review, and review of the facility policy, the facility failed to ensure two abuse allegations were reported within two hours to the State Agency for two of three residents (Resident (R) 70 and R110) reviewed for abuse out of a total sample of 26 residents. This failure had the potential to negatively affect the facility by not making the State Agency aware of the situation timely.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) level one screen was updated with a new major mental illness diagnosis for one of two residents (Resident (R) 19) reviewed for PASARR out of a total of 26 sample residents. This created a potential failure to identify what specialized or rehabilitative services the resident needed and whether placement in the facility was appropriate.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure respiratory equipment was stored in a sanitary manner for one resident of two residents (Resident (R) 67) reviewed for respiratory care out of a total sample of 26. This failure had the potential to expose the resident to infections.

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to adhere to infection control practices and policies during wound care when staff failed to wear a gown for one resident (Resident (R) 36) on Enhanced Barrier Precautions (EBP) and failed to implement EBP for one resident (R92) with open wounds requiring dressing changes of three residents observed for wound care in a total sample of 26 residents. The deficient practice increased the risk for cross contamination and infections.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to offer pneumococcal vaccines based on Centers for Disease Control and Prevention (CDC) guidelines for one of five residents (Resident (R) 51) reviewed for immunizations out of a total of 26 sample residents. The deficient practice had the potential to increase the risk for this resident to contract pneumonia.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan, and the residents' choices. This was true for 3 of 8 residents (Resident #1, #2, and #4,) whose records were reviewed for quality of care. This failure created the potential for harm when residents were not reassessed to ensure the plan of care was effective, when physician orders were conflicting, and physician orders were not implemented or followed when ordered.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure sufficient staff were on-site to provide nursing services. This failure had the potential to affect all residents living in the facility and placed them at risk for harm if their call lights were not able to be answered in a timely manner or care was not provided due to not having adequate numbers of staff.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure resident records were accurately documented in accordance with professional standards of practice. This was true for 1 of 8 residents (Resident #4) whose records were reviewed for accuracy of resident records. This failure resulted in inaccurate clinical documentation.

Inspectors wroteBased on observation, review of the State Operations Manual, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained when 1) staff was assisting residents with meals and 2) medication administration, and 3) unsanitary conditions in the laundry room. This failure had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection.

Inspectors wroteBased on observation, review of the State Operations Manual, policy review, and staff interviews, the facility failed to treat residents with respect and dignity during dining operations. This failed practice had the potential to negatively affect resident's self-esteem, decreased enjoyment of meals and mealtime, and may negatively impact resident's food and fluid intake.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents and their representatives received assistance to exercise their right to formulate an Advance Directive. This was true for 2 of 24 Residents (#18 and #30) whose records were reviewed for Advance Directives. This deficient practice created the potential for harm or adverse outcomes if the residents' wishes were not followed or documented regarding their advance care planning.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) form CMS-10123 at least 2 days prior to discharge for 1 of 3 residents (Resident #302) reviewed for beneficiary protection notification. This deficient practice had the potential to cause financial harm or distress for residents when they were not informed of their potential liability for payment when their Medicare Part A benefits ended.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 1 of 24 residents (Resident #52) whose care plans were reviewed. This placed residents at risk for adverse outcomes if care and services were not provided due to care plans not being revised as resident's needs changed.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure adequate care and treatment was provided to 1 of 1 resident (Resident #21) reviewed for feeding tube use. This created the potential for harm if complications developed from improper tube feeding practice.

Inspectors wroteBased on personnel record review, resident record review, and staff interview it was determined the facility failed to ensure employees had completed the required annual trainings and competencies necessary to care for resident's needs. This was true for 1 of 5 employees whose training information was reviewed and 1 of 1 resident (Resident #32) medical records reviewed. This failure had the potential to affect all residents in the facility and increased the risk of harm to residents if staff were not trained on how to provide care and services to residents.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1 of 3 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 3 medications (8.82%) which affected 1 of 6 residents (Resident #58) whose medication administration were observed. This failed practice placed residents at risk of not receiving their prescribed medication or dosage of their medication.

Inspectors wroteBased on observation, CDC guidelines review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and stored appropriately. This was true for 1 of 1 medication storage rooms inspected and 3 of 5 medication carts audited for labeling and storage of medication. This failure created the potential for residents to have missed doses of medication and to receive expired medications with decreased efficacy.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure a lap tray was used to treat a medical symptom and not used as a physical restraint for 1 of 1 resident (Resident #78) who was observed for use of restraints. This resulted in harm to Resident #78 was left in a wheelchair with a lap tray for long periods which resulted in skin impairment and psychosocial distress.

Inspectors wroteBased on facility record review, review of the Payroll-Based Journal Staffing Data Report, and staff interview, it was determined that the facility failed to have an RN on duty for at least eight consecutive hours daily. This was true for 4 of the 31 days reviewed for RN coverage. This created the potential for harm if routine and/or emergency nursing services went unmet and had the potential to affect all residents residing at the facility.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure food items were dated, labeled, and stored in a sanitary manner in accordance with professional standards for food service safety. This failure had the potential to affect the 87 residents who consumed food prepared by the facility and were at risk for adverse outcomes including foodborne illness.

Inspectors wroteBased on facility record review, staff interview, and Centers for Medicare and Medicaid (CMS) policy manual review, it was determined the facility failed to accurately submit direct care staffing information to CMS.

Inspectors wroteBased on Resident Group interview, policy review, Resident Council Meeting minutes review, and staff interview, it was determined the facility failed to ensure resident concerns were addressed. These negative practices placed residents at risk of ongoing frustration and decreased sense of self-worth, as well as, unmet care needs, when issues of concern to them were not promptly addressed by the facility.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure residents were given the appropriate treatment and services to maintain or improve ability to carry out activities of daily living. This was true for 4 of 4 residents (#18, #28, #31, and #51) reviewed for restorative nursing services. This failure placed residents at risk for decreased range of motion, functional ability, and decreased quality of life.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained when hand hygiene was not performed, equipment was not cleaned, and urinary catheters were not kept . This was true for 2 of 12 residents (Resident #62 and #191) who were observed in their rooms and at meals. This failure had the potential for adverse outcomes due to the risk of cross-contamination and infection.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to identify a positive Level I Preadmission Screening and Resident Review (PASARR) and refer the resident to the appropriate state-designated authority for further review. This was true for 1 of 2 residents (Resident #78) reviewed for PASARR. This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not provided due to a lack of updated PASARR screening.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated. This was true for 1 of 18 residents (Resident #57) whose care plans were reviewed. This created the potential for harm if cares and/or services were not provided appropriately due to inaccurate information on the care plan.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure medications available to residents were dated after opened. This was true for 1 of 2 medication carts reviewed for storage and labeling. This failure created the potential for residents to receive expired medications with decreased efficiency.

Inspectors wroteBased on observation, record review, and resident and staff interview, it was determined the facility failed to ensure oral hygiene and dental services were provided for 1 of 2 residents (Resident #28) reviewed for dental services. This deficient practice had the potential to result in Resident #28 experiencing severe tooth decay and gum disease.