Spokane Falls Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident remained free from sexual abuse for 1 of 3 sampled residents (Resident 1), reviewed for abuse. This placed residents at risk for sexual abuse and psychosocial harm.

Inspectors wroteBased on interview and record review the facility failed to identify multiple incidents of resident-to-resident verbal and physical altercations as potential abuse and ensure the allegations and investigation results were reported to the state agency, as required for 13 of 20 sampled residents (Resident 4, 15, 34, 72, 90, 99, 100, 102, 103, 104, 105, 106, and 107), reviewed for abuse. Additionally, the facility failed to report a resident accident/injury and the investigation results for 1 of 20 sampled residents (Resident 8). These failures placed residents at risk for potential continued abuse, possible safety concerns due to inadequate follow-up, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent and monitor residents after accidents occurred for 4 of 9 sampled residents (Resident 7, 8, 44, and 69), reviewed for accidents. These failures resulted in Resident 7 sustained an injury and placed residents at risk of potentially avoidable accidents, increased falls and defective devices.

Inspectors wroteBased on interview and record review, the facility failed to ensure monthly medication reviews were completed in December 2025, as required, and pharmacist recommendations were not addressed as indicated, for 4 of 5 sampled residents (Resident 3, 69, 6, and 11), reviewed for unnecessary medications. This failure placed residents at risk of inadequately monitored medications, potentially unidentified adverse consequences, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure received and opened dates were placed on food items in the refrigerator and freezer, and in 1 of 1 dry storage areas. Additionally, the tile floor in the kitchen was broken, dirty, and not a cleanable surface and there was an active water leak that had not been addressed. The facility failed to wear facial hair coverings appropriately and maintain a clean cooking environment. These failures placed residents at risk for food-borne illnesses.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a urinary catheter (flexible tube inserted into the bladder) in a dignified manner for 1 of 7 sampled residents (Resident 95), reviewed for resident rights. Additionally, the facility obtained psychotropic (medications that affected the brain, mood, thoughts, behaviors, and perception) medication consent from a severely cognitively impaired resident for 1 of 5 sampled residents (Resident 11), reviewed for unnecessary medications. This failure placed residents at risk of not being fully informed of the potential risks versus benefits associated with treatment, embarrassment and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, and homelike environment for 3 of 7 sampled residents (Resident 7, 35, and 69), reviewed for environment. Additionally, the toilet seats in 2 of 4 shower rooms (Shower room [ROOM NUMBER] - Southeast and Shower room [ROOM NUMBER] - Southwest) were broken and the South unit therapy room tile floor had significant large black and rust stains. These failures placed residents at risk of potentially avoidable accidents and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to coordinate with the State designated authority to ensure residents with a mental disorder received integrated care based on their needs for 1 of 5 sampled residents (Resident 11), reviewed for Pre-admission Screening and Resident Review (PASRR, a mental disorder and intellectual disabilities screening). Specifically, Resident 11's Level I screening was not completed correctly prior to admission. This failure placed the resident at risk of decline in their psycho-social needs or inability to benefit from all services they were entitled to.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement care planned interventions for 2 of 4 sampled residents (Resident 28 and 62), reviewed for quality of care. Specifically, Resident 28 did not have bed rails in place and Resident 62 was not provided large print reading material as care planned. This failure placed residents at risk of unmet care needs and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide bathing for 1 of 3 sampled residents (Resident 6) reviewed for activities of daily living (ADLS). This failure placed residents at risk for poor personal hygiene, diminished quality of life and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received an ongoing program of activities that met their interests for 1 of 2 sampled residents (Resident 6), reviewed for activities. This failure placed the resident at risk for sadness, feeling alone and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide foot care and seek podiatry services (a physician that specialized in care and treatment of the feet) for 1 of 3 sampled residents (Resident 74) reviewed for skin conditions. This failure placed the resident at risk for skin breakdown and unintended health consequences.

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 (Residents 62 and 74) and failed to administer oxygen per provider orders for 1 of 3 sampled residents (Resident 74), 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 routinely complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 2 of 5 sampled staff (Staff AA and BB), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. Specifically, two medication errors were identified during 26 medication administration opportunities. This resulted in an error rate of 7.69 %. This failure placed residents at risk of receiving subtherapeutic (a dosage or concentration that is too low to produce the intended medical effect or treat a disease) effects of their medications, possible adverse side effects, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure refrigerator temperatures were maintained in an acceptable range and expired medications were removed from inventory in 1 of 2 medication rooms (Medication room [ROOM NUMBER] - South Unit) observed. This failure placed residents at risk of receiving potentially compromised or expired medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the ordered diet for 1 of 10 residents (Resident 23), reviewed for food preferences. This failure placed residents at risk for inadequate nutrition, possible weight loss and diminished quality of life.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide food in the correct consistency for 1 of 6 sampled residents (Resident 11), reviewed for nutrition. This failure placed the resident at risk for choking, aspiration pneumonia (an infection caused by inhaling foreign material-such as food, liquid, or vomit into the lungs) and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreements were explained in a form and manner understood by the resident and/or their representative for 2 of 3 residents (Resident 11 and 28) 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 interview, and record review, the facility failed to assess, monitor, and document non-pressure skin conditions for 1 of 3 sampled residents (Resident 1), reviewed for skin conditions. The inconsistent skin assessments and monitoring of identified skin issues placed the residents at risk of unmet needs and potential worsening skin conditions.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as intended by the provider for 2 of 3 sampled residents (Resident 1 and 2), reviewed for medication administration. This failure placed the residents at risk of adverse side effects, worsening infection, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision for 1 of 3 sampled residents (Resident 1), reviewed for elopement (leaving the premises or safe area without authorization). The resident left the facility, unattended, after being identified with poor memory and safety awareness. This failure placed the resident at risk for possible injury and being in an unsafe situation.

Inspectors wroteBased on interview and record review, the facility failed to ensure N-95 mask (a type of mask used to protect the wearer from particles or from liquid contaminating the face) fit testing (a test conducted to verify that a N-95 mask provides the user with the expected protection) was performed in accordance with applicable federal regulations for 103 of 103 employees. This failure placed employees and residents at risk of exposure to COVID-19 (a highly contagious respiratory virus).

Inspectors wroteBased on interview and record review, the facility failed to identify and report potential allegations of abuse and/or negect to the State Survey Agency as required for 3 of 5 sampled residents (Resident 1, 2, and 4), reviewed for abuse and/or negelct. This failure placed the residents at risk for further abuse and/or neglect and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 3 residents (Resident 4) were free of unnecessary psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior). Failure for the facility to obtain informed consent for treatment with psychotropic drugs and to ensure Resident 4 was monitored for adverse side effects, placed residents at risk of not being fully informed of the risks and benefits of treatment with psychotropic drugs and to receive unnecessary psychotropic drugs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 5 of 6 dependent residents (Residents 1, 3, 4, 5, 6), reviewed for Activities of Daily Living (ADL's), received the appropriate number of baths per week. In addition, the facility failed to provide grooming for 4 of 6 dependent residents (Residents 1, 2, 4, and 5), reviewed for nail care. This placed residents at risk for poor hygiene and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of potential verbal abuse for 1 of 1 sampled residents (Resident 8), reviewed for abuse and/or neglect. This failure placed all resident at risk for abuse and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, monitor, and/or measure non-pressure related skin conditions for 2 of 3 sampled residents (Resident 1 and 5), reviewed for skin conditions. This failure placed residents at risk for worsening skin conditions and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff obtained timely weights, re-weighed residents to ensure accuracy, and had measures implemented to prevent significant weight loss for 1 of 3 residents (Resident 4), reviewed for nutrition. In addition, the facility failed to obtain weekly weights for a resident on enteral nutrition (nutrition through a tube into the stomach), to monitor for adequate nutrition, for 1 of 1 resident (Resident 1), reviewed for tube feedings. This failure placed residents at risk for weight loss and unmet nutritional needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure enhanced barrier precautions were implemented during cares and a dressing change for 2 of 4 residents on Enhanced Barrier Precautions (Resident 35 & 61); failed to ensure hand hygiene was completed when indicated during 1 of 3 medication administration observations, and failed to ensure a comprehensive Water Management Plan was developed as required. These failures placed staff and residents at risk for spread of bacterial illnesses, exposure to splashes of body fluids, and illness related to water borne bacteria.

Inspectors wroteBased on interview and record review the facility failed to routinely inform cognitively intact residents and/or the legal representatives of cognitively impaired residents of the facility rules, resident rights and responsibilities including notice of Medicaid rights for 10 of 14 sampled residents (Residents 27, 28, 30, 42, 44, 41, 68, 268, 271, and 270), reviewed for resident rights. This failure placed residents at risk of not being fully informed of their rights, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to routinely provide written information including the facility policy on advanced directives (a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care-a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so), review and thoroughly explained information on the right to formulate advanced directives with cognitively intact residents and/or the resident's legal representative when indicated upon admission, as required for 6 of 12 sampled residents (Residents 68, 28, 271, 44, 20, and 218), reviewed for advanced directives. This failure placed residents and/or their legal representatives at risk of losing their right to have their healthcare preferences and/or decisions honored.

Inspectors wroteBased on interview and record review the facility failed to establish and implement an effective admission policy with all the required components, failed to not require a third-party guarantee of payment to the facility as a condition of admission, and failed to routinely review and complete admission paperwork with cognitively intact residents and/or the resident's legal representative when indicated upon admission, as required for 10 of 14 sampled residents (Resident 27, 28, 30, 42, 44, 41, 68, 268, 271, and 270), reviewed for admission. This failure placed residents at risk of not being fully informed of their rights, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to review and provide written information regarding bed holds (the right to pay the facility to hold their room/bed while hospitalized or on therapeutic leave) including the facility's policy to cognitively intact resident and/or the legal representatives of cognitively impaired residents upon admission for 8 of 14 sampled residents (Resident 27, 28, 42, 44, 68, 268, 270, and 271), reviewed for admission. This failure placed residents at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized or on a therapeutic leave.

Inspectors wroteBased on observation, interview, and record review the facility failed to address subtherapeutic (less than therapeutic) blood values for a resident on a blood thinner, routinely implement the bowel protocol when indicated, and administer medications as ordered for 3 of 6 sampled residents (Residents 268, 27, and 29), reviewed unnecessary medications. This failure placed residents at risk of potentially avoidable accidents, medical complications, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dialysis (a mechanical way of removing waste from the body when the kidneys no longer function) care was delivered comprehensively for 4 of 7 sampled residents (Residents 30, 32, 35, and 63) reviewed for dialysis care. Specifically, individualized care plans were not developed, medications were omitted on days residents attended dialysis treatments, and fluid intake was not monitored for those on fluid restrictions, and one resident had blood drawn from an extremity that had a non-functioning fistula (a surgical connection of a vein and artery, usually in one arm used to conduct dialysis, also referred to as a graft) that was the potential cause of a large hematoma. This failure placed the residents at risk for deterioration of their chronic health conditions and unmet care needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing assistant and licensed nurses competencies/skill sets or performance evaluations were completed yearly as required for 6 out of 10 sampled employees reviewed for sufficient and competent nurse staffing. This failure had the potential to place the residents at risk for unmet care needs and impact the quality of care provided.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure significant medications were given as ordered for 4 of 7 sampled residents (Residents 30, 35, 63 and 221) reviewed for dialysis care. This failure put the residents at risk for sub-therapeutic levels of their medications and unintended health consequences.

Inspectors wroteBased on observation, interview, and record review, the facility administration failed to effectively use its resources to maintain facility compliance with Federal regulatory requirements for 6 of 12 sampled residents (Resident 20, 28, 44, 68, 218, and 271) reviewed for Advance Directives, 10 of 14 sampled residents (Resident 27, 28, 30, 42, 44, 41, 68, 268, 271, and 270) reviewed for admission and resident rights, and 8 of 14 sampled residents (Resident 27, 28, 42, 44, 68, 268, 270, and 271) reviewed for bed hold notification. Failure to ensure the facility's admission Agreement which included information on advance directives, resident rights, and the facility's bed hold notification/policy was completed upon admission and/or timely placed the residents at risk of not being informed of their rights, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents that required urinary catheters (a tube inserted in the bladder that drained urine) had the drainage collection bags maintained in a dignified manner for 1 of 2 sampled residents (Resident 61) reviewed for resident rights. This failure placed the residents at risk for loss of dignity and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consents, information that explained the potential risks associated with the use of psychotropic medications, were obtained prior to administration of psychotropic medications (medications that affected how the brain worked and caused changes in mood, feelings or behavior) for 2 of 6 sampled residents (Residents 20 and 60) reviewed for resident rights. This failure did not allow residents to be fully informed or to participate in their treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the interdisciplinary team (IDT) assessed and determined a resident was clinically appropriate to self-administer medications safely or store medications at the bedside and care plan accordingly for 1 of 14 sampled residents (Resident 68), reviewed for resident rights. This failure placed residents at risk of access to unsecured medications, medication errors, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sink faucets were safe and functional in resident rooms for 2 of 5 residents (Residents 38 and 23) reviewed for environment. Failure to have a working faucet for Resident 38, and failure to repair a loose faucet for Resident 23 placed the residents at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure mail delivery was provided consistently, including Saturdays, for 4 of 8 sampled residents (Residents 13, 29, 44, 50) reviewed for resident rights. This failure placed residents at risk of not having their rights honored to receive and send communication through the mail, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with newly evident mental conditions were referred for a Preadmission Screening and Resident Review (PASRR, an evaluation that ensured residents received the appropriate behavioral health services), and were referred for behavioral health services once recommended for 3 of 11 sampled residents (Residents 35, 54 and 60) reviewed. Specifically, Residents 35 and 60 were diagnosed with depression and started on psychotropic medication therapy (medications that altered mood, behavior and brain function) and a PASRR level I screening and referral for level II was not completed, and Resident 54 had PASRR level II recommendations for behavioral health services and the recommendations were not implemented timely.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with histories of mental disorders were screened appropriately for a need for specialized behavioral health services prior to admission as required for 2 of 11 sampled residents (Residents 20 and 61) reviewed. This failure placed residents at risk for unmet behavioral health needs and potential decline in their psycho-social well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure baseline care plan goals and interventions related to dialysis (a mechanical way of removing waste from the body when the kidneys no longer function) needs were developed in the required timeframe for 2 of 7 sampled residents (Residents 63 and 220) reviewed for dialysis care. This failure put the residents at risk for unmet complex dialysis care needs and potential undesired health complications.

Inspectors wroteBased on interview and record review the facility failed to complete a discharge summary with all the required components including a recapitulation of the resident's stay, the resident's status at time of discharge, a medication reconciliation, or a discharge plan of care, as required for 1 of 2 sampled residents (Resident 66), reviewed for discharge. This failure placed residents at risk of unsafe discharges, unmet care needs and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to evaluate and assess a resident for substance use disorder, thoroughly assess for safe smoking abilities, and monitor a resident after they sustained a fall for 3 of 5 sampled residents (Resident 68, 20, and 23), reviewed for accident hazards and supervision. This failure placed residents at risk of potentially avoidable accidents, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with symptoms of a urinary tract infection (UTI) had interventions implemented timely for 1 of 2 sampled residents (Resident 218) reviewed for UTIs. This failure placed the resident at risk of worsening infection, deterioration of their health and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician orders for nutrition were transcribed completely for one of two sampled residents (60) reviewed for tube feeding (a medical device used to deliver nutrients through a tube directly inserted into the stomach). Failure to ensure previous physician orders for tube feeding formula and water flushes were discontinued when new orders were obtained, placed the resident at risk for adverse medical and nutritional complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to have a system in place that identified residents that were survivors of trauma in order to eliminate or mitigate triggers (a stimulus that causes an adverse emotional response for one with a history of trauma) for 1 of 2 sampled residents (Resident 20) reviewed. This failure put the resident at risk for re-traumatization and for decline in their psycho-social well being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received the appropriate services to address their mental health needs timely for 1 of 2 sampled residents (Resident 54) reviewed. This failure put the resident at risk of having unmet behavioral health needs and a deterioration of their psychosocial well being.

Inspectors wroteBased on interview and record review the facility failed to consistently complete monthly medication regimen reviews and follow-up on recommendations timely, as required for 3 of 6 sampled residents (Resident 27, 29, and 60), reviewed for unnecessary medications. This failure placed residents at risk of receiving unnecessary medications, potential diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure expired medications were removed from inventory in 1 of 2 medication storage rooms (South Hall) and 1 of 2 medication carts (South Hall), observed for medication storage. In addition, one bottle of a liquid oral narcotic was not monitored for loss or diversion as required. This failure placed residents at risk of receiving less than the optimum dose of their medications, placed the facility at increased risk for potential controlled substance drug diversion and detracted from the facility's ability to promptly identify drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure dietary staff had the proper qualifications. Specifically, the failure to ensure the dietary manager had the proper certification placed all residents at risk for nutritional deficits, unmet nutritional needs, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide residents with their preferred beverages upon request for 2 of 3 sampled residents (Resident 27 and 68), reviewed for choices. This failure placed residents at risk of unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate medical records for 1 of 5 residents (Resident 23), reviewed for unnecessary medications. Resident 23 had two medication allergies listed, that were not accurate and were not corrected in their medical record when staff determined that they were not true allergies. This failure placed the resident at risk of unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to explain the arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement in a form, manner and/or language understood by the resident and/or their legal representative for 1 of 4 sampled residents (Resident 272), reviewed for arbitration agreement. 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, interview and record review, the facility failed to consistently communicate and coordinate care with the hospice provider, for 1 of 4 residents (Resident 23) reviewed for hospice (end-of-life) services. In addition, the facility failed to designate an interdisciplinary team member, in writing, to coordinate care and communication with the hospice agency, as required. These failures placed the residents at risk for unmet care needs.

Inspectors wroteBased on interview, and record review, the facility failed to thoroughly investigate allegations of abuse and/or neglect for 2 of 6 residents (Residents 1 and 5), reviewed for abuse and/or neglect. This failure placed residents at risk for abuse and/or neglect and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a Registered Nurse (RN) on duty at least eight hours a day, seven days a week. This failure had the potential to impact all residents present in the building.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 5 sample residents (Resident 1), reviewed for abuse, remained free from mental abuse when Resident 2 made sexually inappropriate comments towards Resident 1. Failure to implement adequate interventions and supervision for Resident 2, placed all residents at risk for psychosocial harm and potential mental abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders, as intended, for 1 of 3 sample residents (Resident 4), reviewed for medication administration. Resident 4 had an order to receive Carvedilol (a heart medication) one tablet twice a day. On 07/11/2024, the medication was changed to once a day with no order to make the change. This failure placed the resident at risk for adverse side effects and diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure dry food and refrigerated food were stored in sanitary conditions. This failure placed residents at risk for food borne illness.

Inspectors wroteBased on observation and interview, the facility failed to maintain a quiet, comfortable, homelike environment for the residents in 4 out of 4 Hallways (Southwest, Southeast, Northwest, and Northeast) during construction. This failure placed all residents at risk for fatigue, unwanted noise, and a non-homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 2 medication storage rooms (North and South medication rooms) stored medications at proper temperatures. This failures placed residents at risk of receiving compromised medications and biologicals.

Inspectors wroteBased on observation and interview, the facility failed to ensure there were functioning call lights in 10 resident rooms out of 13 rooms observed (room [ROOM NUMBER], 30, 34, 37, 38, 39, 62, 79, 81, and 85). The facility was undergoing construction which had caused the call lights to not function correctly. This failure placed the residents at risk for unmet care needs, and the inability to call for assistance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Intravenous (IV) access devices had dressing changes completed weekly, in accordance with professional standards of practice, for 2 of 2 residents (Residents 1 and 2), reviewed for IV therapy. In addition, the facility failed to follow orders to measure the circumference of the resident's arm, measure the length of the Peripherally Inserted Central Catheter (PICC a long, thin tube that is inserted through a vein and passed through to the larger veins near the heart), and ensure normal saline flushes (a solution pushed through the catheter to help prevent blockage) were completed. These failures placed residents at risk for loss of vascular access, infection, and other complications.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper personal protection equipment (PPE's) was used during a COVID outbreak, in accordance with Centers for Disease Control (CDC) guidelines, by 1 of 4 staff (Staff E), when reviewing infection control practices. This failure placed residents and the staff at risk for contracting COVID-19, a respiratory disease caused by a virus.

Inspectors wroteBased on interview and record review, the facility failed to consistently provide showers for 4 of 5 dependent sampled residents (Resident 1, 2, 5, and 6), reviewed for bathing. This failure placed residents at risk for poor hygiene and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement bowel management protocol when indicated for 4 of 4 residents (Resident 1, 2, 3, and 4) reviewed for constipation. This failure placed residents at risk for medical complications and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 of 4 sampled residents (Residents 4, and 5), reviewed for accidents, was free from injury. Resident 4, who had a history of seizure-like activity (spasms/involuntary jerking movements), experienced harm when they were left unsupervised in their wheelchair after a seizure-like episodes earlier that morning, fell out of their wheelchair onto the floor and sustained a neck fracture. Resident 5 experienced harm when their wheelchair was not properly secured in the facility transport van; when the van stopped to avoid an accident, the resident ' s wheelchair flipped backwards which resulted in the resident hitting their head on the back door. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate allegations of abuse and/or neglect for 3 of 4 sampled residents (Resident 1, 2, and 3), reviewed for abuse and/or neglect. This failure placed residents at risk for continued abuse and/or neglect and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly assess and evaluate changes in condition for 1 of 3 sampled residents (Resident 4), reviewed for change in condition. Resident 4 had been observed with seizure-like activity on 01/16/24 by a Collateral Contact (CC). CC reported the incident to a staff member and asked the provider be contacted. Staff G and Staff K, Nursing Assistants (CNA's) and Staff I, Hospitality Aide (HA), had observed Resident #4 with abnormal involuntary movements which had been reported to nursing staff. There was no documentation found to show Resident 4's change in condition and no documentation to show the provider had been notified. This failure constituted a Past Non-Compliance (the facility was not in compliance at the time the situations occurred; [...]

Inspectors wroteBased on interview and record review the facility failed to administer medications according to professional standards of practice and provider orders for 7 of 9 sampled residents (Resident 1, 2, 3, 4, 5, 6, and 7), reviewed for medication administration. This failure placed residents at risk of adverse side effects, potential complications from medical conditions, and diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to thoroughly investigate allegations of abuse and/or neglect for 1 of 3 residents (Residents 1), reviewed for abuse and/or neglect. This failure placed residents at risk for abuse and/or neglect and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to assess and document wound characteristics (size, depth, and tissue appearance) from 06/20/2023 to 07/06/2023 on a vascular ulcer (wounds that develop because of poor circulation) for 1 of 3 sampled residents (Resident 1), reviewed for non-pressure related skin wounds. Failure to thoroughly assess and document the wound appearance, to determine the effectiveness of treatment, and if the wounds got better or worse, placed the resident at risk for unmet care needs and potential worsening of the wounds.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff possessed appropriate competencies and skills to administer medications to residents in 2 of 4 hallways (Southwest and Southeast). This failure placed residents at risk for adverse medication outcomes and potential medication errors.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide thorough assessments and evaluate for changes in condition, for 1 of 3 residents (Resident 1), reviewed for change in condition. Failure to monitor Resident 1's right arm after complaints of pain and increased edema (swelling caused by too much fluid in the tissues)resulted in harm to Resident 1, who was sent to the hospital and diagnosed with blood clots in their right arm and lungs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate pain management for 2 of 4 sampled residents (Resident 1 and 2), reviewed for pain. Resident 2 experienced harm when their pain was not assessed on admission and failed to receive their scheduled narcotic pain medication as ordered until the following day, and was sent to the hospital for intractable (severe, constant, relentless, and debilitating) pain. This failure placed residents at risk of uncontrolled pain and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate allegations of misappropriation of resident property for 4 of 5 residents (Residents 1, 2, 3, and 4), reviewed for personal property. This failure placed residents at risk for misappropriation of personal property and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 2 of 3 residents (Resident 5 and 6) were free from potential sexual abuse. The facility failed to immediately investigate the allegations of sexual abuse and immediately suspend the accused staff member, Staff C, Nursing Assistant, to protect residents. This failure placed all residents at risk for potential sexual abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide thorough assessments and evaluate for changes in condition, for 1 of 3 residents (Resident 7), reviewed for change in condition. Failure to monitor a sudden increase in weight, thoroughly evaluate respiratory status, and consistently monitor for edema (swelling caused by too much fluid in the tissues) placed the resident at risk for worsening symptoms and a potential delay in treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to provide residents with drinks per their request or preferences for 5 of 11 sampled residents (Resident 14, 16, 18, 40, and 53), reviewed for food and nutrtion. This failure placed residents at risk of dehydration, unmet care need, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify misappropriation of resident money as potential abuse, and failed to report to the State Survey Agency as required, for 2 of 3 sample residents (Residents 16 and 273), reviewed for abuse. This failure placed residents at risk for additional abuse and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide bathing/showers for 3 of 5 sampled residents (Residents 16, 40 and 57), reviewed for activities of daily living (ADL). This failure placed the residents at risk for a diminished quality of life and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a system for accurate reconciliation of controlled drugs in 2 of 2 sampled medication rooms (South Hall and North Hall), reviewed for medication storage. This failure placed residents at risk for misappropriation of their controlled medications and placed the facility at increased risk for controlled substance drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a dignified dining experience for 4 of 16 sampled residents (Residents 2, 20, 22, and 123), observed during lunch. This failure placed residents at risk for a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify, investigate and resolve a grievance of missing clothing timely for 1 of 4 sampled residents (Resident 39), reviewed for personal property. Failure to identify and follow up on grievances promptly placed residents at risk for diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure Pre-admission Screening and Resident Reviews (PASRR, a screening tool used to identify behavioral healthcare needs) were completed prior to admission as required for 3 of 5 sampled residents (Residents 21, 47 and 60), reviewed. This failure placed residents at risk for unmet behavioral healthcare needs and diniminshed quality of life.

Inspectors wroteBased on interview and record review, the facility failed to follow-up timely on a doctor's referral for 1 of 2 sampled residents (Resident 18), reviewed for vision and dental needs. This failure placed the resident at risk for diminished quality of life and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for 1 of 2 sampled residents (Resident 1), reviewed for decreased range of motion. This failure placed residents at risk of worsening contractures (fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement), pain, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide follow-up specialty care for 1 of 1 sampled residents (Resident 32) reviewed for bladder incontinence (inability to control urination.) This failure placed the resident at risk for further decline in their bladder function, frustration, and placed residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review the facility failed to follow provider orders for weight monitoring and maintenance of feeding tube equipment for 1 of 1 sampled residents (Resident 39), reviewed for tube feeding. This failure placed residents at risk of unidentified weight fluctuations, potential infections, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to clean and maintain respiratory care equipment consistent with professional standards for 2 of 6 sampled residents (Residents 4 and 32), reviewed. This failure placed the residents at risk for contact with contaminated care equipment and potential respiratory infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess a resident for risk of entrapment, obtain informed consent and care plan for the use of bed rails for 1 of 2 sampled residents (Resident 44), reviewed for restraints. This failure placed residents at risk of entrapment, injury, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure adequate weight monitoring for diuretic (medication that helps rid the body of water) medication use was completed per provider orders and care plan for 1 of 6 sampled residents (Resident 26), reviewed for unnecessary medications. This failure placed the resident at risk of dehydration, muscle weakness, and cardiac arrhythmias (problem with rate or rhythm of one's heartbeat).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure blood pressure medication (hydralazine) was administered according to the ordered parameters for 1 of 5 sampled residents (Resident 59) whose medication regimens were reviewed. Additionally, the facility failed to obtain an order and assess Resident 59 for the ability to safely keep at their bedside and self-administer an albuterol (medication to open the airway when short of breath) rescue inhaler. This failure placed the resident at risk for adverse cardiovascular events, insufficient monitoring of medication effects, and placed the resident at risk for adverse events related to medication errors.

Inspectors wroteBased on observation and interview, the facility failed to store resident foods as required in 2 of 2 nursing unit kitchenettes. This failure placed residents at risk for foodborn illness and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fit testing (a test done to ensure an N95 mask formed a tight seal) was completed for 3 of 13 staff (E, H, and Q) reviewed for fit testing. This failure placed residents and staff at risk for contracting COVID-19, a respiratory disease caused by the SARS-CoV-2 virus. According to the 09/03/2021 Center for Disease Control publication, Fit Testing, Fit testing should be done at least annually to ensure the respirator (N95) continued to fit properly. In addition, a new fit test should be performed if a new brand, model, or size of respirator was used, and when there were changes to weight or facial/dental alterations, as all of these factors can change how the respirator forms a seal. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was offered an influenza and/or pneumococcal immunization as required for 2 of 6 sample residents (62, 65) reviewed for immunizations. This failure prevented the residents from making decisions about their care, and placed the residents at risk for illness, and possible health complications.