Spokane Health & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to assess, evaluate and monitor non-pressure skin conditions for 1 of 3 sampled residents (Resident 1). Resident 1 developed an inflammatory skin rash while in the facility between the folds of skin under their stomach and in the groin area. In addition, the resident was sent to the hospital on [DATE] where it was discovered their staples remained in place from a 12/18/2025 surgery. These failures placed residents at risk of not receiving timely treatment and services to prevent worsening skin conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pressure reducing measures to prevent the development or worsening of a pressure ulcer/injury for 3 of 3 Residents (Residents 1, 2, and 3) reviewed for pressure ulcer/injury (areas of damaged skin and tissue caused by sustained pressure). Resident 1 experienced harm when they developed Stage 3 (a full thickness skin loss potentially extending into the subcutaneous tissue layer) pressure ulcer to their left heel and that required debridement. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure available staff provided the necessary care and services in a timely manner for 8 of 10 sampled residents (Resident 1, 2, 3, 4, 5, 6, 7, and 8), reviewed for call light response. 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 consistently and accurately assess residents smoking abilities and implement safety interventions to prevent smoking related injuries for 3 of 3 sampled residents (Resident 73, 86 and 461), reviewed for smoking. The failure to accurately assess residents' smoking abilities and implement safety interventions to prevent smoking related injuries represented an immediate jeopardy (IJ). On 04/15/2025 at 5:21 PM, the facility was notified of the identified IJ related to F689 CFR 483.25 Accidents and Supervision. [...]

Inspectors wroteBased on interview and record review the facility failed to not request or require residents to waive potential facility liability for losses of personal property upon admission to the facility for 3 of 8 sampled residents (Resident 85, 463, and 41), reviewed for resident rights. This failure placed all residents at risk of inability to exercise their resident rights, unmet needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to repeatedly notify the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes, adult family homes, and assisted living facilities who protect and promote the resident rights under federal and state law and regulations) of residents who discharged the facility or transferred to the hospital for 3 of 3 months (January, February, and March 2025), reviewed for hospitalization and discharge. This failure detracted from all facility residents' rights being protected, the opportunity to explore other options, or provide them with support and advocacy during a potentially stressful and confusing time.

Inspectors wroteBased on observation, interview and record review, the facility failed to repeatedly ensure the facility had enough staff to provide care according to the facility acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and/or care plans for 9 of 17 sampled residents (Resident 16, 46, 61, 64, 65, 15, 22, 63 and 85), reviewed for sufficient staffing. This failure placed all residents at risk for potentially avoidable accidents, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to designate a Registered Nurse (RN) to serve as the Director of Nursing (DNS) on a full-time basis, as required. This failure placed all residents at risk of lack of RN oversight for care provided, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to establish and maintain a written transfer agreement with at least one area hospital approved for participation with Medicare/Medicaid programs. This failure placed all residents at risk for delayed hospital transfers, lack of access to hospital level of care and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Quality Assessment and Assurance (QA&A) program that ensured corrective actions for identified problem areas [activities of daily living, falls/monitoring, care planning conferences and admission procedures] were monitored and sustained. This failure precluded facility staff the opportunity to analyze potential and actual system deficiencies and modify corrective actions for deficiencies placing all residents at risk for a diminished quality of life and care.

Inspectors wroteBased on interview and record review, the facility failed to fully inform residents and/or their representatives on admission to the facility of the care to be provided and/or the professional who would furnish that care for 4 of 5 sampled residents (Residents 12, 262, 263 and 313), reviewed for admission. Additionally, the facility failed to provide information of potential risks and/or benefits of psychotropic medications (medications that treat disorders of the mind and emotions) prior to their use for 3 of 5 sampled residents (Residents 79, 313 and 38), reviewed for unecessary medications. These failures placed residents and/or their representatives at risk of not being fully informed of the risks, benefits or alternative treatment options available before decisions were made regarding medications and/or medical care.

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, regulations governing resident conduct, resident rights including notice of Medicaid rights and responsibilities for 4 of 5 sampled residents (Resident 12, 313, 262, and 263), reviewed for admission. This failure placed residents at risk of not being fully informed of their rights, facility rules, and resident conduct expectations.

Inspectors wroteBased on record review and interview, the facility failed to routinely inform and provide written information regarding the right to formulate an advance directive (legal document that oulined wishes for medical care if a person was unable to make decisions for themselves) for 4 of 19 sampled residents (Resident 3, 15, 69, and 263), reviewed for advanced directives. This failure placed residents at risk of not being able to exercise their rights, not having their wishes honored, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to routinely provide residents and/or their representatives oral and written information on how to apply for and use Medicare and/or Medicaid benefits for 4 of 5 sampled residents (Resident 12, 313, 262, and 263), reviewed for admission. This failure placed residents and/or their representatives at risk of not being fully informed of their Medicare/Medicaid rights, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to routinely inform cognitively intact residents and/or their legal representatives, of items and services included in nursing services which the resident may and may not be charged for and amount of potential costs for services not covered under Medicare and/or Medicaid or by the facility's per diem rate for 4 of 5 sampled residents (Resident 12, 313, 262, and 263), reviewed for admission. Additionally, the facility failed to provide the required beneficiary notices for 2 of 3 sampled residents (Residents 19 and 85), reviewed for required notices and associated choices related to Medicare services ending. These failures placed residents at risk of not being fully informed of their rights and/or financial responsibilities, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to repeatedly ensure resident hospital transfer documentation was completed as required to include the basis for hospital transfer, specific resident needs unable to be met by the facility, facility attempts to meet the needs, services available at the receiving facility to meet needs, and what information was conveyed to the receiving provider for 3 of 4 sampled residents (Resident 16, 41, and 90), reviewed for hospitalization. This failure placed residents at risk of potential delays in emergent hospital treatment, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to routinely review and provide written information regarding bed holds (the right to pay the facility to hold their room or bed while hospitalized or on therapeutic leave) upon admission for 4 of 5 sampled residents (Resident 12, 313, 262, and 263), reviewed for admission and upon transfer to the hospital for 4 of 4 sampled residents (Resident 19, 16, 41, and 90), review for hospitalizations. This failure placed residents at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized or on therapeutic leave.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was developed that contained resident-specific goals and interventions which included the minimum healthcare information necessary to properly care for each resident immediately upon their admission for 4 of 6 sampled residents (Resident 313, 312, 33, and 263) reviewed for baseline care plans. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to repeatedly ensure care plans were developed that included resident specific goals and interventions related to their specific care needs for 3 of 60 sampled residents (Residents 264, 60, and 311), reviewed for care planning. Failure to develop care plans for Residents 264 for nail care, Resident 60 for shaving preferences, and for Resident 311 related to hospice 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 ensure services provided consistently and routinely met professional standards of practice for 12 of 13 sampled residents (Resident 6, 262, 69, 16, 41, 83, 312, 63, 65, 311, 79, and 85), reviewed for skin conditions, constipation and accidents. Failure of staff to monitor wounds, follow and/or clarify physician orders when indicated, develop and implement an effective fall prevention policy and consistently monitor residents for injury after falls, placed residents at risk for a delay in treatment, injury, hospitalization, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 3 of 5 sampled staff (Staff K, L, and M), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to consistently post nurse staffing information on a daily basis, as required for 4 of 4 months (January, February, March and April 2025), reviewed. This failure resulted in residents, families and visitors not being fully informed of the facility's current staffing levels and resident census information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently ensure 2 of 3 sampled medication carts (Med Bridge unit carts 1 and 2) were free from expired medications, and medications were labeled and disposed of properly when unused. In addition, the facility failed to consistently ensure controlled medications (medications that have a high risk for abuse such as narcotics, anti-anxiety, hypnotic and hallucinogenic) were securely stored and monitored for loss or diversion as required for 1 of 2 sampled medication rooms (Med Bridge unit) reviewed for medication storage, and failed to ensure medications were stored securely for Resident 95 who was observed to have medicaiton in their room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional assessments were completed accurately and timely for 4 out of 5 sampled residents (Residents 60, 88, 313, and 263), accurate and timely weights were obtained after a significant weight loss occurred (Resident 60), and the required nutritional supplements were available and/or provided (Residents 88 and 313). These failures placed the residents at risk for weight loss, unmet nutritional needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appetizing and palatable food for 8 of 9 sampled residents (Residents 262, 63, 89, 56, 3, 15, 47, and 16) reviewed for food. This failure placed the residents at risk for decreased nutritional intake, potential weight loss, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food safety. Specifically, some foods were not labeled with the date opened or type of food item, labeled with a resident name (in the nourishment refrigerators) or discarded when expired. Additionally, the facility failed to maintain a clean kitchen environment, ensure dietary personnel wore appropriate hair coverings that fully covered their hair and performed hand hygiene when indicated. These failures placed residents at risk for food borne illness and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene was followed during medication administration and wound care for Resident 89 and during the observation of the lunch meal service, failed to serve food in a sanitary manner for an unidentified resident, failed to ensure signage was placed to inform the staff of residents (Resident 6, 88, 89, 462 and 82) who required Enhanced Barrier Precautions (EBP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, germs that are resistant to many antibiotics]), failed to sanitize equipment between resident use, and failed to timely change and maintain infection control practices for a central line (a thin, flexible tube inserted into a large vein until the tip rested in a major vein near the heart) for Resident 89. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow an established Antibiotic Stewardship Program (ASP) to promote the appropriate use of antibiotics (ABT) for newly admitted residents or those prescribed an ABT by community providers for 3 of 3 months (January, February, and March 2025) reviewed for infection control practices. This failure increased resident risk for multi-drug-resistant organisms (MDRO, germs that are resistant to many antibiotics) and had the potential for adverse outcomes with inappropriate and/or unnecessary use of ABT.

Inspectors wroteBased on observation, interview and record review, the facility failed to repeatedly ensure residents' call lights were readily accessible for 2 of 4 sampled residents (Resident 21 and 65), reviewed for resident call systems. This failure placed residents at risk of potentially avoidable accidents, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was assessed for their ability to self-administer their medications safely for 1 of 5 sampled residents (Resident 22) reviewed for medication administration. This failure placed the resident at risk for adverse side effects or unintended health consequences if under- or over-medicated.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure a clean, comfortable and homelike environment for 3 of 7 residents (Resident 56, 64, and 69) reviewed for environment. Specifically, Resident 56's call light button was dirty, Resident 64's wheelchair was not maintained in a clean manner, and Resident 69's sheets were not changed regularly. These failures placed the residents at risk of a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 7 sampled residents (Resident 264, 79), reviewed for Pre-admission Screening and Resident Review (PASARR, an assessment completed prior to admission into a skilled nursing facility to determine whether a resident with a diagnosis of a serious mental illness needed specialized mental health services) was completed prior to admission, accurately, and if indicated, a referral for a PASARR Level II (a more in-depth screening assessment) had been made. Specifically both residents admitted to the faciity with an exempted hospital stay and should have been referred for a Level II evaluation after they remained in the facility for more than 30 days. This failure placed the residents at risk for unidentified care needs related to their mental health.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan revisions were completed and failed to ensure care plan conferences were held for 3 of 60 sampled residents (Resident 33, 38, and 85) reviewed for care planning. Failure to ensure Residents 33 and 85's care plans were revised to include interventions after the resident;s care needs had changed, and failure to conduct care plan conferences as required for Resident 38, 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 ensure a resident's CPAP machine (a machine connected to a mask, that kept airways open while sleeping) was functional and failed to accurately document its use for 1 of 1 sampled resident (Resident 17) investigated for respiratory care. This failure placed the resident at risk of worsening health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 1 sampled resident (Resident 31) reviewed for prosthesis (an artificial limb designed to replace the function of an amputated or missing arm or leg) received the care and assistance required to be able to use the prosthesis. This failure placed the resident at risk for decreased mobility and balance, delayed discharge from the facility to the community, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it obtained all treatment-related documentation from the dialysis center and the medical records showed the accurate dialysis access site and location of the dialysis center for 1 of 1 sampled resident (Resident 88) reviewed for dialysis (a procedure that removed waste products and excess fluid from the blood when the kidneys failed to do so). This failure placed the resident at risk for delayed treatment and post-dialysis complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident food preferences were honored for 3 of 13 sampled residents (Residents 15, 63 and 89) reviewed for food preferences. This failure placed the residents at risk of unintended weight loss, less pleasure in dining and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 5 sampled residents (Residents 88 and 6) reviewed for infection control practices, received vaccinations for influenza and pneumonia as consented to. This failure placed the residents at risk of contracting pneumonia and influenza and potential complications associated with those illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure equipment was maintained in a safe operational condition for 1 of 4 sampled residents (Resident 17) reviewed for environment. This failure placed the resident at risk of possible injury.

Inspectors wroteBased on observation and interview, the facility failed to ensure a sanitary, comfortable and homelike environment for 1 of 7 sampled residents (Resident 87) reviewed for environment. This failure placed the resident at risk of an unpleasant, uncomfortable living environment and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and treatment for 3 of 3 sample residents (Residents 1, 2, and 3), who had surgically inserted devices to provide intravenous (IV) access. Specifically, the facility failed to show adequate monitoring of the IV site, document maintenance flushes, and change site dressings as required. These failures placed the residents at risk for medical complications associated with the use of IV devices.

Inspectors wroteBased on observation and interview, the facility failed to ensure the staff secured topical (applied on the skin) medications for 1 of 4 units observed. This failure placed residents at risk for medication errors and accidental ingestion.

Inspectors wroteBased on interview and record review, the facility failed to order labs on admission, to act timely in accordance with professional standards for critical lab results and medical provider orders for 1 of 3 residents (Resident 1) reviewed for quality of care. Resident 1 experienced harm when they had the change in condition that required transfer to the hospital for treatment and were diagnoised with acute kidney failure. These failures placed residents at risk for unintended health consequences and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement written abuse policies and procedures related to monitoring for psychosocial harm after abuse and/or neglect allegations for 4 of 6 residents (Residents 7,8, 9 and 10). This failure placed residents at risk for unmet care needs related to possible psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate records for 9 of 10 sampled residents (Residents 1, 2, 3, 4, 5, 6, 12, 13 and 14) whose medical records were reviewed. Failure to ensure completed consents for psychotropics (drugs that affect a person's mental state), signed nutrition documents, accurate documentation in progress notes, complete discharge paperwork, complete assessment and monitoring, accurate code status within a resident chart, and an accurate weight record, placed the residents at risk for unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medication consents were accurate and obtained prior to their administration for 2 of 7 sampled residents (Residents 1 and 2) whose medications were reviewed. This failure placed the residents or their representative at risk of not being fully informed of the potential risks and benefits of taking the medications.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident representative of a significant weight loss experienced by 1 of 7 sampled residents (Resident 1) reviewed for nutrition. This failure placed the resident at risk for delayed decisions for treatment by the legal representative. <Resident 1> In an interview on 02/04/2025 at 12:06 PM, a Collateral Contact stated that on a visit with Resident 1, they observed the resident, looked terrible, skinny. In an interview on 02/05/2025 at 2:47 PM, another Collateral Contact stated that when they visited Resident 1, they were, not touching food when food was in front of [them]. Review of a 12/17/2024 comprehensive assessment showed Resident 1 admitted to the facility on [DATE], had severe cognitive impairment, and required assistance for eating. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation into allegations of neglect, to include a skin assessment, for 1 of 5 residents (Resident 11) reviewed for abuse and/or neglect. Failure to complete a skin assessment placed the resident at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 5 of 12 dependent residents (Residents 1, 2, 3, 6, and 7), reviewed for activities of daily living (ADL's), received the appropriate number of showers per week. This failure placed residents at risk for poor hygiene and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff obtained accurate and timely weights, to include weights on admission and/or ongoing weights per the medical provider order, for 6 of 12 sampled residents (Residents 1, 2, 3, 5, 6, and 7), reviewed for nutrition.

Inspectors wroteBased on interview and record review, the facility failed to provide care according to the medical provider orders for 2 of 12 sampled residents (Resident 1 and 3) reviewed for quality of care. Specifically, Resident 1 did not have their vital signs monitored per the medical provider orders and Resident 3 was on a fluid restriction but did not have evidence that the restriction was monitored. These failures placed residents at risk for unintended health consequences and decreased quality of life.

Inspectors wroteBased on observation and interview the facility failed to consistently implement infection control standards related to handling of contaminated laundry (laundry which has been soiled with blood/body fluids or other potentially infectious materials), for 5 of 13 residents. This failure placed residents at risk for exposure to an infectious disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 9 residents (Resident 7 and 8) reviewed for range of motion/mobility, received monitoring and consistent treatment for identified range of motion limitations. This failure placed the residents at risk for avoidable range of motion declines.

Inspectors wroteBased on interview, and record review, the facility failed to ensure physician ordered medications were available as ordered for 4 of 5 residents (Resident 1, 4, 5 and 6) and that medications were administered per the direction of the physician order for 2 of 5 (Resident 1 and 4) residents reviewed for quality of care. This failure placed residents at risk of not receiving necessary care and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dialysis services consistent with professional standards, and ensure consistent, ongoing communication and collaboration with the dialysis facility for 3 of 3 sampled resident (Residents 1,2 and 3), reviewed for dialysis. These failures placed the residents at risk for unmet care needs and medical complications.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free from neglect for 2 of 5 residents (Resident 7 and 8). The failure to provide incontinence care to residents who were identified by nursing staff to have been incontinent, and required staff assistance for toileting and incontinence care, resulted in a possible diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the discharge summary was completed that included a reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter) for 3 of 3 sampled residents (Residents 2, 3 and 4) reviewed for discharge planning. This failure put residents at risk of complications and delayed treatment of medical conditions by not having the necessary information to ensure continuity of care when discharged to the community.

Inspectors wroteBased on interview and record review, the facility failed to ensure several high risk medications, antidepressants (a medication used to treat low mood) and anticoagulants (a medication used to prevent blood clots), were consistently monitored for 3 of 5 sample resident (1,2 and 7) reviewed for unnecessary medications. This failure placed the residents at risk for potential adverse side effects and medical complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of potential abuse were reported immediately to administration and the State Agency as required, for 1 of 3 sampled residents (1) reviewed for abuse. This failure placed residents at risk for possible abuse.

Inspectors wroteBased on interview and record review the facility failed to repeatedly prepare discharge summaries that include all the required components, complete a final summary of the resident's status upon discharge, complete a discharge plan of care with all the required components, and convey discharge information to the provider continuing care for 3 of 6 sampled residents (Resident 6, 7, and 8), reviewed for discharge planning. This failure placed residents at risk of unsafe discharges, unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to consistently accurately transcribe and implement provider orders, routinely monitor and evaluate residents' conditions, consistently implement care interventions, routinely monitor, evaluate, and/or revise interventions as appropriate, and provide needed care and services for 3 of 8 sampled residents (Resident 2, 5, and 6), reviewed for quality of care. This failure placed residents at risk of medical complications, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to repeatedly identify risks, evaluate and analyze risks, and implement safety interventions to reduce risks and hazards for 2 of 2 sampled residents (Resident 1 and 2), reviewed for substance use disorder. In addition, the facility failed to accurately and routinely assess elopement risk for 4 of 6 sampled residents (Resident 1, 3, 4, and 11), reviewed for accidents and supervision. This failure placed residents at risk of leaving the facility without staff knowledge, potentially avoidable accidents, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to identify and implement interventions to prevent urinary tract infections (UTI) and restore continence to the extent possible for 2 of 8 sampled residents (Resident 9 and 10), reviewed for quality of care. This failure placed resulted in Resident 9 and Resident 10 experiencing recurrent UTIs, placed residents at risk of development of multidrug resistant organisms and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to repeatedly implement antibiotic protocols to ensure antibiotics were appropriately prescribed, and routinely implement a facility-wide system to monitor antibiotic use for 2 of 3 sampled residents (Resident 9 and 10), reviewed for infection control. This failure placed residents at risk of development of antibiotic-resistant organisms, adverse side effects, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to consistently administer medications as ordered by the provider, monitor for potential side effects of missed medication doses and ensure freedom from significant medication errors for 2 of 7 sampled residents (Resident 1, and 2), reviewed for medication administration. This failure placed residents at risk of medical complications, adverse side effects, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from physical and chemical restraints for 1 of 3 sampled residents (6) reviewed for restraints. This failure placed residents at risk for injury, limited freedom of movement and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently provide adequate hygiene for 1 of 3 residents (6) dependent on staff to complete activities of daily living. 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 consistently implement effective preventative measures for falls, for 1 of 3 sampled residents (5), reviewed for accidents. These failures placed residents at risk for repeat falls, injury, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to store controlled drugs in a locked storage compartment and only permit access to authorized personnel for 1 of 9 sampled residents (Resident 4), reviewed for controlled medication storage. This failure caused unauthorized individuals to have access to Resident 4's controlled medications. This failure constituted Past Non-Compliance (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified). The facility immediately implemented and completed a plan of correction which was verified by surveyors. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow transmission-based precautions to prevent the spread of a Multi-Drug Resistant Organisms (MDRO) for 1 of 3 sampled residents (Resident 3), reviewed for infection control. This failure placed residents at risk for transmission of a communicable MDRO diseases, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to evaluate the effectiveness of interventions implemented to prevent accidents to determine if supervision or other interventions were needed to prevent accidents for 2 of 5 sampled residents (Resident 1 and 65), reviewed for accidents. Specifically, Resident 65 was not evaluated for the need for additional supervision after an unwitnessed fall occurred while using the bathroom, then harm w when they fell under similar circumstances four days later which resulted in a broken left femur. In addition, Resident 1 was at risk for harm when they sustained a second degree (blister) to their thigh from a potentially uncontrolled hot coffee temperature and experienced skin tears with repeated falls out of bed when fall interventions were not implemented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure weights were consistently obtained and acceptable parameters of nutrition were maintained for 3 of 10 sampled residents (Residents 9, 65 and 429) reviewed for nutrition. Resident 65 experienced harm when they experienced a significant weight loss, over 25% of their weight from 11/21/2023 to 01/12/2024, when their weight was not consistently and accurately obtained, staff did not provide consistent assistance and cueing with eating, and weight loss was not reported timely to the provider. This failure placed the resident at risk for further decline in their weight, unintended consequences of poor nutrition, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents or their representatives were given quarterly financial statements, as required, for 13 of 13 residents who had trust fund accounts. This failure did not allow residents with trust fund accounts to be fully informed of the facility's management of their money.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify an allegation as potential verbal abuse, ensure allegations of abuse and accidents that caused severe bodily injury were reported to the State Survey Agency as required for 5 of 7 sampled residents (1, 2, 65, 72, and 283), reviewed for abuse. This failure placed residents at risk for further abuse, injuries and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dialysis services (use of a machine to remove waste from the body when the kidneys do not function) according to accepted standards for 2 of 2 sampled residents (9, 429) reviewed. Specifically, the facility had no contract with the dialysis provider, a means of communicating with the dialysis center had not been established, the residents were not assessed for nutritional needs by the Registered Dietician (RD), and weights were not monitored. This failure placed the residents at risk for altered fluid balance, miscommunication regarding care, and poor outcomes.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure that infection control processes were followed by staff during meal service, during medication administration, and during care of residents on Transmission Based Precautions (TBP) for COVID-19 (a viral illness that caused fever, fatigue, respiratory difficulty, and sometimes death) and Clostridium difficile (C-diff, a highly-infectious debilitating diarrheal illness). In addition, the facility failed to report a case of Influenza A to the appropriate state agencies, as required. These failures placed residents at risk of potential exposed to communicable diseases and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care that maintained a resident's dignity for 1 of 2 sampled residents (Resident73) reviewed. This failure placed the resident at risk for psychosocial harm and placed residents at risk for decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate potential allegations of abuse for 1 of 5 sampled residents (1), reviewed for abuse. Specifially, Resident 1 had a bruise on their forehead and the cause of the bruise was not investigated to rule out abuse. This failure placed residents at risk of further potential abuse and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide edema (swelling caused by fluid trapped in body tissues) care according to professional standards of practice for 2 of 2 sampled residents (62 and 37), reviewed for edema management. This failure placed residents at risk of complications due to excess fluid accumulation, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to consistently monitor a non-removable medical device for 1 of 2 sampled residents (2), and Resident 2 developed a pressure ulcer. This failure placed the residents at risk of unidentified pressure ulcers, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement toileting recommendations which contributed to a fall and continued incontinence for 1 of 2 sampled residents (70) reviewed for bowel and bladder incontinence. This failure placed the resident at risk for injuries from further falls and decreased dignity and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify that a resident had separate and concurrent orders for the same medication, for 1 of 5 residents (19) reviewed for unnecessary medications. This failure put the resident at risk for receiving an incorrect amount of medication ordered by the physician, and possible ineffective response and increased side effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure psychotropic (medication that can reduce or relieve symptoms such as hearing or seeing something that is not there) medications were gradually reduced as required for 2 of 5 sampled residents (28, 11), reviewed. Additionally, the facility failed to ensure medications given on an as needed basis had a rationale for continued use, and an appropriate indication for its use. Also, target behaviors were not documented. These failures placed residents at risk of potential adverse side effects from psychotropic medications, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent for 3 of 11 sampled residents (41, 10, 72), observed during medication pass. Specifically, 3 errors were made during 31 medication administration opportunities, resulting in an error rate of 9.68 percent. Errors in medication administration placed residents at potential risk for not receiving the full therapeutic effect of the medication.

Inspectors wroteBased on interview, and record review the facility failed to ensure medications were administered as ordered for 3 of 12 sampled residents (9, 62, 84), reviewed for medication administration and monitoring. Spcifically, Residents 9, 62, and 84 did not receive medications when ordered and multiple doses were omitted, and Resident 9 was on an anti-coagulant (prevents blood clots from forming) that required monitoring, their blood level was high, and the medication was not held and levels rechecked as ordered. This failure placed residents at risk of possible bleeding, decline in their medical conditions and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) remained free from verbal and physical abuse. This failure placed the resident at risk for psychosocial harm, as well as a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 3 sampled residents (Resident 1 and 2) received appropriate services to maintain as much normal bladder function as possible. Failure to provide assistance with toileting placed the residents at risk for decline in urinary function, and diminished quality of life.

Inspectors wroteBased on interviews and record review the facility failed to ensure a safe discharge for one of three residents (Resident 1) reviewed for discharge planning. Failure to ensure the necessary durable medical equipment was available at discharge placed the resident at risk for medical complications, decreased quality of life and readmission to a hospital or nursing facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive, person-centered care plans for 2 of 6 sample residents (42, 56), reviewed for care plans. Resident 42's care plan listed inaccurate diagnoses, was not updated after a wound had healed, and was missing goals and interventions related to limited range of motion (ROM) of their hands. Resident 56's care plan was missing goals and interventions related to having had a heart transplant, use of blood thinning medication, and diabetes. Failure to establish care plans that were individualized and accurately reflected current care needs, placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired supplements were removed from the refrigerator and the dry storage room, in order to prevent the possible use of the supplements. This failure had the potential to affect 1 of 1 sample residents (43), who the facility identified as receiving the supplement via gastrostomy tube (a small flexible tube, inserted into the stomach to provide nutrition and medication). The facility further failed to ensure the hood vent was free of lint and grease. This had the potential to affect 91 of the 93 residents who consumed food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal protective equipment (PPE) was used in accordance with the Centers for Disease Control (CDC) guidelines by 10 facility staff (L,P,Q,R,S,T,U,V,W,X), when reviewing infection control practices. This failure placed residents and staff at risk for contracting COVID-19 (an acute respiratory illness caused by a coronavirus, capable of producing severe symptoms and in some cases death, especially in older people and those with underlying health conditions).

Inspectors wroteBased on record review (to include facility policies and hospital records), and interview, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotics for 3 of 3 sample residents (47, 4, 83) reviewed for urinary tract infections (UTIs), in a total sample of 19. These failures placed the residents at risk for potentially adverse outcomes.

Inspectors wroteBased on interview, record review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer 4 of 6 sample residents reviewed for pneumonia vaccinations (386, 82, 38, 28) and/or their representatives, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to offer the residents the opportunity to be vaccinated with Pneumococcal polysaccharide vaccine (PPSV23), and if this vaccination was not available, to offer one dose of Prevnar 20 (PCV20). This failed practice had the potential to increase the risk for these residents to contract pneumonia.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of five sample residents (9, 28, 56), reviewed for unnecessary medications, and/or their resident representative, were fully informed in writing of the potential risks associated with use of psychotropic medication (a medication which alters thought processes) and antidepressant medication (used to treat depression), prior to starting the medications, as required. This failure placed the residents at risk for adverse medication side effects, and failed to provide the residents and/or their representative at risk for not being able to make an informed decision about a medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 5 sample residents (9, 56), reviewed for Pre-admission Screening and Resident Review (PASARR) [a form to evaluate residents for serious mental illness before going to a nursing facility], received a PASARR Level II screening (a more in-depth screening) for necessary services, as required. This failure placed the residents at risk for unidentified mental health needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently provide grooming for one of four sample residents (337), reviewed for activities of daily living. This failure placed the resident at risk for not being groomed according to their preferences, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow-up on a medical provider's request to have a resident evaluated for a possible contracture (shortening of a muscle, causing the muscle to be resistant to stretching), for 1 of 3 sample residents (43), reviewed for range of motion. This failure placed the resident at risk for a decline in range of motion and unmet care needs.