Tacoma Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to use measured spoons when serving and provide foods listed on the menu for 2 of 2 sampled days (06/17/2026 and 06/22/2026) reviewed for kitchen. This failure placed residents at risk of receiving reduced portions, receiving inadequate nutrition, avoidable weight loss, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was safely stored and prepared and dishes were sanitarily washed when reviewed for kitchen. This failure placed residents at risk of consuming contaminated foods, foodborne illness, a decline in condition, and a diminished quality of life.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure all planned and provided services were included in residents plans of care for 2 of 19 sampled residents (Residents 34 and 9) reviewed for comprehensive care plans. Failure to include Resident 34's denture use and Residents 34 and 9's oxygen use placed residents at risk of unprovided care, decline in clinical condition, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy and hearing support in accordance with professional standards for 2 of 19 sampled residents (Residents 47 and 5) reviewed for quality of care. These failed practices placed the residents at risk for unmet needs and an inaccurate medical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prompt dental services were provided for 1 of 3 sampled residents (Resident 114) reviewed for dental services. This failure placed the resident at risk for continued dental problems and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices related to enhanced barrier precautions (EBP, infection control measures used in nursing homes to prevent the spread of resistant organisms) and hand hygiene for 1 of 2 sampled residents (Resident 12) when reviewed for activities of daily living and catheter (thin flexible tube inserted into the body to withdraw urine). These failures placed the residents at risk of infection, preventable illness, and diminished quality of life.

Inspectors wroteBased on interviews and record review the facility failed to ensure residents were free from abuse for 1 of 3 residents (Resident 1) reviewed for abuse. Resident 1 experienced harm when staff failed to implement and comply with facility abuse prohibition and social media policies that violated their right to privacy and resulted in substantiated mental abuse. This failed practice also placed residents at risk for humiliation, resident-to-resident altercations, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 of 5 staff (Staff E, R, and G) immdiately reported abusive violations to the State Agency (SA) and facility administration. This failure placed residents at risk for abuse, potential for harm, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 2 medication storage room refrigerators were secured (Medication Rooms Front and Back) when reviewed for medication storage. In addition, the facility failed to ensure diagnostic testing medication (PPD, purified protein derivative - a diagnostic skin test used to detect tuberculosis) were stored and dated properly. The facility failed to ensure the medication storage rooms were free of staff personal belongings, food, and drink. These failures had the potential for access to unsecured narcotics, an increased risk of drug diversion, and residents/staff to receive an expired diagnostic medication.

Inspectors wroteResident 45 Resident 45 admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD, chronic inflammatory lung disease that causes obstructed airflow from the lungs), respiratory failure (when the lungs can't get enough oxygen into the blood) and muscle weakness. During an interview on 03/25/2024 at 11:03 AM, Resident 45 stated they continued to be served foods that were on their dislike list. Resident 45 gave the example that they did not like pork; however, they had been served ham and bacon. Observation and review of Resident 45's breakfast tray on 03/27/2024 at 8:31 AM showed a slice of wheat toast, yogurt, milk, cranberry juice, and scrambled eggs and the tray card showed Dislikes and listed Fish group, Pork Group, Peas, Vegetables, Milk, OJ and scrambled eggs. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure necessary maintenance of resident rooms for 2 of 4 sampled halls (Halls C and D) when reviewed for environment. This failure placed residents at risk for injury, lack of privacy, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement individualized comprehensive care plans for 3 of 24 residents (Residents 89, 38 and 45) whose care plans were reviewed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 3 of 24 sampled residents (Residents 89, 104, and 3) reviewed. The facility failed to ensure Resident 89's enteral tube (a method of feeding that used the gastrointestinal [GI] tract to deliver nutrition and calories) and an esophagostomy (spit fistula, an opening in the neck or chest created and connected to the upper esophagus to allow spit to leave the body safely) were managed, Resident 104's peripherally inserted central line catheter (PICC, a long flexible catheter [tube] placed into a vein in the upper arm and into a large vein in the chest) was monitored, and Resident 3's provider order to monitor hours slept were documented. These failures placed residents at risk of medical complications, unmet needs, and a poor quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities of daily living assistance for a dependent resident was provided for 1 of 3 residents (Resident 59) reviewed for activities of daily living. The facility failed to ensure upper and lower denture placement was provided for Resident 59 which placed the resident at risk for decreased self-worth, depression, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received the necessary services to maintain their level of functioning and/or prevent decline for 1 of 4 sampled residents (Resident 50), reviewed for limited range of motion (ROM). This failure placed the resident at risk for decreased ROM, increased pain, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow prepared menus for 2 of 4 halls (Halls C and D) and historically when reviewed for kitchen. This failure placed residents at risk of receiving nonpreferred food, decreased nutritional intake, and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to implement their Abuse, Neglect, and Exploitation policy and procedures and to act timely to ensure residents were free from sexual abuse and mistreatment for 3 of 5 sampled residents (Resident 1, 2 & 3) reviewed for abuse. This caused harm to Resident 1 when they experienced being inappropriately touched in a sexual manner without their consent. This failure placed residents at risk for sexual and physical abuse, psychological harm, feeling uncomfortable and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement their Abuse Policy and Procedures to ensure all residents were free from abuse, failed to conduct timely criminal Background Check Inquiry (BCI) upon hire; failed to perform timely Character, Competence, and Suitability Reviews (CC&SR-a determination made by facility administration to ensure the applicant can work in a position where there is unsupervised access to vulnerable adults by evaluating and analyzing the applicants various historic factors, document their decision, and attach to the BCI report) when indicated to be required by the BCI; and failed to obtain Reference Checks (RC) as part of the hiring process for 6 of 8 sampled residents (Staff D, E, F, G, I & K) reviewed for following and implementing written policies and procedures to prevent abuse and neglect. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure abuse allegations were reported timely to the State Agency (SA) and facility administration by 2 of 5 sampled staff (Staff E and F) reviewed reporting alleged violations. This failure placed residents at risk for abuse, potential for harm, and diminished quality of life.