The Broadview Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene/glove use practices and/or Enhanced Barrier Precautions (EBP- precaution to protect residents from Multidrug-Resistant Organism [MDRO-a germ that is resistant to medications that treat infections]) practices were followed for 5 of 6 Staff (Staff G, H, J, K, & L), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk of infection and related complications.

Inspectors wroteBased on interview and record review, the facility failed to prevent physical abuse for 2 of 6 residents (Resident 3 and 5), reviewed for abuse investigations. These failures placed the residents at increased risk of injury, emotional distress and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a plan for discharge and to notify a resident and/or their representative of a discharge in writing for 1 of 3 residents (Resident 1), reviewed for discharge process. This failure placed the resident and their representative at risk of not having an opportunity to make an informed decision about the discharge and about their rights to appeal the discharge.

Inspectors wroteBased on interview and record review, the facility failed to prevent physical abuse for 1 of 8 residents (Resident 1), reviewed for abuse investigations. Resident 2 initiated physical aggression towards Resident 1 by grabbing her left wrist causing unwanted physical contact, swelling and bruising. This failure placed residents at an increased risk of injury, emotional distress and a reduced quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure bathing/showers were consistently provided for 1 of 3 residents (Resident 1), reviewed for activities of daily living (ADL). This failure placed the residents at risk for poor hygiene, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) was adequately monitored for a change in level of consciousness and decreased oxygen saturation (level of oxygen present in the blood), reviewed for quality of care. Additionally, the facility failed to promptly initiate oxygen therapy and to offer prompt transfer to a hospital for evaluation of change of condition. These failures placed the resident at risk of a delay with a higher level of care and associated complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate assessment and supervision for electronic cigarette use and ensure safe storage of smoking materials for 1 of 1 resident (Resident 7) that constituted an Immediate Jeopardy (IJ) and failed to supervise and restrain a pet (dog) for 1 of 1 staff (Staff F), reviewed for accident/hazards. Resident 9 experienced harm when they sustained a laceration (cut) on the back of their head when a staff member's dog was unleashed, wandered under the table in the dining room, startled the resident who fell backwards in their wheelchair hitting their head and required transport to the hospital for further evaluation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) included a completed facility-based and community-based risk assessment, the facility resources to include a list of medical and non-medical equipment description, and contracts, memorandums of understanding and other agreements with third parties to provide services or equipment to the facility both during normal and emergency situations. This failure placed the residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation and/or include a corrective action to prevent reoccurrence of an incident for 3 of 4 residents (Resident 4, 1 & 2), reviewed for abuse investigations. This failure placed the resident at risk for repeated incidents and unidentified abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure bathing/showers were consistently provided for 4 of 6 residents (Residents 2, 6, 3 & 5), reviewed for activities of daily living (ADL). This failure placed the residents at risk for poor hygiene, unmet care needs, decreased self-esteem, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed with actual hours worked for each shift for 7 of 10 days (09/01/2025, 09/02/2025, 09/03/2025, 09/04/2025, 09/05/2025, 09/09/2025 & 09/10/2025), reviewed for sufficient and competent staffing. This failure placed the residents and residents' representatives at risk of not being fully informed of the current staffing levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were served at proper temperature for 1 of 7 nursing units (Transitional Care Unit [TCU]), and 4 of 4 residents (Residents 3, 5, 6 & 16), reviewed for food temperatures and palatability. This failure placed the residents at risk for decreased nutritional intake, weight loss, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified social worker that met the educational requirements and supervised social work experience for one year in a health care setting for 4 of 4 social workers (Staff L, M, N & O), reviewed for social worker qualifications. This failure placed the residents at risk for unmet social services care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure shower preferences were reasonably accommodated for 2 of 6 residents (Residents 2 & 3), reviewed for preferences. This failure placed the residents at risk of unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop care plans for 2 of 2 residents (Residents 8 & 4), reviewed for comprehensive care plans. The failure to develop care plans for assistive device use, independent community outings, and refusal of incontinent care (toileting assistance) 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 monitoring for latent (hidden or not active yet) signs of injury and prompt medical evaluation for treatment was provided in accordance with professional standards of practice for 1 of 1 resident (Resident 8), reviewed for change of condition. These failures disallowed an opportunity to promptly evaluate the resident for a change in condition, which resulted in a delay of medical services, and placed the resident at risk for adverse consequences, related complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide/replace a pressure relieving bed mattress (Dolphin Mattress-a type of mattress that alternated fluid through the mattress) as recommended by the wound consultant to prevent and protect skin/wounds from further breaking down for 1 or 3 residents (Resident 3), reviewed for pressure ulcers. This failure placed the resident at risk for related medical complications, a decrease in healing potential, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 2 residents (Residents 3 and 17) were free from significant medication errors. The failure to provide intravenous (IV- administered through a vein) antibiotic medications (to treat infection) placed the residents at risk for a decline in their medical condition, a life-threatening infection, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure aerosol contact precautions (safety steps used to keep germs from spreading) that included keeping the door closed at all times and proper use of Personal Protective Equipment (PPE - gown, gloves, N95 [respirator -medical face mask that filters out at least 95% of tiny particles in the air] and face shield) were followed for 2 of 2 staff (Staff X & Z), reviewed for infection control. This failure placed the residents, staff, and visitors at risk for facility acquired or healthcare-associated infections and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the survey result binder included the recent recertification survey results and associated plan of correction for 2 of 3 years (November 2022 and February 2023), reviewed for availability of survey reports. This failure prevented residents, their representatives, and visitors from exercising their right to review past survey results and the facility's plan of correction.

Inspectors wroteBased on interview and record review, the facility failed to obtain and/or renew guardianship papers, and/or failed to offer assistance in formulating an Advance Directive (a written document describing a resident's wishes for care if they became incapacitated such as a living will or Durable Power of Attorney [DPOA] for health care) for 3 of 4 residents (Residents 43, 77 & 102), reviewed for Advance Directives. These failures placed the residents and/or their representatives at risk of losing their right to have their preferences honored to receive care according to their choice.

Inspectors wroteRESIDENT 98 Review of a face sheet printed on 06/05/2025 showed Resident 98 was admitted to the facility on [DATE]. Review of Resident 98's EHR showed a physician's order initiating an antidepressant (a drug used to treat mental health condition that causes a persistent feeling of sadness and loss of interest in activities, significantly impacting daily life) 7.5 milligrams (mg- unit of measurement) on 05/15/2025, and a dose increased to 15 mg on 05/20/2025. Review of Resident 98's May 2025 MAR, printed on 06/04/2025 did not show monitoring or documentation for target behaviors and potential adverse side effects. A joint record review and interview on 06/04/2025 at 10:52 AM with Staff D, showed Resident 98 had been taking an antidepressant since 05/15/2025. Staff D stated that adverse side effects and target behaviors were not monitored or documented and that they should have. [...]

Inspectors wroteNAIL CARE RESIDENT 76 Review of a quarterly MDS dated [DATE], showed Resident 76 needed substantial/maximal assistance (helper does more than half the effort) for personal hygiene. Observation on 06/02/2025 at 11:55 AM, showed Resident 76's right thumb fingernail was long and had brown matter underneath them. The left great toenail had black discoloration, and the right great toenail had brown discoloration. Both great toenails were thick and had brown matter underneath them. Resident 76 stated they could not clip or clean their nails and had requested staff assistance and were told, We will get to it when we have [a] chance. A joint observation and interview on 06/06/2025 at 10:37 AM, Staff T, License Practical Nurse, showed Resident 76's right thumb fingernail was long and had brown matter underneath them. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed and posted with actual hours worked after the start of each shift for 7 of 7 days (05/29/2025, 05/30/2025, 06/02/2025, 06/03/2025, 06/04/2025, 06/05/2025 & 06/06/2025), reviewed for sufficient and competent staffing. This failure placed the residents and their representatives at risk of not being fully informed of current staffing levels, potentially affecting their understanding of staff availability and care delivery. Findings Included . Review of the facility's policy titled, Posting Nursing Staffing Policy, dated 10/06/2022, showed the facility was required to post the daily nurse staffing information in a prominent location accessible to residents and visitors. [...]

Inspectors wroteRESIDENT 1 Review of a face sheet printed on 06/05/2025, showed Resident 1 readmitted to the facility on [DATE]. Review of Resident 1's facility provided document titled, Note to Attending Physician/Prescriber, dated 03/05/2025, showed a copy of the recommendation to Please consider ordering a new BMP [Basic Metabolic Panel- a blood test that measures the levels of different substances in your blood]. Most BUN [Blood Urea Nitrogen-a blood test to measure kidneys [organs responsible for filtering blood, regulating fluid balance and waste management through urine production function] lab [laboratory] shows it abnormally high . It further showed that the Physician/Prescriber Response was not completed. [...]

Inspectors wrote300 UNIT MEDICATION STORAGE ROOM A joint observation and interview on 06/05/2025 at 9:09 AM with Staff D, RNUM, showed the following expired medical supplies: -Four unopened safety scalpels with an expiration date of 09/30/2023. -Two unopened disposable dermal (skin) curette (medical instrument used to scrape or remove unwanted tissue/skin) with an expiration date of 03/01/2023. -One unopened Bard-[NAME] (brand) scalpel with an expiration date of 07/31/2022. Staff D stated that they were expired and that they should have been discarded. Staff D stated that the Unit Managers checked the medication storage rooms and that the staff that used the medical supplies should have checked the five rights, which included to check for expiration date. In an interview on 06/06/2025 at 1:18 PM, Staff B stated that they expected expired medical supplies to be disposed of. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 1 of 1 dry storage room (Kitchen Dry Storage Room), 3 of 4 refrigerators (Kitchen Cooler A Refrigerator, Kitchen Cooler H Refrigerator and Kitchen Cooler D Refrigerator), 1 of 1 seasoning shelf (Kitchen Seasoning Shelf) and 5 of 6 dining room refrigerators (500 unit, 300 unit, 100 unit, 600 unit & 700 unit), reviewed for food services. The failure to date and discard expired food items and/or before use by date, placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Infection Prevention and Control Program (IPCP) policies and procedures were reviewed annually as required, failed to handle a urinary catheter (a semi-flexible tube inserted into the bladder to drain urine) drainage bag appropriately for 1 of 2 residents (Resident 1), and failed to disinfect/sanitize medical equipment between resident use for 1 of 2 staff (Staff I), reviewed for infection control. In addition, the facility failed to ensure Enhanced Barrier Precautions (EBP-precaution to protect residents from Multidrug-Resistant Organism [MDRO-a germ that is resistant to medications that treat infections]) practices were followed for 2 of 8 residents (Residents 77 & 219). These failures placed the residents, staff, and visitors at an increased risk of infection and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to inform a resident and/or their representative about risks and benefits of positioning a bed against the wall for 1 of 3 residents (Resident 93), reviewed for accidents. The failure to conduct an assessment, evaluation and/or providing information regarding bed positioning prevented the resident and/or their representative to exercise their right to make an informed decision.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident choices/preferences regarding shower/bathing were honored for 2 of 3 residents (Residents 41 & 10), reviewed for Activities of Daily Living (ADLs). This failure placed the residents at risk of being unable to exercise their rights, not having their choices/preferences honored, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy and confidentiality of medical information were maintained during a medical provider visit for 2 of 3 residents (Resident 42 & 51), reviewed for confidentiality of records. This failure placed the residents at risk for having their medical and personal information not kept confidential and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation for 1 of 2 residents (Resident 101), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.

Inspectors wroteBased on interview and record review, the facility failed to timely complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS-an assessment tool) for 1 of 3 residents (Resident 76), reviewed for SCSA. This failure placed the residents at risk for delayed care planning, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess 3 of 20 residents (Residents 1, 97 & 90), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments for oral/dental status, medications, and hospice care (support for end-of-life care) placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. [...]

Inspectors wroteRESIDENT 101 Review of a face sheet printed on 06/02/2025, showed Resident 101 admitted to the facility on [DATE]. Review of Resident 1's Level I PASARR dated 02/12/2025 showed that Section IV (Service Needs and Assessor Data) was marked No level II evaluation indicated at this time due to exempted hospital discharge. Level II must be completed if discharge does not occur. Review of the census tab in the EHR printed on 06/02/2025, showed Resident 101's status was active. In an interview and joint record review on 06/02/2025 at 2:21 PM, Staff F, Social Worker, stated that if a resident was marked for hospital exempted discharge on their Level I PASARR that was completed prior to their admission, they would have to complete a new Level I PASARR if the resident was in the facility for more than 30 days. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the State PASARR (Pre-admission Screening and Resident Review-an assessment used to identify people [resident] referred to nursing facilities with Serious Mental Illness [SMI], intellectual disabilities [ID], or related conditions are not inappropriately placed in nursing facility for long term care) Coordinator after a significant change in condition for 3 of 8 residents (Residents 76, 1 & 10), reviewed for PASARR. This failure placed the residents at risk for unmet mental health services necessary to obtain the resident's highest level of psychosocial well-being and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were revised timely and accurately to reflect changes in care related to discontinuation of hospice (a service that provides quality of life care for chronic conditions) services, initiation of comfort care or end-of-life care, and/or discontinuation of medication for 3 of 7 residents (Residents 76, 90 & 1), reviewed for care planning. These failures placed residents at risk for unidentified and unmet care needs, and a diminished quality of life. RESIDENT 76 Review of a face sheet printed on 06/02/2025 showed Resident 76 was readmitted to the facility on [DATE]. Review of a nursing progress note dated 06/12/2025 showed Resident 76 was admitted to hospice services on 06/12/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was an ongoing activity program to meet the needs of 1 of 1 resident (Resident 95), reviewed for activities. This failure placed the residents at risk for unmet activity pursuit, social isolation, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform skin evaluations, implement appropriate monitoring and treatment after sustaining a skin injury, and/or failed to monitor and obtain daily weights for a resident on diuretic (water pill) therapy in accordance with professional standard of practice for 2 of 7 residents (Residents 21 & 98), reviewed for quality of care. These failures placed the residents at risk for unmet care needs and diminished quality of life. Findings Included . SKIN INJURY RESIDENT 21 During an observation and interview on 06/02/2025 at 10:43 AM, Resident 21 had two scabs (a dry protective) on their left knee and another two scabs on their right shin. Resident 21 stated that their skin injuries occurred due to a fall and that they were not receiving treatment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a prescribed therapeutic diet of small, portioned meals for 1 of 3 residents (Resident 36), reviewed for nutrition/hydration. This failure placed the resident at risk for unintended weight loss, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage and labeling of respiratory equipment, and document oxygen (O2) saturation (the amount of O2 in the blood) for 1 of 3 residents (Resident 98), reviewed for respiratory care. These failures placed the resident at risk for respiratory infection, related complications, and a diminished quality of life. Findings Included . Review of the facility's undated policy titled, Oxygen Administration, showed that during O2 setup or adjustment, staff were instructed to check the mask, tank, humidifying (that increase humidity/moisture in the air) jar [container], to ensure they were in good working order and securely fastened. The policy further instructed staff to document the date and time the setup was performed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders were followed and/or clarified in accordance with professional standards of practice for 3 of 9 residents (Residents 16, 321 & 219), reviewed for medication administration. This failure placed the residents at risk for receiving incorrect medication dosage and formulation, adverse side effects, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dental services were offered and/or provided for 1 of 1 resident (Resident 36), reviewed for dental services. This failure placed the resident at risk for unmet dental care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meal preferences were provided for 2 of 7 residents (Residents 35 & 10), reviewed for food preferences. This failure placed the residents at risk of not having their food choices honored, dissatisfaction with food served, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure clinical or medical records were complete and accurate for 1 of 3 residents (Resident 118), reviewed for resident records. The failure to document resident health condition (assessment and evaluation) placed the resident at risk for incomplete and inaccurate medical records and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pneumococcal vaccine (used to prevent pneumonia [a lung infection]) and influenza vaccine (used to prevent influenza [an infection of the nose, throat, and lungs]) were offered for 1 of 5 residents (Resident 54), reviewed for immunizations and infection control. This failure placed the residents at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from pneumococcal and influenza disease.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) was updated to include a contingency plan (to handle potential challenges or disruptions based on the findings from the facility assessment) and plans to maximize direct care staff recruitment and retention. This failure placed the residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary supervision for 1 of 3 residents (Resident 1), reviewed for elopement. The failure to provide the necessary supervision for Resident 1 resulted in an elopement and placed the resident at risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to provide timely and necessary assistance with Activities of Daily Living (ADL) for 2 of 3 residents (Residents 1 & 2), reviewed for ADLs. The failure to provide the residents who were dependent on staff with assistance with toileting, changing soiled clothing, and bed linens placed the residents at risk for skin impairments, low self-esteem, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in a manner that maintained and promoted dignity while entering a resident's room for 1 of 6 residents (Resident 34), use of urinary catheter (a flexible tube inserted into the bladder to drain urine) drainage bag for 2 of 3 residents (Residents 110 & 17), use of a mechanical lift sling for 1 of 1 resident (Resident 99), and meal assistance for 3 of 5 residents (Residents 99, 46 & 16) reviewed for dignity. These failures placed the residents at risk for a diminished self-worth and over-all well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to inform residents and/or their representatives of risks and benefits before placement of bed against the wall for 2 of 2 residents (Residents 73 & 74), use of tilt in space (a type of wheelchair that can lower the seated person's head and raises their feet at the same time) wheelchair for 1 of 1 resident (Resident 74), installation of a transfer pole for 1 of 2 residents (Resident 5), and prior to starting psychotropic (mind-altering) medications for 1 of 5 residents (Resident 99), reviewed for resident rights. These failures placed the residents at risk for not being fully informed before making decisions regarding their health care, alternative treatment options, and the right to refuse care.

Inspectors wroteBased on interview and record review, the facility failed to periodically review resident rights with residents during their stay at the facility for 16 of 16 residents (Residents 91, 6, 7, 10, 16, 20, 39, 42, 61, 63, 64, 78, 80, 100, 122 & 379) reviewed for resident rights. This failure placed the residents at risk of not understanding their rights and a reduced ability to self-advocate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the website address of the Washington State Long-Term Care Ombudsman (an advocacy group for residents in a nursing home) on the posted contact information in 7 of 7 facility areas (notice boards in units 100, 300, 400, 500, 600, 700, and inside of one elevator), reviewed for residents' rights. This failure placed the residents at risk for not being able to report their concerns online to the State Long-Term Care Ombudsman.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy and confidential information were maintained regarding residents' weights for 9 of 9 rooms (Rooms 306B, 308A, 312B, 305B, 203, 205, 302B, 303A & 307B), and failed to ensure residents' medical records and representatives' information were maintained for 4 of 5 residents (Residents 67, 17, 16 & 100), reviewed for privacy. These failures placed the residents at risk for having their medical and personal information not kept confidential and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment when residents were served their meals on trays for 2 of 6 dining rooms (100 Unit Dining Room & 500 Unit Dining Room), reviewed for dining observations. This failure placed the residents at risk for a less than homelike environment and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS- an assessment tool) was completed timely for 4 of 23 residents (Residents 86, 14, 90 & 99), reviewed for significant change in condition. This failure placed the residents at risk for delayed care planning, further Activities of Daily Living (ADL) decline, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive care plans for 5 of 23 residents (Residents 73, 74, 120, 95 & 39), reviewed for care plans. The failure to develop care plans for bed against the wall, tilt-in space (a type of wheelchair that can lower the seated person's head and raises their feet at the same time) wheelchair, bed enablers (bed rails)/halos (type of bed rail shaped like a ring), and vision 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 foods were handled appropriately in accordance with professional standards of food safety for 2 of 3 walk-in kitchen refrigerators (Produce Walk-in Refrigerator & Dessert Walk-in Refrigerator), for 1 of 1 dry storage room, for 1 of 3 resident refrigerators (100 Unit Resident Refrigerator), for 1 of 1 kitchen, for 2 of 2 dining rooms (400 Unit Dining Room and 100 Unit Dining Room), and for 1 of 7 units (600 Unit) reviewed for food service. The failure to label, date, and discard food items, sanitize thermometers between use, and perform hand hygiene placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store clean linens appropriately for 1 of 7 units (200 Unit) and failed to ensure hand hygiene practices and/or proper use of gloves were followed before, during, and after resident care and with meals trays for 6 of 7 staff (Staff CCC, LLL, ZZ, S, TT & V), reviewed for infection control. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light (an alerting device for staff to assist residents in need) was within reach for 1 of 2 residents (Resident 115), reviewed for accommodation of needs. This failure placed the resident at risk for delayed care, accidents/falls, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure an advance directive (a written instruction, such as a living will or durable power of attorney for health care) was obtained from the resident and/or their representative and ensure a copy was readily available in the medical records for 1 of 3 residents (Resident 120), reviewed for advance directives. This failure placed the resident and/or their representative at risk for losing their right to have their preferences honored to receive care according to their choice.

Inspectors wroteBased on interview and record review, the facility failed to ensure bed-hold notices were provided at the time of transfer to the hospital for 1 of 3 residents (Resident 71), reviewed for hospitalization. This failure placed the resident at risk of lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 2 of 27 residents (Residents 14 & 99), reviewed for Minimum Data Set (MDS - an assessment tool). The failure to ensure accurate hospice and medication coding placed the residents at risk for unidentified or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representatives were invited to participate in care plan meetings/care conferences for 2 of 2 residents (Residents 89 & 42), reviewed for care planning. This failure placed the residents at risk for not having input regarding care goals, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) assistance were consistently provided for 2 of 8 residents (Residents 89 & 81), reviewed for ADLs. This failure placed the residents at risk for poor hygiene, decreased self-esteem, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident environment remained free from accident hazards for 2 of 2 offices (Transitional Care Unit [TCU]/Resident Care Manager] RCM] office and the office next to the TCU/RCM office), reviewed for accident hazard. This failure placed residents at risk for avoidable accident and/or injury and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with urinary catheters (a flexible tube inserted into the bladder to drain urine) received appropriate care and services for 2 of 3 residents (Residents 110 & 17), reviewed for urinary catheter. The failure to ensure urinary catheters were off the floor placed the residents at risk for infections and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure tube feeding (a medical device used to provide nutrition into the stomach if resident is unable to swallow safely) supplies (tubing set) including the irrigation syringe were labeled/dated for 1 of 2 residents (Resident 4), reviewed for tube feeding management. This failure placed the residents at risk for infection and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided according to professional standards of practice for 1 of 1 resident (Resident 90), reviewed for respiratory care. The failure to have an oxygen administration order, maintain, label/date, and properly store oxygen nasal cannula (flexible tubing that sits inside the nose and delivers oxygen) properly placed the resident at risk for unmet care needs, respiratory infections, and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to comprehensively assess and evaluate the need for bed rails for 1 of 3 residents (Resident 95), reviewed for bed rail use. This failure placed the resident at risk for entrapment, injury, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) had the appropriate competencies, skills set and proficiencies to apply a condom catheter (external flexible tube that is used to collect urine from the body) for 1 of 5 nursing staff (Staff S), reviewed for competent nursing staffing. This failure placed the resident at risk for infection, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed the total number of staff and actual number of hours worked for each shift for 1 of 7 days reviewed for posted nurse staffing information. This failure placed the residents and residents' representatives at risk of not being fully informed of the current staffing levels.

Inspectors wroteBased on interview and record review, the facility failed to ensure monthly pharmacy recommendations were followed up on for 2 of 5 residents (Resident 90 & 57), reviewed for unnecessary medications. This failure placed the residents at risk of receiving unnecessary medications, medication-related adverse consequences, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard expired medication for 1 of 4 medication carts (Unit 200 Medication Cart), reviewed for medication storage. This failure placed the resident at risk to receiving expired or compromised medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer/serve food substitutes and/or serve food that accommodated preferences for 1 of 2 residents (Resident 35), reviewed for food preferences. This failure placed the resident at risk for dissatisfaction with food, weight loss, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct routine maintenance to ensure bed rails and/or halos (type of bed rail shaped like a ring) were safe for 3 of 5 residents (Residents 35, 95 & 74), reviewed for bed rails safety. This failure placed the residents at risk for injury and/or entrapment.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services consistent with professional standards of practice for 1 of 3 residents (Resident 1), reviewed for quality of care. The failure to monitor hypoglycemia (low blood glucose [a measurement of the amount of glucose (sugar) in the blood] and hyperglycemia (high blood glucose level) placed the resident at risk for unmet care needs and negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure suction machines (a medical device to remove secretions [mucus/saliva/blood] obstructing a person's airway) were functioning properly, and medical crash cart (easily accessible supplies/equipment for life saving procedures) were stocked for 6 of 6 nursing units (Transitional Care, 100 Unit, 400 Unit, 500 Unit, 600 Unit & 700 Unit), reviewed for essential equipment. This failure placed Resident 1 and other residents at risk for choking, unmet care needs, and other medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove outdated food from the residents' refrigerator on the 700 Unit and failed to ensure food stored in the dietary's walk-in coolers were labeled, dated when first opened and/or discarded after the expiration date. In addition, the facility failed to ensure food items were covered when non-food items were stored in the walk-in cooler. These failures placed the residents at risk for food borne illness (caused by ingestion of contaminated food or beverages) and a diminished quality of life.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure a medication error rate was less than 5% for the 27 medication administrations for 4 of 9 residents (Residents 111, 72, 95 & 33) reviewed for medication administration. The facility's medication error rate was 14.18%. This failure placed the residents at risk of experiencing adverse side effects, ineffective medication, and potential negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired liquid supplements, medical ointments, and wound treatment supplies were disposed of timely in accordance with current accepted professional standards of practice for 3 of 3 medication storage rooms (Medication Storage Rooms in Unit 700, 400 & Memory Care) reviewed for medication storage and labeling. In addition, the facility failed to ensure no food items was stored in the medication storage refrigerator in the Memory Care Medication Storage. These failures placed the residents at risk of receiving compromised medical supplements, treatment supplies, food snacks, and possibly experience adverse side effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 of 2 residents (Residents 33 & 45) had been assessed for the self-administration of medication. The facility's failure to assess the residents for self-administration of medications placed the residents at risk for the improper administration of the medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely reporting of potential abuse to appropriate entities as required for 1 of 2 residents (Resident 32) reviewed for abuse. This failure placed the resident at risk for abuse and neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were consistently receiving showers/grooming services for 2 of 3 residents (Residents 432 and 50) reviewed for Activities of Daily Living (ADLs). This failure placed the residents at risk for poor hygiene, medical complications, and a diminished quality of life.

Inspectors wroteBased on observations, interview and record review, the facility failed to consistently monitor nutrition and/or provide interventions as needed to prevent weight loss for 1 of 3 residents (Residents 54) reviewed for nutrition and weight loss. Resident 54 experienced a significant weight loss of 5.1 percent (%) in 1 month and 14.68% in 6 months. This failure placed the resident at risk for continued weight loss, worsened nutritional status and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident received adequate assessment and monitoring for the use of CPAP (Constant Positive Airway Pressure) machine for 1 of 1 resident (Resident 432) reviewed for respiratory care and services. In addition, there was no order for the use of the CPAP machine, and no monitoring and/or maintenance of the CPAP machine to ensure proper usage. These failures placed the resident at risk for respiratory infection, unmet care needs, and potential negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to provide risks and benefits of taking a psychotropic (psychoactive - mind altering) medication when there was a change in dosage for 1 of 1 resident (Resident 111) reviewed for unnecessary medications. This failure placed the resident at risk for unnecessary psychotropic medication, adverse side effects, and a diminished quality of life.