University Place Nursing and Rehabilitation Center

Inspectors wroteBased on observations and staff interviews, the facility failed to remove a dented can located on shelf ready for use and failed to reseal and label and date leftover food items stored for use. These practices occurred in 1 of 1 walk-in freezer and 1 of 1 dry storage room and had the potential to affect food served to residents.

Inspectors wroteBased on observations, record review, resident, staff, and Nurse Practitioner interviews the facility failed to protect a resident's right to be free from abuse when Resident #23 hit Resident #96 in the face with a closed fist resulting in a slightly swollen area to the outer aspect of Resident #96's left eye. This affected 1 of 8 residents (Resident #96) reviewed for resident-to-resident abuse.

Inspectors wroteBased on observations, staff interviews, and record reviews the facility failed to remove expired medications stored in 1 of 4 medication carts (Garden City).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to implement their policy for hand hygiene when Nurse #3 failed to perform hand hygiene during medication administration after handling medication bottles and dispensed pills into her bare hand before placing the pills in a medicine cup. In addition, the facility failed to implement their policy for enhanced barrier precautions (EPB) when Nurse Aide (NA) #3 failed to wear personal protective equipment (PPE) during a high contact care activity that included transferring Resident #122 who had a chronic wound and an indwelling urinary catheter and when NA #3 and NA #4 transferred Resident #117 who had an indwelling urinary catheter. This was for 3 of 5 staff members observed for infection control practices (Nurse #3, NA #3 and NA #4).

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain accurate records related to documentation of treatment to a pressure ulcer for 1 of 3 residents reviewed for accurate medical records (Resident #110).

Inspectors wroteBased on observations, record review, and staff, Resident Representative, Physician Assistant and Pharmacist interviews, the facility failed to ensure a resident was free of significant medication errors when they failed to administer a daily dose of Cenobamate (seizure medication) from 9/05/24 through 9/18/24. Resident #1 was observed having a mild seizure (eyes rolled back and upper body twitching that lasted approximately 2 minutes) on 9/18/24. This deficient practice occurred for 1 of 3 residents reviewed for medication errors. (Resident #1)

Inspectors wroteBased on record review, and staff interviews, the facility failed to accurately document the administration of 14 doses of a seizure medication in the medical record for 1 of 1 resident reviewed for accurate medical records (Resident #1).

Inspectors wroteBased on record review, and resident, staff, and Physician Assistant interviews the facility failed to dispose of a plastic bag that had been used to crush medications for Resident #24 and the plastic bag ended up on Resident #23's breakfast tray. Resident #23 believed the crushed white substance was powdered sugar and sprinkled it on his breakfast. This affected 1 of 5 residents reviewed for medication errors.

Inspectors wroteBased on observations, a resident interview, interviews with staff and record review, the facility failed to provide food in a form to meet the individual needs of a resident with a physician order for a regular diet with mechanical soft texture (Resident #19). This failure occurred for 1 of 3 sampled residents reviewed for mechanically altered diets.

Inspectors wroteBased on observations, a resident interview, interviews with staff and record review, the facility failed to provide a resident scrambled eggs for breakfast per his preference. This failure occurred for 1 of 3 sampled residents reviewed for food intolerances and preferences (Resident #19).

Inspectors wroteBased on observation, record review, staff interviews, the facility failed to safely assist a resident without causing injury to 1 of 3 residents (Resident #1) reviewed for accidents. Resident #1 was documented to be transferred by a lift and was assisted by Nurse Aide #1 alone.

Inspectors wrote2. Resident #3 re-admitted to the facility on [DATE]. Review of Resident #3's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #3 was cognitively intact with no psychosis, behaviors, or rejection of care. Review of Resident #3's medical record revealed no documentation that Resident #87 had been assessed to self-administer medications. Further review of Resident #3's medical record revealed no care plan for self-administration of medications. An observation of Resident #3 completed on 05/29/24 at 10:17 AM revealed her to be in her room, sitting in her wheelchair watching television. On Resident #3's overbed tray was a bottle of antacid chewable tablets. Additional observations made on 05/29/24 at 12:50 PM, 2:44 PM, and 3:00 PM all revealed the antacid chewable tablets remained on Resident #3's overbed table. [...]

Inspectors wroteBased on record review, observations, and Resident Representative (RR) and staff interviews the facility failed to provide nail care for 2 of 3 dependent residents reviewed for activities of daily living (ADL) (Resident #4 and Resident #5).

Inspectors wroteBased on record review, facility activity calendar, and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 4 of 5 residents reviewed for activities (Resident #17, 31, 35, and 110). The residents expressed not being able to leave the facility for over a year made them feel more dependent, less social, sad, and they missed getting out with the group to shop and socialize.

Inspectors wrote3. Resident #84 was admitted to the facility on [DATE] with diagnoses of dementia, schizophrenia, and anxiety. The most recent annual Minimum Data Set assessment dated [DATE] indicated Resident #84 was not currently considered by the state level II PASRR process to have serious mental illness. Review of Resident #84's electronic medical record revealed a Halted level II PASRR identification number noted in the demographic information. During an interview on 2/29/24 at 3:34 PM MDS Coordinator #1 indicated it was the responsibility of the MDS coordinator to enter PASRR information onto the MDS assessment at admission and annually. She further indicated she initially understood Resident #84's PASRR to be halted and therefore Resident #84 was not considered to have a level II PASRR determination. [...]

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to provide sufficient nursing staff to ensure resident were administered medications per the physician orders for 8 of 16 residents reviewed for significant medication errors (Residents #7, #28, #47, #51, #73, #79, #88, and #110) and provide assistance with showers and hair washing for 1 of 10 residents reviewed for assistance with activities of daily living (Resident #94).

Inspectors wroteBased on record reviews, and family member, staff, and Medical Director interviews, the facility failed to prevent significant medication errors when Nurse #9 administered medications to Resident #83 prescribed for Resident #30 which included Lasix (fluid pill), Ativan (a medication used to treat anxiety, Seroquel (an antipsychotic), Celexa (an antidepressant), and Diltiazem (used to treat cardiac disorders). The facility also failed to prevent significant medication errors when medications were not administered as ordered by the physician. This deficient practice affected 9 of 16 residents reviewed for significant medication errors (Resident # 83, #7, #28, #47, #51, #73, #79, #88, and #110.) .

Inspectors wroteBased on observations, staff interviews, and record review the facility failed to record an open date on multi-dose insulin pens, failed to discard an expired insulin pen and failed to store unopened insulin pens in the refrigerator for 2 of 4 medication carts (Garden City Cart #1 and Arboretum Cart #2) which were reviewed for medication storage.

Inspectors wroteBased on observation and staff interviews, the facility failed to remove expired food items and unlabeled items which belonged to staff for 1 of 3 resident's nourishment rooms. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the focused infection control survey that occurred on 02/13/21, the recertification and complaint investigation surveys that occurred on 06/24/21 and 08/25/22. This failure was for three deficiencies that were originally cited in the areas of Accuracy of Assessments (F641), Food Procurement, Store/Prepare/Serve Food Under Sanitary Conditions (F812) and Infection Prevention and Control (F880) and were subsequently recited on the current recertification and complaint investigation survey of 02/29/24. The repeat deficiencies during multiple surveys of record show a pattern of the facility's inability to sustain an effective QA program.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to ensure staff implemented their handwashing/hygiene policy as part of their infection control policy when the Treatment Nurse did not perform hand hygiene and don clean gloves after cleaning two wounds with wound cleanser and one wound with normal saline and before applying treatment to the wounds for two residents (Resident #128 and Resident #43) and did not doff gloves, sanitize hands and don clean gloves after wound care and prior to touching the resident's (Resident #128) pillows and bedding. [...]

Inspectors wroteBased on observations, record reviews, resident, and staff interviews, the facility failed to provide the resident's preference of showers for 1 of 10 residents reviewed for activities of daily living (ADL) (Resident #49).

Inspectors wroteBased on record review and staff interviews the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed for resident with mental health diagnosis upon admission and residents with new mental health diagnoses for 3 of 6 residents (Resident# 141, #31, #49) reviewed for PASRR.

Inspectors wroteBased on record review, staff interviews, and observations the facility failed to revise a smoking care plan for Resident #75, resolve inactive care plans for Resident #51 and schedule quarterly care plan meetings (Resident #83) for 3 of 5 sampled residents.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to follow physician orders for 1 of 4 wounds (non-pressure of left knee) on 1 of 3 residents (Resident #128) reviewed for wound care and failed to administer medications as ordered by the physician for 2 of 16 residents reviewed for medication errors (Residents #28 and #110).

Inspectors wroteBased on observations, record reviews, resident, and staff interviews, the facility failed to provide showers and hair washing to 1 of 10 residents (Resident #94) and failed to provide incontinence care as trained for 1 of 10 residents (Resident #51). These failures occurred for 2 of 10 residents reviewed for activities of daily living (ADL).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to follow physician orders for 1 of 4 wounds (pressure ulcer of right outer ankle) on 1 of 3 residents (Resident #128) reviewed for wound care.

Inspectors wroteBased on record review and staff interviews the facility failed to complete a quarterly smoking assessment 1 of 3 residents reviewd for smoking (Resident #75).

Inspectors wroteBased on record reviews, family member and staff interviews, the facility failed to provide effective orientation to a new nurse when Nurse #8 failed to supervise Nurse #9 during medication administration resulting in a resident receiving the wrong medications. This deficient practice affected 1 of 1 resident reviewed for medication administration. (Resident #83).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to discard produce with signs of spoilage, remove expired food items and date leftover food stored ready for use in the walk-in cooler. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure garbage was contained in a closed dumpster and maintain a clean grease trap free of buildup.

Inspectors wroteBased on observations, record review and interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place on 12/27/19. This was for a deficiency in Accuracy of Assessments that was originally cited on the 11/22/19 recertification and complaint investigation survey. The QAA committee failed to maintain implemented procedures and monitor the interventions that the committee put into place on 07/19/21. This was for a deficiency in Food Procurement Store, Prepare, Serve, Sanitary that was originally cited on the 06/24/21 recertification and complaint investigation survey. The continued failure of the facility during three federal surveys showed a pattern of the facility's inability to sustain an effective QAA Program.

Inspectors wroteBased on observation, record review and interviews with residents and staff, the facility failed to provide access to control the light fixture behind the bed for 1 of 1 resident reviewed for accommodate of needs (Resident #96).

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to keep a sanitary environment in a shared bathroom for 2 of 2 residents reviewed for homelike environment (Residents #35 and #70).

Inspectors wroteBased on observation, record review and interviews with residents and staff, the facility failed to accurately code the Minimum Data Set (MDS) related to tobacco use for 3 of 3 residents reviewed for smoking (Resident #3, #138, and #139).