Washington Senior Living

Inspectors wroteBased on interview and record review the facility failed to remove a staff member from resident care after an allegation of abuse. This failure has the potential to affect all 84 residents who currently reside in the facility. The Facility's Abuse Prevention Program dated 10/2022 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of good and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. The Facility's Abuse Prevention Program dated 10/2022 documents The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered. [...]

Inspectors wroteBased on interview and record review the facility failed to recognize an incident as an allegation of abuse and failed to thoroughly investigate a bruise of unknown origin for one resident (R1) of three residents reviewed for abuse. The Facility's Abuse Prevention Program dated 10/2022 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of good and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. The Facility's Abuse Prevention Program dated 10/2022 documents The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered. [...]

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse to the State Reporting Agency and the family for one resident (R1) of three residents reviewed. The Facility's Abuse Prevention Program dated 10/2022 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of good and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. The Facility's Abuse Prevention Program dated 10/2022 documents The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to post grievances/complaints procedures in a prominent location throughout the facility. This failure has the potential to affect all 67 residents residing in the facility.

Inspectors wroteBased on Interview and Record Review, the facility failed to ensure that direct resident care staffing was adequate to meet the needs of residents in the facility. This failure has the potential to affect all 67 residents residing in the facility.

Inspectors wroteBased on interview, observation and record review the facility failed to provide and offer snacks throughout the day and evening for all residents in the facility. This failure has the potential to affect all 67 residents residing in the facility.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to ensure the main kitchen and serving kitchen's refrigerated food items and dry food items were labeled, dated and free from expiration, the facility's dish machine chemicals were tested daily to ensure effective sanitation levels, cool down temperatures were taken for food items cooked ahead and then stored in the refrigerator, and that a fan utilized at meal times and blown towards prepared food was kept clean and without dust and debris. This failure has the potential to affect all 67 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident room floors were clean and free of debris for four of four residents (R8, R10, R16, R36) reviewed for clean and homelike environment in the sample of 48.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a call light was in reach for three of 18 residents (R14, R36, and R54) reviewed for call lights in the sample of 48.

Inspectors wroteBased on Interview and Record Review, the facility failed to ensure residents were provided information on Advance Directives and ensure that a POLST (Physician's Order for Life Sustaining Treatment) and emergency code status were documented in the resident's medical record for three of four residents (R46, R77, R78) reviewed for Advanced Directives in the sample of 48.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to document an appropriate diagnosis, provide justification for a failed gradual dose reduction (GDR), and identify and monitor targeted behaviors to warrant the use of Seroquel (antipsychotic medication) and for one of one resident (R39) reviewed for antipsychotic medications in the sample of 48.

Inspectors wroteBased on record review and interview, the facility failed to obtain a level II PASRR (Pre-admission Screening and Resident Review) for three of five residents (R3, R55, and R69) reviewed for pre-admission screenings in the sample of 48.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to ensure a resident's independent smoking assessment was accurate and smoking materials were not kept in the resident's possession when not in use, and ensure a dependent resident was provided assistance of two staff members during a mechanical lift transfer, for two of four residents (R46, R55) reviewed for accidents in the sample of 48.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure indwelling urinary catheter tubing and the collection bag were positioned below the level of the bladder and remained off the floor for one of two residents (R49) reviewed for indwelling urinary catheters in the sample of 48.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen tubing/humidification and a nebulizer mask, canister, and tubing was dated, changed every seven days, and placed in a bag when not in use and ensure an order was in place for oxygen for three of three residents (R27, R50, and R78) reviewed for respiratory care in a sample of 48.

Inspectors wroteBased on observation, interview and record review the facility failed to properly store urine-soiled resident clothing in a bag during incontinence care for one resident (R14) and failed to follow Contact Isolation Precautions and don appropriate PPE/Personal Protective Equipment before manipulating an indwelling urinary catheter collection bag for one resident (R49) of 18 residents reviewed for infection control procedures in the sample of 48 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to educate residents on what a grievance is, provide grievance forms, and provide a clear and noticeable destination for grievances to be submitted. This failure has the potential to affect all 63 residents who reside in the facility. Findings Include:The Filing Grievances/Complaints policy dated 12/2004 documents Our facility will assist residents, their representatives (sponsors), other interested family members, or resident advocates in filing grievances or complaints when such requests are made. The Ombudsman Program Residents' Rights Booklet (undated) documents Your personal property rights. You have the right to keep and wear your own clothing. Your facility must try to keep your property from being lost or stolen. If your property is missing, the facility must try to find it. [...]

Inspectors wroteBased on interview and record review the facility failed to notify the Residents Family/Representative promptly of a change of condition for one of three residents (R1) reviewed for injury of unknown origin in the sample of three.

Inspectors wroteBased on interview and record review the facility failed to promote an environment free of inappropriate staff behavior and failed to provide respect and dignity for residents. This failure has the potential to affect all 79 residents residing in the Facility.

Inspectors wroteBased on interview and record review the facility failed to conduct a thorough abuse investigation for two of four residents (R1 and R2) reviewed for abuse and failed to protect residents from further potential abuse. This failure has the potential to affect all 79 Residents residing in the Facility.

Inspectors wroteBased on interview and record review the Facility failed to notify Resident Physicians and Resident Representatives for an Abuse incident for two of four Residents (R1 and R2) reviewed for notification of change in a sample of four.

Inspectors wroteBased on interview and record review the Facility failed to protect one of four Residents (R1) from a Resident Perpetrator (R2) reviewed for abuse in the sample of four.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse to the local State Agency for two of four residents (R1and R2) reviewed for Abuse in a sample of four.

Inspectors wroteBased on interview and record review the facility failed to immediately report an allegation of misappropriation of funds to the State Agency and the administrator and immediately report an allegation of sexual abuse to the State Agency one of three residents (R1) reviewed for Abuse in the sample of three.

Inspectors wroteBased on interview and record review the facility failed to investigate an allegation of abuse for one of three residents (R1) reviewed for investigation of abuse in the sample of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure mechanical lift transfers were safely completed for one (R2) of three residents reviewed for falls in the sample of nine.

Inspectors wroteBased on observation, interview, and record review the facility failed to report a potential allegation of abuse to the State Agency for one (R1) of three residents reviewed for abuse in the sample of eight.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify and investigate a potential allegation of abuse for one (R1) of three residents reviewed for abuse in the sample of eight.

Inspectors wroteBased on interview and record review, the facility failed to investigate thoroughly and protect (by not removing the male CNA/Certified Nurse Aid) pending an investigation for one (R4) of three residents reviewed for abuse in a sample of seven.

Inspectors wroteBased on observation, interview and record review the facility failed to provide daily sanitation of the facility and resident rooms during outbreaks of respiratory and gastrointestinal viruses. This failure has the potential to affect all 76 residents in the facility.

Inspectors wroteBased on Observation, Interview and Record Review the facility failed to prevent neglect of a cognitively impaired, high fall risk resident for one of three residents (R1) reviewed for neglect in the sample of five. This failure resulted in R1 lying on a cold, hard floor for an undetermined amount of time and was found to be cold with a shivering body appearance and chattering teeth in the early hours of the morning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a routine cleaning schedule for the kitchen, document or have an expiration date for bread, keep the floor and steamer oven clean, store food off the floor, keep sanitization logs for the dishwasher, and keep freezer/cooler/refrigerator temperature logs. These failures have the potential to affect all 73 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to have a procedure to reduce the risk of Legionella in the facility's water system. This failure has the potential to affect all 73 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation of COVID-19 staff vaccinations, screening, offering, or education. This failure has the potential to affect all 73 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete thorough fall investigations for three (R15, R48, and R49) residents of eight residents reviewed for falls in the sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility's survey results, including previous five years, were readily and easily accessible to residents for review. This failure has the potential to affect all 73 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to document in the resident's Electronic Medical Record or provide written notification to the resident/resident representative, of the reason for emergent hospital transfer/discharge. This failure has the potential to affect all 73 residents residing at the facility. Findings Include: Facility's Transfer and Discharge Policy (Undated) documents: Policy: To assure resident transfers and discharges will be conducted in accordance with residents' rights, physician's orders, and in such a manner as to maintain continuity of care for the resident. Facility's Notice of a Transfer or Discharge Policy (Undated) documents: Our facility shall provide a resident and/or the resident's representative (sponsor) with appropriate notice of an impending transfer or discharge. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of the Bed Hold Policy notification to residents/residents' representatives for emergent hospital transfer/discharge. This failure has the potential to affect all 73 residents residing in the facility. Findings Include: Facility's Bed Hold Policy Notification (Undated) documents: This Bed Hold Policy will be given to you at the time of admission and a copy will be given to you each time you are transferred from the facility. Under normal circumstances, if you leave the facility for a hospitalization, you will be readmitted to the first available bed in a semi-private room. Facility's Transfer and Discharge Policy (Undated) documents: Policy: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the nurse staffing posting was completed daily, included the total nursing hours worked and failed to retain 18 months of the posting. This failure has the potential to affect all 73 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident (R2) from sexual abuse by another resident (R1) and failed to ensure a resident (R4) was free from physical abuse by another resident (R3) with a known history of verbal and physical aggression for two of four residents reviewed for abuse in a sample of six. This failure resulted in R3 verbally yelling and physically slamming his door on R4's hand. R4 sustained bleeding lacerations and fractures to three fingers on R4's right hand which required hospitalization evaluation where 12 sutures were placed to R4's fingers; further surgical intervention is pending. These failures have the potential to affect R4 and other dementia residents residing in the facility. This failure resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the required in-service training was completed for Certified Nursing Assistants/CNA. This failure has the potential to affect all 61 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their Abuse Prevention Program to protect residents from repeated physical abuse for one (R4) of four residents reviewed for abuse in the sample of six.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of resident-to-resident verbal and physical abuse for two (R3 and R4) of four residents reviewed for abuse in a sample of six.

Inspectors wroteBased on interview and record review the facility failed to investigate a potential allegation of resident-to-resident verbal and physical abuse for two (R3 and R4) of four residents reviewed for abuse in a sample of six.

Inspectors wroteBased on interview and record review the facility failed to provide a copy of the bed hold policy for residents transferring to the hospital for one (R3) of three residents reviewed for bed holds in the sample of six. Findings Include: The facility's undated Bed Hold Policy documents, There may be instances when a Facility Resident leaves the Facility for medical or therapeutic reasons. If the Resident pays the Facility to hold the bed open, the Facility guarantees availability of a bed on Resident's return to the Facility. In such cases, Facility may be able to re-admit Resident to the same room and bed, but this is not assured. The facility's Transfer and Discharge Policy, dated March 2014, documents, Policy: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to serve food at a palatable and appetizing temperature. These failures have the potential to affect all 68 residents residing within the facility.

Inspectors wroteBased on record review and interview, the facility failed to notify a resident's representative of a significant change in condition for 1 of 3 (R1) residents reviewed for Improper Nursing Care.

Inspectors wroteBased on interview and record review the facility failed to allow a resident readmission to the facility; initiate the required Involuntary Discharge Documents which include evidence the resident was a danger to the facility upon his return; and failed to assist the resident in finding an alternate, suitable placement. This affected one resident (R1) of three residents (R3, R4) reviewed for Transfer and Discharge.

Inspectors wroteBased on record review and interview the facility failed to offer bedtime snacks to six of 18 residents (R6, R19, R50, R54, R65, R130) reviewed for bedtime snacks in the sample of 27.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a call light was in reach for three residents (R31, R55, and R280) out of 18 residents reviewed for call lights in the sample 27.

Inspectors wroteBased on record review and interview the facility failed to obtain a level II PASARR (Pre-admission Screening and Resident Review) evaluation for one of one resident (R6) reviewed for no level II PASARR with the diagnosis of a mental illness in the sample of 27.

Inspectors wroteBased on interview and record review, the facility failed to complete and implement gradual dose reductions (GDR) while continuing psychotropic medication for one (R61) of three residents reviewed for psychotropic medications in a sample of 27.

Inspectors wroteBased on observation, interview and record review the facility failed to wear hairnets while in the kitchen around food and clean dishes. This failure could affect all 76 residents who currently reside in the facility. Findings Include: The Facility's Hair Restraints policy dated 2020 documents Hair restraints shall be worn by all Dining Services staff when in food production areas, dishwashing areas, or when serving food. Hair restrains, hats, and/or beard guards shall be used to prevent hair from contacting exposed food, Facial hair is discouraged. Any facial hair that is longer the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. On 12/20/23 at 8:50 AM V10 (Cook) was standing in the kitchen. V10 did not have a hat, head covering or hair restraint of any sort on. V10 stated I try to always remember to put a hair net on. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store medications for two residents (R13, R14) during a routine medication pass. Findings Include: The Facility's Storage of Medications policy dated 10/27/2014 documents, (This Pharmacy) dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers. Nurses may not transfer medications from one container to another or return partially used medication to the original containers. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. On 12/20/23 at 9:00 AM V6 (Registered Nurse) opened the top of her medication cart and there was a clear medication cup full of medicines. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's bed was free from debris and an eating container for one (R4) of three residents reviewed for comfortable living environment in a sample of three.

Inspectors wroteBased on interview and record review, the facility failed to prevent a fall, and failed to provide immediate transfer to emergent medical care for one (R1) of three residents reviewed for accidents/hospital transfers in a sample of three. This failure resulted in R1 being hospitalized with left hip fracture.