Washington Veteran Home-Retsil

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the safety of 2 out of 3 residents (Resident 1 and Resident 2) reviewed for the right to be free from abuse. This failure caused both Resident 1 and Resident 2 to sustain minor injuries at the hands of Resident 3 and placed other residents at risk for harm and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents with personal funds accounts had access to their accounts after business hours and on the weekends for 7 of 10 sampled residents (Resident 121, 135,15, 3, 232, 4 & 14) reviewed for personal funds accounts. This failure placed residents at risk of not having access to their accounts during non-banking hours, a decreased sense of autonomy and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a system that ensured copies of advanced directives (written instruction, such as a living will or durable power of attorney for health care) were requested from residents who indicated they had one, and/or to provide information and assistance to residents who expressed an interest in formulating one for 6 of 6 residents (Resident 105, 121, 135, 148, 10 & 232) reviewed for advanced directives. These failures placed residents at risk of not having their healthcare choices honored and/or detracted from residents' ability to have their healthcare preferences known.

Inspectors wroteBased on record review and interview, the facility failed to ensure psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) included adverse side effects and target behaviors were thoroughly documented and monitored, that as needed psychotropic medications limited to 14 days was reassessed, and Abnormal Involuntary Movement Scale (AIMS, a standardized, clinician-administered assessment designed to observe, quantify, and track involuntary movements in patients, especially those taking long-term antipsychotic medications) testing was completed within required timeframes for 4 of 5 sampled residents (Resident 19, 2, 121 & 13) reviewed for unnecessary medications. This failure placed residents at risk of unnecessary medication usage, increase in side effects without interventions, and a diminished quality of life.

Inspectors wroteBased on observation and interviews, the facility failed to have sufficient staff to ensure residents received timely call light responses during mealtimes. This failure placed residents at risk for accidents, injuries and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain proper refrigerator, freezer and dishwasher temperatures logs for 1 of 1 kitchen and 4 of 4 serveries (AC, ABCD, EG, EFGH serveries) and prevent contamination during meal preparation services for 1 of 1 serveries (AC) reviewed for food service safety. The failure to maintain documented refrigerator/freezer and dishwasher temperature logs and prevent cross contamination placed residents at risk of foodborne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal privacy was protected for 2 of 2 sampled residents (Residents 25 and 75) reviewed for resident rights. This failure placed the residents at risk for embarrassment, a violation of their privacy, and a diminished quality of life.

Inspectors wroteBased on record review and interview the facility failed to initiate a grievance for 1 of 2 sampled residents (Resident 215) reviewed for missing personal property. This failure placed the resident at risk of unmet needs, personal loss and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify allegations of abuse or neglect for 2 of 4 sampled residents (Resident 11 and 98) reviewed for abuse. This failure placed residents at risk for unidentified and repeated potential abuse, neglect, or mistreatment, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure minimum data set (MDS) assessments accurately reflected residents' health status and/or care needs for 1 of 34 sample residents (Resident 13) reviewed. The failure to accurately code resident active diagnoses, placed residents at risk for unidentified and unmet psychosocial and/or behavioral care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop, implement and/or ensure residents' comprehensive care plans accurately reflected care needs for 3 of 34 sampled residents (Resident 19, 13 & 4) reviewed for care plans. These failures placed residents at risk for unidentified and/or unmet care needs, medical complications and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 3 residents (Residents 4) reviewed for limited range of motion. Facility nurses demonstrated a pattern of falsely documenting the application of bilateral wrist splints, that were not applied. This failure resulted in a resident losing trust in assigned nursing staff and placed residents at risk of contracture formation/progression, loss of independence and/or increased dependence on staff and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide timely incontinent care for 1 of 2 residents (Resident 11) reviewed for activities of daily living (ADL) for dependent residents. This failure placed dependent residents at risk for skin breakdown, poor hygiene and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide bowel care in accordance with the facility's bowel protocol for 3 of 8 residents (Resident 3, 8 & 29) reviewed for bowel management. This failure placed residents at risk for nausea/vomiting, abdominal pain/discomfort, decreased appetite, and other negative health outcomes associated with untreated constipation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 3 residents (Residents 11) was consistently offered/received services to maintain or prevent declines in mobility when reviewed for range of motion (ROM). This failure placed the residents at risk of decreased motion, mobility and a diminished quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure non-pharmacological interventions (NPIs, non-medication interventions) were attempted prior to the administration of as needed (PRN) pain medications for 2 of 5 residents (Residents 2 & 121) reviewed for unnecessary medications. This failure placed residents at risk of unnecessary medication usage and a diminished quality of life. Resident 2 Resident 2 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 05/01/2026, documented Resident 2 was severely cognitively impaired and was able to make needs known. A physician's order, dated 03/23/2021, documented, Pain Non-Pharmacological Codes: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to thoroughly assess resident risk for elopement and provide the level of supervision required to prevent residents from eloping (exiting the facility without the required supervision) for 1 of 4 residents (Resident 1) reviewed for accidents. This failure placed residents at risk for inadequate supervision, elopement and potential of life-threatening situations.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegations of abuse/neglect/mistreatment for 1 of 6 residents (Resident 3) reviewed for allegations of abuse/neglect. Failure to thoroughly investigate the allegations of abuse/neglect placed the residents at risk for continued mistreatment, unmet needs, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the level of supervision required to prevent residents from eloping (exiting the facility without the required supervision) or attempting to exit the facility for 2 of 6 sampled residents (Resident 1 and 2) reviewed for accidents and failed to timely correct the wander guard system in place. These failures placed residents at risk of significant injury and a decreased quality of life. Review of the facility policy titled, Missing Resident/Elopement, dated 09/22/2023, showed that residents would be identified for risk of wandering and/or elopement and those at risk would be monitored and staff were to take necessary precautions to ensure resident safety. Resident 1 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow manufacturer's guidelines during the use of a mechanical lift and the lift sling for 2 of 3 residents (Residents 1, 5) reviewed for falls. The facility failed to assess, evaluate the root cause, and implement fall prevention interventions specific to resident needs for 4 of 6 sampled residents (Residents 1, 2, 3, and 4) reviewed for accidents. In addition, the facility failed to follow manufacturer instructions for routine, documented inspection of the mechanical lift slings. Resident 1 experienced harm when they sustained a hip fracture when transferred with a mechanical lift and sling in a manner inconsistent with the manufacturer instructions. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately assess Minimum Data Sets (MDS, an assessment tool) for 5 of 35 sampled residents (Resident 41, 42, 108, 74 &75) reviewed. The failure to ensure complete and accurate assessments regarding appropriate diagnoses, communication, nutrition and mobility placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Level I Preadmission Screening and Resident Reviews (PASRR) were complete and accurate for 4 of 7 sampled residents (Resident 69, 129, 150 & 78) reviewed for PASRR. This failure placed the residents at risk of unmet and unidentified care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were administered Covid vaccinations in a timely manner, informed consent was obtained (review risk/benefits), and/or physicians orders were followed for 6 of 35 sampled residents (Residents 78, 75, 167, 204, 132 & 108). These failures placed residents at risk of contracting disease, not understanding services consented for, and medical complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were screened on admission and/or during influenza season for influenza and/or pneumococcal vaccination and failed to obtain informed consent for vaccination for 5 of 5 residents (Residents 78, 75, 167, 204 & 132) reviewed for immunizations. This failure placed residents at risk of contracting disease, increased complications, not understanding services consented for, 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 promoted dignity for 1 of 1 sampled residents (Resident 184) reviewed for dining services and 1 of 3 sampled residents (Resident 74) reviewed for urinary catheter (thin tube to remove urine). The facility failed to honor resident rights related to privacy of personal mail and/or medical appointments for 2 of 4 residents (Resident 166 & 132) when reviewed for resident rights. These failures placed residents at risk for feelings of diminished self-worth, embarrassment and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident funds were transferred to the resident's representative or the resident's estate within 30 days of death or discharge, for 2 of 2 discharged residents (Resident 259 & 260) reviewed for trust accounts. This failure placed the residents and/or their representatives at risk for loss of funds and the interest accumulated.

Inspectors wroteBased on interview and record review, the facility failed to initiate, investigate, and resolve a grievance for 1 of 3 sampled residents (Residents 63) reviewed for grievances. This failure placed the residents at risk for emotional distress and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete care plans for 2 of 35 sampled residents (Resident 41 & 2) reviewed for care planning. The failure to ensure complete and accurate care plans regarding appropriate diagnoses, mobility and restorative programs, placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for 1 of 3 residents (Resident 166) reviewed for ADLs. Failure to provide oral care for Resident 166, who was dependent on staff for oral care, placed the resident at risk for unmet needs, poor hygiene and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure quality of care for bowel management for 1 of 6 residents (Resident 60) reviewed for bowel management, and services for 1 of 1 resident (Resident 132) reviewed for edema. These failures placed residents at risk of medical complications, delay in care and services, and a diminished quality of life.

Inspectors wrote2) Resident 27 was admitted to the facility on [DATE] with diagnoses of Bipolar disorder (a mental health condition characterized by significant shifts in mood, energy, and activity levels, ranging from periods of intense happiness or irritability (mania or hypomania) to periods of deep sadness or hopelessness (depression)), depression (a common mental health condition characterized by a persistent low mood, loss of interest or pleasure in activities, and other symptoms that can significantly interfere with daily life) and anxiety (a normal human emotion characterized by feelings of unease, worry, or fear, often about something that is about to happen or could happen in the future). Resident 27 required substantial assistance with most activities of daily living. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a Gradual Dose Reduction (GRD, progressively minimizes a patient's medication levels over time) was completed for 1 of 5 sampled residents (Resident 78) reviewed for unnecessary medications. The failure to complete a GDR placed residents at risk for overuse of psychotropic (mind altering) medication, health complications and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to maintain locked medication carts for 2 of 11 medication storage carts (Cart D and Cart G) when reviewed for medication storage. This failure placed the residents at risk for missing medications, medication discrepancies and impaired quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare and serve food to residents in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety. The failure to maintain documented dishwasher temperatures, to throw out expired/moldy foods and maintain sanitary conditions placed residents at risk of foodborne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff-maintained infection control practices by donning and doffing their Personal Protective Equipment (PPE) for 1 of 1 COVID (G2 Hall) unit and to correctly carry out hand hygiene by staff when reviewed for infection control. The facility also failed to perform urinary catheter (thin tube to remove urine) care per standards of practice for 2 of 2 residents (Resident 26 & 135) reviewed for catheter care observation. This failure placed residents at risk for the spread of infection and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to report to the state agency and log allegations of abuse/mistreatment by staff on the reporting log within five working days for 8 of 14 residents (1, 2, 3, 7, 8, 10, 14, & 15) reviewed for abuse and neglect. This failure placed residents at risk for repeated incidents, unmet care needs and unidentified abuse and/or neglect.

Inspectors wroteBased on interviews and record review, the facility failed to thoroughly investigate an allegation for 2 of 14 residents (3 & 7) reviewed for accidents. Facility failure to complete investigations placed residents at risk for ongoing neglect and abuse, unmet needs, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure interventions were consistently implemented and monitored for effectiveness for 1 of 3 residents (Resident 1) reviewed for accidents and hazards. This failure placed residents at risk for falls, injury and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor the efficacy for use of an indwelling urinary catheter (a small flexible tube inserted into the bladder to drain urine) for 1 of 3 sampled residents (1), reviewed for catheter use. This failure placed the residents at increased risk of a catheter associated urinary tract infections, pain, and urethral trauma.

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

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services as evidenced by information provided in Resident/Surveyor interviews for 7 residents (Residents 84, 389, 14, 6, 41, 184 & 67) interviewed, and 9 staff (Staff Q, R, J, K, L, M, N, O & P) interviewed. The facility had insufficient staff to ensure residents received assistance with restorative services, meal tray delivery times, and Activities of Daily Living (ADLs) including showers and shaving. Additionally, the aides from the Restorative Nursing Program (RNP) department were removed from restorative nursing duties to cover direct care staff absences resulting in the RNPs not being done for 3 of 3 residents (Residents 48, 97 & 102) reviewed for RNP. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer and/or honor bathing choices for 3 of 5 residents (Residents 97, 102 & 125) reviewed for choices. The failure to promote and facilitate resident self-determination by offering and honoring residents' choices related to bathing frequency, placed residents at risk for poor hygiene, feelings of powerlessness, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to thoroughly investigate 3 of 4 allegations of abuse, neglect and/or misappropriation for 2 of 2 residents (Residents 97 and 105) whose investigation were reviewed. The failure to establish a timeline of events, ensure all staff who were present, involved and/or had knowledge of alleged incidents were reviewed, and to implement identified interventions to prevent reoccurrence, placed residents at risk for unidentified and/or continued abuse, neglect, and/or misappropriation of their property.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to ensure a resident's ability to participate in activities of daily living did not diminish for 3 of 3 residents (Resident 97, 102 & 48) reviewed for rehabilitation and restorative services. The failure to provide restorative programs at the frequency residents were assessed to require, placed residents at risk for avoidable decline in activities of daily living (ADL), and increased dependence on facility staff to meet their ADL needs.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to maintain the highest practicable level of well-being for 5 of 7 residents (Residents 239, 91, 155, 175 & 82) reviewed for bowel management and 1 of 1 resident (Resident 125) reviewed for a fluid restriction. The failure to initiate bowel care in accordance with physicians' orders and to accurately document, total, and assess fluid intake, placed residents at risk for fluid and electrolyte imbalances, nausea/vomiting, pain/discomfort and other health complications related to untreated constipation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were safe from falls for 1 of 6 sampled residents (Residents 171) reviewed for accidents and hazards. This failure placed residents at risk for fall related injury and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were dated when opened when required and expired drugs and biologicals were discarded in accordance with currently accepted professional standards of practice for 2 of 4 medication carts (G2 & G1) and 2 of 3 medication rooms (G2/H2 & A2/B2) reviewed. Additionally, the facility failed to ensure medications were secured in locked storage for 2 of 2 residents (Resident 116 and 125) observed with medications at bedside. This placed residents at risk for accidentally taking another resident's medication and/or receiving expired/outdated medications and biologicals.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food at appetizing temperatures when reviewed for kitchen services. This failure placed residents at risk of lowered nutritional intake, potential weight loss, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and maintain a current hospice Plan of Care (POC) in collaboration with hospice, which identified what services were to be provided, and which delineated hospice versus facility responsibilities for 4 of 4 sampled residents (Resident 137, 118, 37 & 87) reviewed for hospice. This failure placed residents at risk for not receiving necessary care and services and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided in a respectful and dignified manner for 1 of 2 residents (Resident 87) reviewed for dignity. This failure placed residents at risk for being treated with a lack of dignity and respect and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to accurately assess 1 of 2 sample residents (Resident 137) reviewed for change of condition. This failure placed residents at risk for not receiving adequate and/or appropriate care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 4 of 52 sample residents (Residents 116, 97, 239 & 87) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 4 of 30 sample residents (Residents 239, 97, 116, 125) reviewed. Facility nurses' failure to obtain, accurately transcribe, follow, and clarify physician's orders when indicated, and to only sign for tasks that were completed, placed residents at risk for medication errors, delays in treatment, unmet care needs and potential negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure urinary catheter (a tube inserted into the bladder which drains urine into a collection bag outside the body) tubing and drainage bags were covered, appropriately positioned off the floor, below the level of the bladder, and in a manner to ensure unobstructed urine flow for 2 of 4 residents (Residents 164 & 116) reviewed for urinary catheter use. These failures placed residents at risk for catheter associated urinary tract infections, bladder pain and other medically related consequences.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure intravenous (IV) access devices were assessed, maintained and monitored in accordance with professional standards of practice for 1 of 1 resident (Residents 239) reviewed for IV therapy. The facility failed to ensure Peripherally Inserted Central Catheter (PICC/ a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) orders included direction to perform weekly PICC dressing changes, replace needleless injection caps, assess, and record external length upon admission/insertion and then weekly and as needed. Additionally, the facility failed to ensure nursing staff were trained and competent in the use of dial-a-flow infusion sets. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide consistent behavior monitoring for the use of psychotropic medications (affecting the mind) for 2 of 5 residents (Resident 175 and 82) reviewed for unnecessary medications and psychotropic medication side effects. Failure to develop target behaviors, adequately monitor the behaviors and interventions for effectiveness, and monitor changes in orthostatic blood pressures, placed the residents at risk for incorrect dose and duration of psychotropic medications, unwanted side effects, medical complications, and decreased quality of life.

Inspectors wroteBased on interviews and record reviews, the facility staff failed to notify a provider when moderate and severe medication interactions were alerted on new medication orders for 1 of 5 residents (Resident 1) reviewed for medications. This failure placed residents at risk for adverse impact on physical health and well-being and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain and provide a safe, sanitary, and homelike environment for 1 of 5 sampled residents (Resident 1) reviewed for homelike environment. This failure placed residents at risk for a diminished quality of life. Resident 1 was admitted to the facility on [DATE]. The Minimum Data Set (MDS), an assessment tool, dated 07/27/2023, documented Resident 1 had severe cognitive impairment, behaviors that interfered with care and was visually impaired. On 10/23/2023 at 2:27 PM, Collateral Contact (CC 1) said they had an ongoing concern regarding Resident 1's care. CC 1 said they frequently found the room smelled of urine and was messy with bagged, dirty laundry left on the floor. CC 1 said staff were to clean Resident 1's room when he was out for meals but they did not feel that was happening. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bathing and nail care was provided on a consistent basis for 1 of 5 residents sampled residents (Resident 1) dependent on staff assistance for activities of daily living (ADLs). This failure placed residents at risk for poor hygiene, unmet care needs and a diminished quality of life. Resident 1 was admitted to the facility on [DATE]. The Minimum Data Set (MDS), an assessment tool, dated 07/27/2023, documented Resident 1 had severe cognitive impairment, behaviors that interfered with care, was visually impaired and required extensive assistance for staff to complete bathing and personal hygiene activities. Resident 1's care plan, initiated 11/22/2019, documented Resident 1 was to receive a weekly shower on Mondays and nail care was to be completed on shower days. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents who experienced dementia-related sleep disorders and Sundown syndrome (late day/evening increase in behaviors) received care and services to attain the highest practicable physical, mental and psychosocial well-being when it did not identify and implement individualized, person-centered interventions, document the results of those interventions and consistently implement the care plan over time and across shifts for 3 of 4 residents reviewed for dementia care. These failures placed residents at risk for risk for unmet needs for non-medication interventions when behaviors increased, unnecessary medication and a diminished quality of life.