Wellspring Health & Rehabilitation of Cascadia

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure medications were labeled with open and discard dates, individual insulin syringes were labeled with the resident's name, expired medications were disposed of and not made available, and unknown pill left in pill cup on the medication cart for two of two medication carts (200 hall and 300/500 hall) reviewed. This had the potential to cause medication errors, adverse medication reactions, and residents to receive suboptimal therapeutic actions of medications.

Inspectors wroteBased on observation, resident interview, staff interview, and record review, it was determined the facility failed to: 1. a. protect residents who had tested negative for COVID-19 and had a roommate who tested positive for COVID-19 from continuing to be exposed by their cohort and, b. ensure infection control measures were implemented and executed in accordance with professional standards of practice for hand hygiene and use of personal protective equipment (PPE) to prevent the spread of COVID-19. These failures placed the 84 residents currently residing in the facility in immediate jeopardy of serious illness, harm, impairment, or death due to the increased risk of contracting COVID-19. 2. provide COVID-19 vaccinations to every resident who requested vaccination. This was true for 1 of 5 residents whose vaccination records were reviewed. [...]

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure a person who received nutrition through an enteral tube received the appropriate treatment to prevent complications. This was true for 1 of 2 residents (Resident #85) whose records were reviewed for the use of enteral feeding tubes. This failure harmed Resident #85 and placed other residents who used enteral feeding tubes at risk for feeding tube complications.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained in a sanitary manner. These deficiencies had the potential to affect 69 of 80 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on review of the glucometer calibration documentation, policy review and staff interview, it was determined facility failed to ensure glucometers were calibrated to maintain accuracy, ensure reliability, and ensure correct results for 2 of 4 halls (100 Hall and 200 Hall) whose glucometer were reviewed. This deficient practice had the potential for a higher risk for improper blood sugar monitoring of residents who required blood glucose monitoring.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure grievances were promptly resolved and ensure all written grievance decisions included the date of the grievance, a summary of the resident's grievance, a summary of the findings, a statement as to whether the grievance was confirmed or not confirmed, corrective action taken as a result of the grievance, and the date the decision was issued. Specifically, the facility failed to ensure grievances about call lights, voiced by residents during resident council were documented, investigated, resolved, and followed up on by the facility. This failure had the potential to placed residents at risk of ongoing frustration and decreased self-worth, as well as, unmet care needs, when issues of concern to them were not promptly addressed by the facility.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to notify the physician of a significant change in weight loss. This deficiency had the potential to affect 1 of 1 resident (Resident #50) whose record was reviewed for timely physician notification. This placed the resident at risk of experiencing complications related to unexpected weight changes.

Inspectors wroteBased on record review, policy review and staff interview, it was determined the facility failed to ensure investigation of allegation of verbal abuse and medication errors were thoroughly investigated. This was true for 2 of 2 residents (#44 and #81) reviewed for abuse and neglect. This failure created the potential for harm due to lack of an investigation.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to develop and implement comprehensive resident-centered care plans. This was true for 2 of 22 residents (#26 and #74) whose care plans were reviewed. These failures placed residents at risk of negative outcomes if services were not provided, or provided incorrectly, due to a lack of information in their care plan.

Inspectors wroteBased on observation, record review, policy review and staff interviews, it was determined the facility failed to ensure residents' incontinence care were met. This was true for 1 of 2 residents (Resident #4) reviewed for incontinence care. This deficient practice placed Resident #4 at risk for experienced embarrassment, isolation, decreased sense of self-worth, skin impairment, and compromised physical and psychosocial well-being.

Inspectors wroteBased on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure physician orders for the maintenance of supplemental oxygen, ensuring respiratory equipment was changed, and documenting treatment outcomes were followed. This was true for 2 of 6 residents (#48 and #231) reviewed for supplemental oxygen use and respiratory care. This placed residents at risk for respiratory infections when the supplemental oxygen and nebulizer tubing and humidifier bottle were not dated when changed, and treatment outcomes were not documented.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure residents who were offered and consented to the pneumococcal and influenza vaccine, received the vaccines. This was true for 3 of 5 residents (Resident's #52, #64, and #73) whose records were reviewed for pneumococcal and influenza vaccinations. This failure created the potential for residents to have an increased risk of contracting pneumococcal (bacterial) pneumonia and influenza.

Inspectors wroteBased on observation, policy review, guardian and staff interview, it was determined the facility failed to respect a resident's dignity and individuality when staff did not dress the resident in her personal clothing. This was true for 1 of 15 residents (Resident #39) who were reviewed for dignity. This created the potential for psychosocial harm if a resident experienced embarrassment or a lack of self-esteem due to being observed in a hospital gown.

Inspectors wroteBased on record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated. This was true for 2 of 15 residents (#18 and #44) whose care plans were reviewed. This created the potential for harm if cares and/or services were not provided appropriately due to inaccurate information on the care plans.

Inspectors wroteBased on observations, record review, policy review, activity calendar review, and resident representative and staff interview it was determined the facility failed to ensure a resident was provided with activities that met the individual needs of 1 of 3 residents (Resident #39) reviewed for activities. This failure created the potential for residents to experience boredom and a lack of stimulation.

Inspectors wroteBased on observation, record review, policy review, resident and staff interview, it was determined the facility failed to ensure residents received appropriate care to prevent skin breakdown. This was true for 2 of 4 residents (#10 and #39) reviewed for skin breakdown. This failure created the potential for harm if residents developed pressure ulcers and skin breakdown.

Inspectors wroteBased on record review, policy review, and resident and staff interviews, it was determined the facility failed to ensure effective pain management was provided for 1 of 4 residents (Resident #44), reviewed for pain. This failure created the potential for harm should residents not receive effective pain management.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure appropriate hand hygiene was performed. This was true for 2 of 15 residents (#33 and #39) reviewed for infection control practices. This deficient practice created the potential for harm if residents experienced infections from cross contamination.

Inspectors wroteBased on record review, policy review and staff interview, it was determined the facility failed to ensure the daily nurse staffing information was posted daily and per shift and only included the licensed and unlicensed nursing staff directly responsible for residents' care. Additionally, the facility failed to maintain the posted daily nurse staffing hours information for a minimum of 18 months.