9 CMS Surveys
Inspection Report — Dec 29, 2025
Date: Dec 29, 2025
Visit Reason
The inspection was conducted to investigate the facility's compliance with providing appropriate treatment and care according to medical orders, resident preferences, and goals, specifically related to a failure in timely care for a resident with a change in condition.
Findings
The facility failed to ensure timely care and treatment for Resident 1 who sustained an acute hip fracture during transport to dialysis. There was a significant delay in processing a STAT x-ray order and notifying the medical provider of the fracture, resulting in the resident being sent to dialysis instead of the hospital. The report documents multiple staff interviews confirming the failure to notify the provider promptly.
Deficiencies (1)
F 0684 - The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals, resulting in delayed diagnosis and notification of an acute hip fracture for one resident. This failure placed residents at risk for harm and diminished quality of life.
Report Facts
Residents reviewed for accidents and injury: 3
Residents affected: 1
Hours delay for STAT x-ray completion: 33
Hours delay for order confirmation: 4.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Assistant Director of Nursing | Stated expectations for immediate notification of medical provider upon x-ray results and described communication failures |
| Staff C | Licensed Practical Nurse | Evening shift nurse who received x-ray report but did not notify medical provider |
| Staff D | Licensed Practical Nurse | Night shift nurse who was not informed of fracture and described expected notification procedures |
| Staff A | Director of Nursing | Provided statements on investigation findings and expectations for STAT x-ray and notification procedures |
| Nurse Practitioner | Assessed resident, ordered STAT x-ray, and described expectations for notification and follow-up |
Inspection Report — Apr 21, 2025
Routine
Date: Apr 21, 2025
Visit Reason
The inspection was a routine survey to assess compliance with state and federal regulations related to resident care, safety, and facility operations.
Findings
The facility was found to have multiple deficiencies including failure to obtain resident consents for vaccinations, psychotropic medications, and safety devices; failure to thoroughly investigate and resolve resident grievances; failure to provide timely notifications for resident transfers and bed-hold rights; inaccurate resident assessments; delays and inaccuracies in PASRR evaluations; incomplete and untimely care plan updates and meetings; failure to meet professional standards in medication administration and resident care; medication errors; improper medication storage; inadequate infection control practices; and unsafe bed rail use. Some deficiencies were corrected on site, but many remained open.
Deficiencies (19)
F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. The facility failed to obtain resident consent for vaccinations, psychotropic medications, and safety devices for multiple residents. Consent forms were missing or incomplete, and resident representatives were not properly notified.
F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. The facility failed to thoroughly investigate and resolve grievances for residents reporting missing personal items, resulting in unresolved concerns and resident frustration.
F 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. The facility failed to notify the State Long-Term Care Ombudsman and provide written transfer/discharge notices to residents or representatives for multiple hospitalizations.
F 0625 Notify the resident or the resident's representative in writing how long the nursing home will hold the resident's bed in cases of transfer to a hospital or therapeutic leave. The facility failed to provide timely written bed-hold notices and obtain resident or representative signatures for multiple residents.
F 0641 Ensure each resident receives an accurate assessment. The facility failed to accurately assess multiple residents' cognitive, dental, vision, behavioral, and discharge status, placing residents at risk for unmet needs.
F 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. The facility failed to timely complete required Level 2 PASRR evaluations for multiple residents, delaying identification of mental health care needs.
F 0645 PASARR screening for Mental disorders or Intellectual Disabilities. The facility failed to accurately complete PASRR assessments and follow up on Level 2 referrals for multiple residents, risking inappropriate placement and unmet mental health needs.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. The facility failed to update care plans to reflect current resident needs and failed to provide care plan meetings for several residents.
F 0658 Ensure services provided by the nursing facility meet professional standards of quality. The facility failed to follow or clarify physician orders, monitor medication effects, follow up on outside provider recommendations, and provide appropriate care for multiple residents.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. The facility failed to provide timely podiatry services and appropriate foot care for multiple residents with diabetes and foot problems.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. The facility failed to assess and implement interventions to prevent accidents related to smoking for one resident.
F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. The facility failed to ensure medical justification and discontinuation plans for indwelling catheters for one resident.
F 0692 Provide enough food/fluids to maintain a resident's health. The facility failed to ensure consistent, timely weights and follow Registered Dietician recommendations for one resident and failed to offer and provide hydration services to two residents.
F 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. The facility failed to ensure clinical justification for dose increases, adequately monitor, and attempt GDRs for psychotropic medications for multiple residents.
F 0759 Ensure medication error rates are not 5 percent or greater. The facility failed to properly administer 5 of 25 medications for 3 residents observed during medication pass, resulting in a 20% medication error rate.
F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. The facility failed to remove discontinued medications from medication carts and medication room and failed to secure medications at bedside for one resident.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. The facility failed to ensure dishwasher sanitizer levels were adequate and staff failed to report inadequate sanitation, placing residents at risk for foodborne illness.
F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. The facility failed to maintain complete and accurate records for multiple residents including missing podiatry consults and incomplete documentation.
F 0880 Provide and implement an infection prevention and control program. The facility failed to ensure staff performed hand hygiene before and after resident care, properly labeled and contained personal care items, administered medications while maintaining infection control, and wore masks appropriately.
Report Facts
Medication error rate: 20
Weight loss: 14.2
Weight loss percentage: 6.25
Edema assessment: 3
Inspection Report — Mar 22, 2024
Complaint Investigation
Date: Mar 22, 2024
Visit Reason
The inspection was conducted based on complaints and observations regarding failure to develop and implement person-centered comprehensive care plans for certain residents, insufficient nursing staff to meet residents' needs, and failure to provide timely assistance with toileting and call light response.
Complaint Details
The investigation was triggered by complaints and observations about inadequate care planning for residents 30, 226, and 71, and insufficient nursing staff leading to delayed call light responses and unmet care needs. Multiple resident interviews, grievance forms, call light reports, and staff interviews documented these issues. The complaint was substantiated with findings of deficient care planning and staffing.
Findings
The facility failed to develop and implement complete care plans for three residents, including discharge planning and intervention implementation. The facility also had insufficient nursing staff, resulting in delayed call light responses and unmet care needs for multiple residents. Observations and interviews confirmed these deficiencies, placing residents at risk for negative health outcomes.
Deficiencies (2)
F 0656 - The facility failed to develop and implement a complete care plan that meets all the resident's needs, including discharge planning and timely interventions, for 3 of 21 residents reviewed. This placed residents at risk for inconsistent and unmet care needs and increased anxiety.
F 0725 - The facility failed to provide enough nursing staff daily to meet residents' needs, resulting in delayed toileting assistance and call light responses, and failure to provide restorative nursing programs as ordered for some residents.
Report Facts
Residents affected by care plan deficiency: 3
Residents affected by staffing deficiency: 8
Residents affected by restorative nursing program deficiency: 3
Call light response times: 44
Call light response times: 39
Call light response times: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff NN | Certified Nursing Assistant | Observed providing care to Resident 30 despite care plan specifying female staff only |
| Staff L | Chief Nursing Officer | Stated male CNA should not be assigned to Resident 30 as per care plan |
| Staff O | Social Services Director | Confirmed discharge care plans were not developed for Residents 226 and 71 |
| Staff J | Certified Nursing Assistant | Stated restorative aide was responsible for applying splint to Resident 55 |
| Staff C | Assistant Director of Nursing | Acknowledged restorative aides were sometimes pulled from duties and expected call lights to be answered timely |
| Staff KK | Certified Nursing Assistant | Reported staffing was inconsistent and night shift was short-staffed |
| Staff MM | Registered Nurse | Reported working night shift and staying over due to staffing conflicts |
| Staff N | Licensed Practical Nurse | Reported responsibility for residents on two halls and staffing shortages |
| Staff B | Director of Nursing | Expected call lights to be answered within 15 minutes and acknowledged night shift call light delays |
Inspection Report — Mar 17, 2024
Routine
Date: Mar 17, 2024
Visit Reason
The inspection was a routine survey of North Auburn Rehab & Health Center to assess compliance with healthcare facility regulations, including resident care, safety, and administrative requirements.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, personal funds security, advance directive assistance, beneficiary notification, environmental conditions, grievance investigations, discharge notifications, care planning, medication administration, restorative nursing, accident prevention, respiratory care, dialysis communication, staffing adequacy, dental care, dietary services, and medication storage. Several residents' care plans and assessments were inaccurate or incomplete, and staff failed to provide timely assistance and follow-up on ordered treatments and services.
Deficiencies (26)
WAC 388-97-0180 - The facility failed to provide care and services that ensured privacy and dignity for residents, including failure to document refusals to wear clothes and assist with toileting, placing residents at risk for diminished rights and self-worth.
WAC 388-97-0340(6) - The facility failed to ensure residents' personal funds in trust accounts were fully covered by a surety bond, placing residents at risk of loss of funds.
WAC 388-97-0280(3)(c)(i-ii) - The facility failed to ensure residents were informed and assisted in formulating Advance Directives, placing residents at risk for loss of rights and preferences regarding end-of-life care.
WAC 388-97-0300(1)(e),(5),(6) - The facility failed to provide Skilled Nursing Facility Notice of Medicare Non-coverage to a resident, risking loss of appeal rights.
WAC 388-97-0880 - The facility failed to maintain a safe, clean, and homelike environment, including failure to repair walls, eliminate overhead paging, maintain window coverings, and provide sufficiently warm water temperatures.
WAC 388-97-0460 - The facility failed to initiate and complete grievance investigations for residents, including lost property and environmental noise complaints, risking resident frustration and diminished quality of life.
WAC 388-97-0120(1)(2) - The facility failed to notify the Office of the State Long-Term Care Ombudsman of resident hospital transfers for multiple residents, preventing advocacy and education opportunities.
WAC 388-97-0120(4) - The facility failed to provide written notice of bed hold policy and document resident or representative decisions regarding bed hold for multiple residents.
WAC 388-97-1000(3)(b) - The facility failed to identify the need for and complete a Significant Change in Status Assessment for a resident with a significant decline in condition.
WAC 388-97-1000(1)(b) - The facility failed to complete accurate Minimum Data Set assessments for multiple residents, including inaccurate feeding tube data and vision impairment coding.
WAC 388-97-1915(1)(2)(a-c) - The facility failed to revise PASARR screenings to reflect mental health changes and complete required Level 2 evaluations for residents with serious mental illness.
WAC 388-97-1020(2)(c)(d) - The facility failed to develop complete care plans within 7 days of assessment and failed to conduct care plan meetings for several residents, resulting in inaccurate care plans and lack of resident involvement.
WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i) - The facility failed to clarify physician orders for pain medications, measure orthostatic blood pressures as ordered, and follow medication parameters, placing residents at risk for unmet care needs and adverse outcomes.
WAC 388-97-1060(2)(c) - The facility failed to provide assistance with activities of daily living including oral hygiene and nail care for dependent residents, resulting in poor hygiene and diminished dignity.
WAC 388-97-1060(1) - The facility failed to provide appropriate treatment and care according to orders for skin conditions and self-medication administration, including delayed ultrasound and improper insulin injection site rotation.
WAC 388-97-1060(3)(a) - The facility failed to assist a resident in gaining access to vision services and did not provide timely eye care despite documented vision impairment and resident complaints.
WAC 388-97-1060(3)(b) - The facility failed to provide appropriate pressure ulcer care and prevent new ulcers by not setting an air mattress to the ordered pressure setting.
WAC 388-97-1060(3)(d) - The facility failed to provide restorative nursing programs including splinting to maintain or improve range of motion for residents with contractures.
WAC 388-97-1060(3)(g) - The facility failed to identify, assess, and implement interventions to prevent accidents related to smoking, use of bolster air mattress, and wander guard alarm monitoring, placing residents at risk for injury and elopement.
WAC 388-97-1900(1),(6)(a-c) - The facility failed to ensure ongoing communication and collaboration with the dialysis center regarding resident dialysis treatment and post dialysis paperwork, resulting in incomplete documentation and potential unmet care needs.
WAC 388-97-1080(1) - The facility failed to provide timely assistance with call light response and toileting for multiple residents, with documented delays up to 44 minutes, and insufficient staffing to meet resident needs.
WAC 388-97-0960(1) - The facility failed to provide medically-related social service interventions addressing resident refusals of therapy and medications, resulting in early termination of skilled care and unmet care needs.
WAC 388-97-1300(1)(b)(ii),(c)(ii-iv) - The facility failed to ensure expired medications were disposed of timely and controlled pain medications were properly secured in the medication room.
WAC 388-97-1200(1) - The facility failed to ensure residents received prescribed therapeutic diets, serving incorrect desserts to residents on Consistent Carbohydrate diets.
WAC 388-97-1100(3),-2980 - The facility failed to store and prepare food under sanitary conditions, including failure to label opened food, maintain handwashing supplies, clean extractor fans, and properly handle food brought from outside the facility.
WAC 388-97-1620(2)(a)(b)(i),-0180(1-4) - The facility failed to ensure the arbitration agreement was signed by the resident's Durable Power of Attorney for financial affairs as required, risking forfeiture of resident rights.
Report Facts
Call light response time: 44
Expired medications: 10
Expired medications: 13
Expired medications: 30
Expired medications: 30
Expired medications: 37
Expired medications: 15
Narcotic pain medications: 21
Weight: 242
Ultrasound delay: 134
Inspection Report — Dec 14, 2023
Enforcement
Date: Dec 14, 2023
Visit Reason
The inspection was conducted due to a serious failure in staff response to a resident requiring CPR, resulting in an Immediate Jeopardy situation affecting multiple residents with CPR directives.
Findings
The facility failed to ensure staff performed CPR on a resident with a physician order and signed POLST for full code status, placing 38 other residents at risk. The Immediate Jeopardy was removed after the facility corrected the deficiencies by auditing records, educating staff, performing CPR drills, and implementing a plan of correction.
Deficiencies (1)
F 0678 - The facility failed to provide basic life support including CPR to a resident with a full code order, did not locate the resident's POLST form in an emergency, and staff did not follow CPR directives, resulting in Immediate Jeopardy to resident health and safety.
Report Facts
Residents with CPR directives: 38
Total residents in facility: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse | Named in finding for not performing CPR on Resident 1 despite full code status |
| Staff A | Interim Director of Nursing | Provided interview confirming staff expectations and corrective actions |
Inspection Report — Aug 30, 2023
Complaint Investigation
Date: Aug 30, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide pharmaceutical services that meet the needs of residents, including medication administration and reconciliation.
Complaint Details
The complaint investigation focused on medication administration failures for Residents 1, 2, 3, and 5. Resident 1 did not receive heart medications on admission day and was discharged with incorrect medication without proper review. Resident 2 missed insulin and other medications with no documentation explaining omissions. Resident 3 had medications not administered without explanation. Resident 5 received wrong anti-coagulant medication and had multiple missed doses. Documentation and reconciliation failures were noted throughout. The complaint was substantiated by these findings.
Findings
The facility failed to ensure pharmacy services met residents' needs for 4 of 5 residents reviewed, including failure to administer medications on admission day, reconcile medications accurately, and properly manage medication storage and disposition. Documentation was lacking for omitted doses, and medications were dispensed incorrectly or without proper orders, placing residents at risk for medication errors and diminished quality of care.
Deficiencies (1)
F 0755 - The facility failed to provide pharmaceutical services to meet the needs of residents, including ensuring medications were administered on admission day, reconciling pharmacy deliveries accurately, and properly managing medication storage and disposition.
Report Facts
Medications dispensed: 30
Medications not administered: 3
Medications scheduled: 7
Inspection Report — Jul 14, 2023
Complaint Investigation
Date: Jul 14, 2023
Visit Reason
The inspection was conducted due to complaints and grievances raised by residents regarding the facility's smoking policy enforcement, grievance handling, and allegations of neglect and mistreatment.
Complaint Details
The complaint investigation focused on grievances from multiple residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, and 23) and Resident Councils (RC1 and RC2). Issues included failure to provide smoking accommodations, unresolved grievances about care, food, environment, and staff behavior, and failure to report and investigate allegations of abuse and neglect. Resident 1 experienced psychological harm due to denied smoking requests and self-harm. The grievance system was largely nonfunctional, with many grievances unlogged or unresolved. The facility failed to report multiple allegations to the State Agency and did not conduct thorough investigations.
Findings
The facility failed to ensure residents' rights to self-determination regarding smoking, did not properly notify or assess residents for smoking privileges, and lacked a safe designated smoking area. The grievance system was ineffective, with many grievances uninvestigated, unresolved, and not properly logged. The facility also failed to timely report and investigate allegations of abuse, neglect, and mistreatment, placing residents at risk for harm and diminished quality of life.
Deficiencies (3)
F 0561 - The facility failed to honor residents' rights to self-determination and support resident choice by not providing a safe designated smoking area and failing to notify residents of the smoking policy on admission, causing psychological harm to residents.
F 0585 - The facility failed to implement an effective grievance policy, resulting in unacknowledged, undocumented, and unresolved grievances from residents regarding care, food, environment, and staff behavior.
F 0610 - The facility failed to respond appropriately to alleged violations by not timely reporting or thoroughly investigating allegations of abuse, neglect, misappropriation, and mistreatment reported through grievances.
Report Facts
Grievance entries: 29
Grievance entries: 15
Residents affected by grievances: 23
Residents affected by abuse/neglect allegations: 6
Days delay: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Social Services Director and Grievance Officer | Named in findings related to failure to follow up on smoking policy assessments and grievance system failures |
| Staff A | Administrator | Named in interviews regarding grievance backlog and failure to ensure timely reporting and investigation |
| Staff D | Assistant Director of Nursing | Named in investigation of Resident 1's self-harm incident and reporting failures |
| Staff E | Social Services Assistant | Named in observation of staff smoking area and resident notification procedures |
| Staff B | Director of Nursing | Named in interview regarding assumptions about incident reporting |
Inspection Report — May 26, 2023
Complaint Investigation
Date: May 26, 2023
Visit Reason
The inspection was conducted to investigate deficiencies related to the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing in residents, based on observations, interviews, and record reviews of five sampled residents with pressure ulcers.
Complaint Details
The investigation focused on 5 residents with pressure ulcers, revealing systemic failures in wound care management, documentation, and care planning. Interviews with staff confirmed lack of awareness and inconsistent practices. The complaint was substantiated by multiple findings of inadequate care and documentation.
Findings
The facility failed to implement its policies for pressure ulcer prevention and treatment, including inadequate monitoring, documentation, care planning, and implementation of physician orders. Weekly skin evaluations and wound assessments were frequently missed or incomplete. Several residents had unhealed or worsening pressure ulcers, and the facility did not consistently follow wound care protocols or update care plans accordingly. The deficiencies placed residents at risk for delayed healing, infection, pain, and diminished quality of life.
Deficiencies (1)
F 0686 - The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for 5 of 5 sampled residents. Failures included lack of routine skin monitoring, incomplete care plans, failure to implement physician orders, and inadequate wound evaluation and documentation.
Report Facts
Residents sampled for pressure ulcer review: 5
Wound measurements: 13.5
Wound measurements: 10
Wound measurements: 3
Wound measurements: 2
Wound measurements: 2
Wound measurements: 2.5
Inspection Report — Dec 1, 2022
Immediate Jeopardy
Date: Dec 1, 2022
Visit Reason
The inspection was conducted to evaluate compliance with state and federal regulations related to resident care, safety, infection control, medication management, and facility environment.
Findings
The facility was cited for multiple deficiencies including failure to maintain emergency exit doors operable and connected to fire alarm system, inadequate infection control practices including hand hygiene and sanitizer availability, medication errors and supply shortages, failure to provide adequate nutrition and accommodate dietary preferences, failure to provide timely and coordinated medical and dental care, inadequate care planning and follow-up for significant changes in condition, and failure to ensure resident rights and dignity. Immediate Jeopardy was identified related to life safety code violations with emergency exit doors and unsafe food preparation and service practices. The facility took corrective actions during the survey to remove the immediate jeopardy.
Deficiencies (23)
Life Safety Code - Emergency Exit Doors (EE) 2 and 3 on east side of building were locked and non-functional for over 7 days, disconnected from fire alarm system, and lacked staff supervision during fire alarm testing and normal operation, placing residents at risk for injury or death in emergency.
IFC 1008.1 (2018) - Facility failed to maintain emergency exit doors free of locks or latches requiring special knowledge or equipment, violating federal life safety code and fire marshal orders.
WAC 388-97-1060(3)(b) - Facility failed to provide weekly skin assessments and wound care documentation for Resident 6, and wound vac supplies were unavailable, risking wound deterioration and infection.
WAC 388-97-1060(2)(c) - Facility failed to monitor and provide grooming and hygiene care including nail and hair care for Resident 46, who had long facial stubble and nails, with no documented preferences or orders.
WAC 388-97-1260(3)(a) - Facility failed to ensure timely nephrology referral and daily weight monitoring for Resident 45 with worsening kidney disease and fluid overload, resulting in avoidable hospitalizations and acute kidney injury.
WAC 388-97-1020(1),(2)(a)(b) - Facility failed to develop and implement individualized care plans reflecting current resident needs for Residents 12, 27, 45, 49, 51, 6, 42, 65, and 22, including care for transfers, nutrition, medication monitoring, and fall prevention.
WAC 388-97-1060(3)(k)(ii) - Resident 51 did not receive prescribed antidepressant and pain patch medications for multiple days due to facility medication supply shortages.
WAC 388-97-1060(3)(k)(ii) - Resident 23 missed administration of prescribed constipation medication and topical pain gel due to unavailable medications; medication documented as given when not administered.
WAC 388-97-1300(1)(b)(ii),(2) - Medication room refrigerator temperatures frequently exceeded 41°F and expired medications and supplies were stored in medication room, medication carts, and emergency crash carts.
WAC 388-97-1060(3)(h) - Facility failed to provide required supervision during meals for residents with swallowing difficulties (Residents 24, 40, 42, 46, 66), resulting in risk for choking and aspiration.
WAC 388-97-1100(1) - Facility failed to accommodate religious dietary preferences for Resident 52 who did not eat pork or beef but was repeatedly served bacon and beef.
WAC 388-97-1160(1)(a)(b)(c)(iii-iv), -1180(1), -1200(1)(2) - Facility failed to prepare and serve food according to prescribed modified diets and thickened liquid consistencies for Residents 40, 42, and 66, serving inappropriate food textures and liquids.
WAC 388-97-1620(1) - Facility administration failed to ensure effective and sustainable Quality Assurance and Performance Improvement (QAPI) program with no documented PIPs or prior QAPI records, impacting quality of care.
WAC 388-97-1060(3)(k)(i) - Facility failed to ensure medication administration hand hygiene compliance; staff observed administering medications without hand hygiene before and after.
WAC 388-97-1060(3)(b) - Facility failed to ensure wound care staff used gloves properly and documented weekly skin assessments for Resident 41 and Resident 6; wound care supplies were unavailable.
WAC 388-97-1320(1)(a)(c), (5)(a) - Facility failed to maintain hand sanitizer dispensers in working order and adequately stocked throughout the facility, limiting staff hand hygiene opportunities.
WAC 388-97-1620(1) - Facility administration failed to act promptly to repair emergency exit doors and ensure wound care supplies and linens were available, resulting in resident safety risks and care deficiencies.
WAC 388-97-1060(3)(b) - Facility failed to provide adequate assistance and supervision to prevent falls for Residents 35, 42, 51, and 20, failed to update care plans and implement fall interventions after multiple falls.
WAC 388-97-1060(3)(h) - Facility failed to provide required supervision and assistance during meals for Residents 24, 40, 42, 46, 66, resulting in risk of choking and aspiration.
WAC 388-97-1060(3)(f) - Facility failed to conduct interdisciplinary team assessments to evaluate continued need for feeding tube for Resident 40 who was able to eat orally with supervision.
WAC 388-97-1620(3)(a) - Facility failed to ensure timely laboratory testing for Residents 51, 49, and 32, delaying monitoring and treatment of medical conditions.
WAC 388-97-1340(1)(2) - Facility failed to offer and document pneumococcal vaccinations per CDC guidelines for Residents 34, 32, 51, and 49, placing residents at risk for vaccine-preventable illness.
WAC 388-97-1780(1)(2)(a)(i)(b) - Facility failed to educate and offer COVID-19 vaccinations to Residents 51 and 49 per guidelines, and failed to document vaccination status and refusals.
Report Facts
Medication error rate: 11.54
Weight loss: 23.3
Weight gain: 72
Weight gain: 37
Weight loss: 88
Weight loss: 6.9
Weight loss: 6.53
Weight loss: 5.98
Weight loss: 14
Weight loss: 23.3
Medication administration missed: 53
Medication administration missed: 24
Medication administration missed: 16
Medication administration missed: 12
Medication administration missed: 8
Medication administration missed: 7
Medication administration missed: 6
Medication administration missed: 3
Medication administration missed: 2
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