Deficiencies (last 3 years)
Deficiencies (over 3 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% worse than Washington average
Washington average: 6.3 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 12
Nov 15, 2024
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, care planning, medication management, safe environment, food safety, and staffing requirements at the nursing home.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights to share rooms, failure to inform residents of their rights, incomplete advanced directives, lack of timely transfer and bed hold notifications, incomplete care plans for PTSD, inconsistent implementation of bowel care protocols, unsafe environment related to recliner chairs and common area ovens, failure to post actual nurse staffing hours, failure to provide non-pharmacological interventions prior to pain medication, unsanitary food preparation and storage, and unclean wheelchair equipment.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Level of Harm - Potential for minimal harm: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure married residents were provided the right to share a room for 2 of 2 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to periodically inform residents of their rights after admission for 8 of 8 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to determine if a resident had current advanced directives and update accordingly for 1 of 4 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide written notification of reason for hospital transfer for 1 of 1 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide written bed hold notice at time of hospital transfer for 1 of 1 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop a comprehensive care plan addressing PTSD for 1 of 8 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to consistently implement bowel program when needed for 1 of 5 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a safe environment related to reclining chair and common area ovens for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to post actual nurse staffing hours for 11 of 11 months reviewed. | Level of Harm - Potential for minimal harm |
| Failed to initiate non-pharmacological interventions prior to administration of as needed pain medication for 1 of 5 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to sanitarily prepare food and monitor resident refrigerators for 1 of 2 resident refrigerators. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a sanitary piece of equipment (wheelchair armrest) was available for 1 of 2 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication administration count: 18
Medication administration count: 6
Months missing nurse staffing postings: 11
Days with no bowel movement: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator | Provided multiple interviews regarding facility policies and deficiencies |
| Staff B | Director of Nursing Services | Interviewed regarding care planning, bowel program, pain medication interventions, and recliner chair safety |
| Staff C | Social Services Coordinator | Interviewed regarding room sharing and PTSD care planning |
| Staff F | Staffing Coordinator | Interviewed regarding nurse staffing postings |
| Staff N | Dining Room Supervisor | Interviewed regarding kitchen sanitation and food storage |
| Staff E | Central Supply | Interviewed regarding wheelchair armrest repair |
| Staff Q | Maintenance Supervisor | Interviewed regarding common area ovens |
Inspection Report
Routine
Deficiencies: 3
Jan 8, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding medication monitoring, medication storage, and food safety in the facility.
Findings
The facility failed to adequately monitor residents for adverse side effects of anticoagulant medications, ensure proper labeling and dating of medications on medication carts, and serve meals at appropriate temperatures. These failures placed residents at risk for adverse health effects, compromised medication safety, and foodborne illness.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to adequately monitor for adverse side effects of anticoagulant medications for 2 of 5 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure drugs and biologicals were labeled, dated, or discarded in accordance with professional standards for 2 medication carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were served meals at appropriate temperatures. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for unnecessary medications: 5
Medication carts reviewed: 2
Residents affected by medication monitoring deficiency: 2
Residents affected by medication labeling deficiency: 2
Residents affected by food temperature deficiency: Some
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Resident Care Manager | Stated expectation that residents receiving blood thinning medications be monitored for signs of abnormal bleeding or bruising. |
| Staff G | Minimum Data Set Registered Nurse | Stated Resident 9 had an order to monitor for adverse effects of anticoagulant medication, but it was not showing for nurses to complete. |
| Staff B | Director of Nursing Services | Stated expectation that residents receiving anticoagulant medications be monitored for signs of abnormal bleeding/bruising and that this was not being completed for Residents 15 and 9; also stated expectation that all multiuse vials/tubes be dated and labeled when opened. |
| Staff H | Registered Nurse | Stated all multiuse vials such as eye drops should be labeled with resident's name and date opened. |
| Staff J | Licensed Practical Nurse | Stated Resident 18 had completed treatment with erythromycin eye ointment and tube should have been dated and discarded when completed. |
| Staff D | Cook | Stated responsibility for taking temperature of soup at approximately 10:00 AM. |
| Staff E | Dietary Aide | Observed temping the soup during meal service. |
| Staff C | Dietary Manager | Stated expectation that temperature logs be completed accurately and that all foods be temped before and ideally during service. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 31, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement the planned preventative measure of two-person assist when using mechanical devices to ensure safety and prevent falls for Resident 1.
Findings
The facility failed to follow its Safe Resident Handling Transfers Policy by allowing a single staff member to transfer Resident 1 using a sit-to-stand lift, resulting in Resident 1 sustaining a left upper arm fracture. Staff interviews and record reviews confirmed the incident and identified the root cause as failure to use two-person assistance as required.
Complaint Details
The complaint investigation found that Resident 1 was injured on 08/09/2023 during a transfer with one person assist instead of the required two-person assist. Staff statements confirmed the incident and failure to report it. The facility acknowledged the root cause as failure to follow policy requiring two-person mechanical lift transfers.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement the planned preventative measure of two-person assist when using mechanical devices, resulting in harm to Resident 1 with a left upper arm fracture. | Level of Harm - Actual harm |
Report Facts
Residents affected: 1
Incident date: Aug 9, 2023
X-ray date: Aug 14, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Certified Nursing Assistant | Attempted to transfer Resident 1 alone despite two-person assist requirement and did not report the incident |
| Staff D | Licensed Practical Nurse | Assisted in transferring Resident 1 using sit-to-stand lift without incident earlier on 08/09/2023 |
| Staff G | Certified Nursing Assistant | Notified nursing after Resident 1 called out in pain during repositioning on 08/09/2023 |
| Staff F | Licensed Practical Nurse | Reported Resident 1 voiced pain during movement on 08/09/2023 |
| Staff E | Certified Nursing Assistant | Stopped repositioning Resident 1 after pain was expressed on 08/10/2023 and informed nurse |
| Staff A | Administrator | Confirmed root cause of incident was failure to transfer Resident 1 with two people |
| Staff B | Director of Nursing Services | Confirmed root cause of incident was failure to transfer Resident 1 with two people |
Inspection Report
Routine
Deficiencies: 15
Sep 20, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including medication management, resident care, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to inform residents of medication changes, failure to provide timely Medicaid/Medicare notices, late completion of assessments, inaccurate resident assessments, incomplete and inaccurate care plans, failure to meet professional standards in medication administration and care, inadequate infection control practices, failure to implement antibiotic stewardship, and failure to provide proper staff training on abuse reporting.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 15
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to inform residents in advance of proposed changes to medication regimens and obtain consent. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide Notification of Medicare Non-Coverage at least two calendar days before Medicare services ended. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Quarterly Minimum Data Set was completed within 14 days of the Assessment Reference Date. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately assess residents' Minimum Data Sets regarding behaviors, diagnoses, immunization status, falls, and activities. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure resident care plans were reviewed, revised, and accurately reflected residents' care needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure services met professional standards including medication administration, order changes, and treatment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely bowel management and non-pressure skin care assessments and treatments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate care to maintain or improve range of motion for residents with limited ROM. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure environment was free from accident hazards and provide adequate supervision to prevent accidents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide catheter care in accordance with professional standards including proper catheter size and bladder flushes. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to procure food from approved sources, discard expired food, label seasonings properly, and maintain sanitary food preparation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow infection control practices for quarantining residents on Transmission Based Precautions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement an antibiotic stewardship program to monitor antibiotic use. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure influenza and pneumococcal vaccines were offered and/or provided to residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide effective staff training on dementia care and reporting abuse, neglect, and exploitation. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication administration days signed: 28
Medication administration days signed: 15
Days without bowel movement: 5
Days without bowel movement: 10
Days without bowel movement: 4
Days without bowel movement: 5
Days without bowel movement: 5
Oxygen saturation readings: 60
Oxygen saturation below 93%: 2
Oxygen saturation readings below 93%: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing Services | Acknowledged multiple deficiencies including failure to notify physician of held medications, failure to ensure weekly weights, failure to provide bowel care, failure to monitor edema, failure to ensure proper catheter care, failure to ensure immunization documentation, failure to ensure psychotropic medication monitoring, failure to ensure infection control, and failure to provide staff training on abuse reporting. |
| Staff A | Administrator | Acknowledged failure of abuse training program and lack of antibiotic stewardship program. |
| Staff T | Registered Nurse | Acknowledged failure to validate TED hose application and failure to perform weekly bladder flushes. |
| Staff X | Resident Care Manager | Changed Resident 1's Parkinson's medication administration time without physician contact. |
| Staff C | Dietary Manager | Observed failing food safety practices and improper PPE use. |
| Staff U | Director of Rehabilitation Services | Acknowledged lack of restorative nursing program for Resident 1's ROM. |
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