Inspection Reports for
Renton Health and Rehabilitation
80 SW 2nd St, Renton, WA 98057, United States, WA, 98057
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
27.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
333% worse than Washington average
Washington average: 6.3 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Routine
Deficiencies: 17
Date: Sep 16, 2024
Visit Reason
Routine inspection of Renton Health & Rehabilitation facility to assess compliance with healthcare regulations including resident care, safety, infection control, medication management, and facility environment.
Findings
The inspection identified multiple deficiencies including failure to obtain informed consent for psychotropic medications and bed rails, inadequate notification of Medicaid balances, failure to provide Medicare non-coverage notices, poor maintenance of resident rooms, inaccurate resident assessments, incomplete care plans, failure to provide nursing care within professional standards, inadequate assistance with activities of daily living, unsafe medication storage and handling, delayed dental care, unsanitary food service practices, and lapses in infection control practices.
Deficiencies (17)
F 0552: Facility failed to ensure informed consent was obtained prior to administration of psychotropic medications for 2 residents and for bed rails for 1 resident, placing residents at risk for unwanted treatment.
F 0569: Facility failed to notify Medicaid recipients when personal fund balances approached resource limits and failed to reimburse funds to the state within 30 days of discharge for 1 resident.
F 0582: Facility failed to provide Skilled Nursing Facility Notice of Medicare Non-coverage to 2 residents, risking loss of appeal rights.
F 0584: Facility failed to maintain resident rooms in a homelike condition including wall gouges, unmounted televisions, unclean fans, and unsanitary bathroom fixtures for 9 rooms.
F 0641: Facility failed to ensure Minimum Data Set assessments accurately reflected resident status for 3 residents, risking unmet care needs.
F 0645: Facility failed to ensure accurate PASARR screening for mental health conditions for 1 resident, risking inappropriate placement and care.
F 0656: Facility failed to develop and implement comprehensive care plans for 4 residents, including failure to care plan bed rails, urinary catheters, and refusal of care.
F 0658: Facility failed to provide nursing care within professional standards including failure to follow physician orders for pain medication dosing and documentation for 4 residents.
F 0677: Facility failed to provide adequate assistance with activities of daily living for 3 residents and 1 supplementary resident, risking poor hygiene and diminished self-worth.
F 0688: Facility failed to ensure restorative nursing programs were implemented timely after therapy referral for 1 resident, risking decline in function.
F 0689: Facility failed to maintain a safe environment by leaving laundry room door unlocked and allowing fall hazards and clutter in resident rooms for 1 laundry room and 1 resident.
F 0692: Facility failed to adequately monitor resident weights for 1 resident, risking weight loss and negative health outcomes.
F 0761: Facility failed to ensure medications were stored securely, labeled, dated, and discarded when expired; medication carts were left unlocked; and medications were left unsecured at bedside for 1 medication room, 2 medication carts, and 1 resident.
F 0791: Facility failed to provide or obtain timely dental services for 2 residents, risking oral discomfort and diminished quality of life.
F 0812: Facility failed to maintain sanitary food service practices including uncovered food during transport, dirty unit refrigerator, dirty ice machine, unclean fans, and poor hand hygiene by dietary staff.
F 0880: Facility failed to implement infection control practices including use of personal protective equipment, hand hygiene, catheter care, and maintaining cleanable surfaces for residents with infectious conditions.
F 0881: Facility failed to implement an effective antibiotic stewardship program, including failure to follow orders for urine testing, communicate abnormal lab results, and review antibiotic use for 3 residents.
Report Facts
Residents reviewed: 19
Residents reviewed for dental services: 5
Residents reviewed for PASARR: 5
Residents reviewed for ADL assistance: 6
Residents reviewed for weights/hydration: 1
Residents reviewed for infection control: 3
Residents affected by Medicaid balance notification failure: 5
Residents affected by failure to provide Medicare non-coverage notice: 2
Residents affected by failure to obtain informed consent: 3
Residents affected by failure to provide ADL assistance: 4
Residents affected by failure to provide dental services: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff P | Registered Nurse Manager | Named in findings related to informed consent, nursing care, and refusal of care |
| Staff C | Registered Nurse Manager | Named in findings related to informed consent, care planning, and medication errors |
| Staff B | Director of Nursing | Named in multiple interviews regarding expectations for care, medication, infection control, and dental follow-up |
| Staff K | Licensed Practical Nurse - Infection Control | Named in infection control findings |
| Staff AA | Dietician | Named in findings related to nutrition and weight monitoring |
| Staff Z | Dietary Supervisor | Named in food service sanitation findings |
| Staff R | Medical Records Supervisor | Named in findings related to informed consent, dental appointment scheduling, and hospice documentation |
| Staff HH | Certified Nursing Assistant | Named in dental referral scheduling |
| Staff M | Licensed Practical Nurse Supervisor | Named in medication storage and medication administration findings |
| Staff V | Certified Nursing Assistant | Named in hygiene and infection control findings |
| Staff U | Certified Nursing Assistant | Named in infection control findings |
| Staff W | Nurse Practitioner | Named in antibiotic stewardship findings |
| Staff GG | Director of Rehabilitation | Named in fall prevention findings |
| Staff II | Director of Rehabilitation | Named in restorative nursing program findings |
| Staff S | Licensed Practical Nurse | Named in medication cart security findings |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 5, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision and safety concerns related to resident-to-resident altercations involving two residents in the facility.
Complaint Details
The complaint investigation involved incidents where Resident 2 entered Resident 1's room, took belongings, wore Resident 1's clothes, left feces on Resident 1's bed, and sat on Resident 1's surgically repaired leg causing discomfort. Staff failed to adequately assess wandering risk or implement care plans for Resident 2. Resident 2 was moved to another room only after concerns were raised by Resident 1's collateral contact and an x-ray was obtained. Documentation of staff actions was lacking.
Findings
The facility failed to provide adequate supervision to prevent accidents and resident-to-resident altercations involving two residents. Documentation and care plans were insufficient to address wandering risks and behaviors, and staff responses to incidents were not properly documented.
Deficiencies (1)
F 0689: The facility failed to provide adequate supervision to prevent accidents and resident-to-resident altercations for 2 of 5 residents reviewed. The lack of supervision placed residents at risk for verbal and physical abuse, injury, pain, and diminished quality of life.
Report Facts
Residents reviewed for supervision and accidents: 5
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Social Services Director | Documented Resident 1 agreed to Resident 2 being moved to another room and coordinated evaluation |
| Staff E | Licensed Practical Nurse | Documented Resident 1 would have an x-ray and reported Resident 2's behaviors |
| Staff F | Resident Care Manager | Conducted investigation interviews regarding Resident 2's behaviors and incidents |
| Staff A | Administrator | Informed of resident conflicts and confirmed Resident 2 was moved due to incompatibility |
| Staff I | Registered Nurse/Resource Nurse | Discussed admission referral review and expectations for wandering risk assessments |
| Staff B | Director of Nursing Services | Acknowledged lack of wandering risk care plan and documentation |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 25, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to honor residents' advance directives and failure to provide timely basic life support including CPR during medical emergencies.
Complaint Details
The complaint investigation found substantiated failures in honoring residents' advance directives and initiating CPR timely during emergencies, resulting in immediate jeopardy for some residents.
Findings
The facility failed to ensure Physician Orders for Life Sustaining Treatment (POLST) forms were complete and accessible for residents, and failed to initiate timely CPR for residents during emergencies, placing multiple residents at risk. Additionally, the facility did not maintain required in-service training for nursing assistants.
Deficiencies (3)
F 0578: The facility failed to ensure POLST forms were available and complete for residents, risking residents' rights to have their medical treatment preferences honored.
F 0678: The facility failed to initiate basic life support including CPR immediately as required, placing residents at immediate jeopardy to health or safety.
F 0947: The facility failed to provide required annual in-service training of at least 12 hours for nursing assistants, risking less than competent care.
Report Facts
Residents reviewed for Advance Directives: 8
Residents reviewed for unexpected death: 3
Additional residents at risk: 35
Nursing Assistants reviewed for training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Resource Nurse | Confirmed absence of POLST form for Resident 3 |
| Staff A | Administrator | Confirmed incomplete POLST form for Resident 4 and lack of AED training |
| Staff F | Registered Nurse | Initiated CPR for Residents 1 and 2 during emergencies |
| Staff E | Licensed Practical Nurse | Responded to Resident 1 emergency and called 911 |
| Staff G | Certified Nursing Assistant | Assisted in CPR initiation for Resident 1 |
| Staff C | Director of Nursing - Interim | Interviewed regarding emergency response and CPR initiation failures |
| Staff H | Corporate Consultant | Re-interviewed staff and confirmed CPR initiation issues |
| Staff I | Licensed Practical Nurse | Assessed Resident 2 and called Code Blue but did not initiate CPR due to back injury |
| Staff J | Certified Nursing Assistant | Assisted in moving Resident 2 to floor for CPR |
| Staff L | Certified Nursing Assistant | Lacked required annual in-service training |
| Staff M | Certified Nursing Assistant | Lacked required annual in-service training |
| Staff N | Certified Nursing Assistant | Lacked required annual in-service training |
| Staff O | Vice President of Operations | Acknowledged lack of system to ensure required in-service training |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 31, 2024
Visit Reason
The inspection was conducted to investigate complaints related to resident safety, medication management, and food allergy accommodations at Renton Health & Rehabilitation.
Complaint Details
The complaint investigation focused on incidents involving falls of Resident 1 on 01/09/2024, 01/10/2024, and 01/11/2024, unsafe transfer practices placing Resident 2 at risk, unnecessary psychotropic medication use in multiple residents, and failure to accommodate food allergies for Residents 1 and 6.
Findings
The facility failed to conduct thorough investigations and implement preventative measures to ensure resident safety, particularly regarding falls and transfers. The facility also failed to ensure residents were free from unnecessary psychotropic medications and did not adequately monitor medication effectiveness. Additionally, the facility failed to provide meals that accommodated resident food allergies and preferences.
Deficiencies (3)
F 0689: The facility failed to conduct thorough investigations and implement preventative measures to ensure the safety of 2 residents reviewed for accidents, resulting in risk of injury from falls and inadequate supervision.
F 0758: The facility failed to ensure 4 of 6 residents were free from unnecessary psychotropic medications and did not adequately monitor medication effectiveness for insomnia.
F 0806: The facility failed to provide meals that accommodated food allergies and preferences for 2 of 4 residents reviewed, placing them at risk for allergic reactions and dissatisfaction.
Report Facts
Non-injury falls: 3
Number of residents reviewed for psychotropic medication: 6
Number of residents affected by psychotropic medication deficiency: 4
Number of residents reviewed for food allergies/preferences: 4
Number of residents affected by food allergy deficiency: 2
Number of times Resident 2 was transferred by one person: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Resource Nurse | Provided interview statements regarding fall investigations for Resident 1. |
| Staff F | Certified Nursing Assistant (CNA) | Involved in unsafe transfer of Resident 2 and provided statements about transfer practices. |
| Staff B | Interim Director of Nursing | Interviewed regarding transfer practices of Resident 2. |
| Staff G | Resident Care Manager | Provided information on Resident 1's medication review and family concerns. |
| Staff H | Dietary Manager | Provided information on awareness of Resident 1's shellfish allergy and dietary accommodations. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 6, 2023
Visit Reason
The inspection was conducted due to allegations of abuse, neglect, and failure to protect residents, including an Immediate Jeopardy notification related to the facility's failure to identify, report, investigate, and protect residents from abuse and neglect.
Complaint Details
The complaint investigation was triggered by multiple allegations of abuse, neglect, and failure to protect residents. The facility was notified of an Immediate Jeopardy on 08/31/2023 related to failure to identify, report, investigate, and protect residents from abuse and neglect. Several residents expressed fear and reluctance to call for help due to staff behavior. The facility failed to log, report, or investigate allegations properly and allowed alleged perpetrators access to residents before investigations were complete. Staffing shortages and inadequate training were also noted.
Findings
The facility failed to identify and investigate allegations of abuse and neglect for multiple residents, did not protect residents from alleged perpetrators, failed to report incidents timely, and did not provide adequate staffing or training. Investigations were incomplete, and residents expressed fear and reluctance to call for help due to staff behavior. The facility also failed to ensure sufficient nursing staff on night shifts to meet resident needs.
Deficiencies (4)
F610: The facility failed to identify, report, investigate, and protect residents from allegations of abuse and neglect, placing residents at serious risk of harm.
F0689: The facility failed to ensure fall prevention strategies were implemented for a resident at risk for falls, resulting in a fall with injury.
F0725: The facility failed to schedule sufficient nursing staff on night shifts to meet residents' needs, placing residents at risk for unmet care needs and injuries.
F0835: The facility failed to administer resources effectively, including failure to provide adequate staff training on abuse and neglect, failure to protect residents during investigations, and failure to conduct thorough investigations and reporting.
Report Facts
Residents requiring two-person assist: 23
Facility census: 79
Residents requiring 1-2 person assist with transfers: 55
Residents dependent on staff for toileting: 3
Residents requiring 1-2 person assist with toileting: 69
Staff training hours required: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Certified Nursing Assistant (CNA) | Named in multiple abuse and neglect allegations and returned to work before investigation completion. |
| Staff J | Certified Nursing Assistant (CNA) | Named in multiple abuse and neglect allegations and not suspended during investigation. |
| Staff B | Director of Nursing Services (DNS) | Acknowledged failures in reporting, investigation, and training. |
| Staff C | Administrator in Training (AIT) | Allowed Staff I to return to work and did not suspend Staff J during investigation. |
| Staff U | Certified Nursing Assistant (CNA) | Involved in neglect allegation for Resident 8; was suspended after investigation. |
| Staff G | Interviewed residents and reviewed grievances related to abuse allegations. | |
| Staff Q | Registered Nurse (RN) | Reported not receiving abuse and neglect training prior to 09/01/2023. |
Inspection Report
Routine
Deficiencies: 19
Date: May 24, 2023
Visit Reason
Routine state inspection survey of Renton Health & Rehabilitation to assess compliance with regulatory requirements including resident care, safety, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to honor resident bathing preferences, inadequate response to resident council concerns, failure to notify residents of Medicaid fund balances, lack of surety bond coverage for resident funds, missing advance directives, unsafe and unclean environment, failure to provide written bed hold notices, incomplete and untimely resident assessments, inaccurate care plans, failure to follow physician orders, inadequate assistance with activities of daily living, insufficient activity programming, failure to provide hearing aids, delayed dental care, improper diet texture preparation, missed therapy services, medication labeling and storage issues, and infection control lapses.
Deficiencies (19)
F 0561: Facility failed to honor bathing preferences for 2 of 8 residents, providing bed baths instead of showers despite resident requests, risking frustration and diminished quality of life.
F 0565: Facility failed to promptly address concerns raised by residents at Resident Council regarding patio cleanliness and access, risking resident frustration and less homelike environment.
F 0569: Facility failed to notify 7 Medicaid residents of personal fund balances nearing resource limits and delayed reimbursement of funds for discharged resident, risking financial liability and delayed account reconciliation.
F 0570: Facility failed to ensure 18 of 25 residents' trust accounts were covered by a surety bond, risking inability to recover funds if lost.
F 0578: Facility failed to ensure advance directives were available in records for 5 of 12 residents, risking unnecessary care and failure to honor end-of-life wishes.
F 0584: Facility failed to maintain a safe, clean, comfortable, and homelike environment in multiple areas including patio, resident rooms, therapy gym, and dining/activity room, limiting resident access and comfort.
F 0625: Facility failed to provide written notice of bed hold policy to 3 residents or their representatives at time of hospital transfer, risking uninformed decisions about bed holding and costs.
F 0637: Facility failed to complete or timely complete Significant Change Minimum Data Set assessments for residents with significant health changes, risking unmet care needs and delayed planning.
F 0641: Facility failed to ensure 6 residents' Minimum Data Set assessments were accurate, including errors in denture status, mental illness indicators, race coding, hearing ability, medication use, and care refusals.
F 0656: Facility failed to develop comprehensive care plans for 3 residents, omitting care needs such as constipation, hearing difficulties, vision problems, and dental needs.
F 0657: Facility failed to update and revise care plans for 10 residents to reflect current care needs and conditions, risking unmet needs and negative outcomes.
F 0658: Facility failed to follow physician orders for 4 residents, clarify orders for 2 residents, and sign only for performed tasks for 1 resident, risking medication errors and unmet care needs.
F 0677: Facility failed to provide Activities of Daily Living assistance to 8 of 9 residents as needed, risking poor hygiene and diminished self-worth.
F 0679: Facility failed to provide meaningful activity programs meeting the needs of 4 residents, risking boredom, frustration, and diminished quality of life.
F 0685: Facility failed to provide hearing aids and follow up for 1 resident with hearing loss, risking frustration and diminished quality of life.
F 0686: Facility failed to ensure 1 resident received prescribed mechanical soft diet texture, serving inappropriate food risking choking and aspiration.
F 0812: Facility failed to maintain sanitary food preparation and serving practices including improper sanitizing solution testing, lack of hair coverings, bare-hand contact with food, unclean food thermometer, and incorrect preparation of thickened liquids, risking foodborne illness and aspiration.
F 0825: Facility failed to provide specialized rehabilitative services as ordered for 2 residents, risking decline in physical and functional status.
F 0880: Facility failed to maintain an infection prevention and control program, including inconsistent hand hygiene, improper glove use, failure to clean equipment between residents, and use of soiled gloves during oral care, risking transmission of infections.
Report Facts
Residents notified of Medicaid fund balances: 7
Residents with trust accounts not covered by surety bond: 18
Days since medication opened: 53
Days since medication opened: 31
Days since medication opened: 47
Missed therapy sessions: 5
Missed therapy sessions: 5
Bathing opportunities missed: 3
Narcotic pain medication given outside order parameters: 23
Insulin given below ordered blood sugar level: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Chief Nursing Officer | Confirmed bathing preference process and communication issues. |
| Staff D | Resident Care Manager | Provided multiple interviews regarding care plan and bathing deficiencies. |
| Staff E | Activities Supervisor | Discussed activity programming and documentation deficiencies. |
| Staff F | Maintenance Director | Acknowledged facility maintenance and environmental issues. |
| Staff G | Social Services Director | Discussed advance directives and dental referral issues. |
| Staff H | Infection Control Preventionist | Discussed hand hygiene and infection control expectations. |
| Staff U | Resident Care Manager | Discussed medication monitoring and care plan accuracy. |
| Staff B | Director of Nursing | Confirmed medication administration errors and monitoring lapses. |
| Staff SS | Occupational Therapist, Director of Rehabilitation | Discussed therapy service delivery failures. |
| Staff LL | Dietary Cook | Discussed sanitizing solution and food thermometer use. |
| Staff FF | Dietary Supervisor | Discussed food preparation and tray service issues. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 24, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to honor resident bathing preferences and failure to address concerns raised by residents at the Resident Council.
Complaint Details
The visit was complaint-related, investigating allegations that the facility did not honor resident bathing preferences and failed to address Resident Council concerns about the patio. The deficiencies were substantiated as the facility did not have processes to capture or honor bathing preferences and did not act on patio concerns.
Findings
The facility failed to accommodate resident bathing preferences for two residents, resulting in risk of frustration and diminished quality of life. Additionally, the facility did not promptly address or act on concerns raised by residents about the patio area, leaving it cluttered and inaccessible.
Deficiencies (2)
F 0561: The facility failed to honor resident bathing preferences for 2 of 8 residents reviewed, providing bed baths instead of showers despite resident requests. This failure placed residents at risk for frustration and diminished quality of life.
F 0565: The facility failed to consider and act promptly on concerns raised by residents at the Resident Council regarding the patio area. The cluttered patio prevented safe access and left residents at risk for frustration and a less-than-homelike environment.
Report Facts
Residents reviewed for bathing preferences: 8
Residents affected by bathing preference deficiency: 2
Residents affected by Resident Council deficiency: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff CC | Registered Nurse | Interviewed regarding Resident 85's bathing preferences and wristband |
| Staff C | Chief Nursing Officer | Interviewed about facility bathing preference processes |
| Staff D | Resident Care Manager | Interviewed about bathing preferences and care plans |
| Staff E | Activities Supervisor | Interviewed about Resident Council concerns and communication |
| Staff F | Maintenance Director | Interviewed about patio area maintenance and resident concerns |
| Staff A | Administrator | Interviewed about awareness of Resident Council concerns |
Inspection Report
Inspection Report
Deficiencies: 33
Date: Nov 10, 2021
Visit Reason
The inspection was conducted to assess compliance with state and federal regulations related to resident care, safety, and facility operations, including complaint investigations and routine oversight.
Findings
The facility was found deficient in multiple areas including resident dignity and choice, financial account management, advanced directives documentation, notice of Medicare non-coverage, resident privacy, environmental maintenance, abuse investigation, bed hold notifications, comprehensive and accurate resident assessments, care planning, nursing services, restorative nursing, medication management, infection control, dietary services, and quality assurance. Several residents experienced unmet care needs, delayed or inadequate services, and documentation deficiencies.
Deficiencies (33)
F 0550: The facility failed to provide care and services in a dignified manner for residents, including catheter care and toileting assistance, risking diminished quality of life.
F 0561: The facility failed to accommodate resident choice regarding bathing preferences, resulting in residents not receiving preferred bathing types or frequencies.
F 0569: The facility failed to timely reimburse resident funds to the state and notify Medicaid recipients of account balances, risking financial liability for residents.
F 0570: The facility failed to ensure personal funds of residents were covered by a surety bond exceeding trust balances, risking loss of resident funds.
F 0578: The facility failed to obtain and maintain required documentation for residents' advanced directives and powers of attorney, risking loss of resident rights.
F 0582: The facility failed to provide required Notices of Medicare Non-Coverage and Advance Beneficiary Notices timely and with proper documentation, risking residents' appeal rights.
F 0583: The facility failed to maintain resident privacy by not ensuring staff knocked and waited for permission before entering rooms.
F 0584: The facility failed to maintain linens, walls, doorways, and windows in good condition, risking diminished quality of life.
F 0610: The facility failed to thoroughly investigate and timely report allegations of abuse for multiple residents, risking resident safety.
F 0625: The facility failed to provide written notice of bed hold policies to residents or their representatives upon hospital transfer for multiple residents.
F 0636: The facility failed to complete comprehensive resident assessments timely and accurately for multiple residents, risking unmet care needs.
F 0641: The facility failed to ensure accurate Minimum Data Set assessments for multiple residents, resulting in inaccurate care planning.
F 0644: The facility failed to coordinate and implement recommendations from Pre-admission Screening and Resident Review (PASRR) Level II assessments for residents with mental health needs.
F 0655: The facility failed to develop and provide baseline care plans to newly admitted residents and failed to provide copies to residents or representatives.
F 0657: The facility failed to develop and revise resident care plans accurately and failed to include resident and representative participation for multiple residents.
F 0658: The facility failed to provide sufficient nursing staff to meet resident needs, resulting in delays in care and restorative services.
F 0669: The facility failed to provide timely restorative nursing services as ordered, limiting residents' ability to maintain or improve function.
F 0684: The facility failed to provide ongoing assessments and prevention of pressure ulcers and failed to provide appropriate positioning and wound care for residents with pressure injuries.
F 0685: The facility failed to provide vision services and assistive devices as ordered, resulting in unmet vision care needs for residents.
F 0686: The facility failed to provide appropriate catheter care including securing catheters with straps, risking trauma and dislodgement.
F 0690: The facility failed to provide appropriate continence care including assessments and toileting programs for residents with incontinence.
F 0692: The facility failed to ensure timely weights, identify significant weight changes, and notify appropriate parties for residents at risk of nutritional decline.
F 0698: The facility failed to ensure timely pharmacist medication regimen reviews and timely implementation of recommendations for multiple residents.
F 0725: The facility failed to provide adequate nursing staff to meet resident needs, resulting in delays in care and restorative services.
F 0744: The facility failed to provide appropriate treatment and services for dementia, including individualized behavior monitoring and non-drug interventions prior to antipsychotic use.
F 0756: The facility failed to ensure timely and adequate therapy services as ordered, delaying resident rehabilitation and recovery.
F 0761: The facility failed to ensure monthly pharmacist medication regimen reviews were completed and recommendations implemented timely.
F 0770: The facility failed to ensure medication monitoring and gradual dose reductions were performed timely and appropriately for residents on psychotropic medications.
F 0791: The facility failed to ensure medication monitoring and non-drug interventions were implemented prior to administration of PRN psychotropic medications.
F 0805: The facility failed to ensure medications were properly stored, expired medications were discarded timely, and dishwasher sanitation met required standards.
F 0812: The facility failed to ensure timely laboratory testing as ordered, risking delayed identification and treatment of health conditions.
F 0791: The facility failed to ensure residents received timely dental services and referrals, resulting in unmet dental care needs.
F 0805: The facility failed to ensure therapeutic diets were served according to physician orders, including appropriate texture and fortified foods, risking nutritional imbalances.
Report Facts
Residents tested for COVID-19: 76
Residents with missing COVID-19 test documentation: 12
Dishwasher tests below minimum standards: 9
Residents with delayed or missing weights: 3
Residents with delayed therapy evaluations: 2
Residents with missed restorative therapy: 10
Residents with delayed or missing pharmacist medication regimen reviews: 6
Residents with missing dental referrals: 2
Residents with missed therapy sessions: 3
Residents with missed medication doses on dialysis days: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Director of Nursing | Named in multiple findings related to care planning, assessments, restorative therapy, medication management, and abuse investigation |
| Staff E | Social Services Director | Named in findings related to advanced directives, PASRR, abuse investigation, and behavior monitoring |
| Staff B | Administrator in Training | Named in findings related to QAPI meetings, abuse investigation, and staffing |
| Staff D | MDS Coordinator / Nurse | Named in findings related to assessments, care planning, and restorative therapy |
| Staff H | Director of Therapy Services | Named in findings related to therapy evaluations and restorative therapy |
| Staff J | Activity Supervisor | Named in findings related to resident activities and engagement |
| Staff L | Infection Prevention Nurse | Named in findings related to COVID-19 testing |
| Staff M | Registered Nurse | Named in findings related to medication storage and expired medications |
| Staff O | Resident Care Manager | Named in findings related to abuse investigation, care planning, restorative therapy, and medication management |
| Staff FF | Dietician | Named in findings related to nutrition and dietary services |
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