Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rockwood South Hill during CMS and state inspections, most recent first.
A resident with a mental health disorder was admitted on a provider’s order for Seroquel 25 mg to be given once daily in the evening, but the order was incorrectly transcribed into the MAR as 25 mg once a day, give 0.5 mg in the evening. Based on this erroneous entry, the pharmacy dispensed 12.5 mg tablets (½ of a 25 mg tablet), and nursing staff administered 12.5 mg nightly over an extended period instead of the prescribed 25 mg dose. Interviews with the RCM and DON confirmed that the original order was for 25 mg every evening and that the resident received the wrong dose due to the transcription error.
The facility failed to ensure proper hand hygiene and use of hair coverings during meal service, did not monitor food temperatures for all items, and had issues with food storage and labeling. Staff were observed not changing gloves between tasks, serving food without hairnets, and not checking temperatures for mechanical soft and pureed foods. Additionally, food items were found uncovered, unlabeled, and expired, and staff lacked competency in preparing thickened liquids.
The facility failed to maintain complete and accurate medical records for three residents regarding informed consents for psychotropic medications. The consents lacked drug class categories and symptoms for medications like Nuplazid, Trazodone, citalopram, buspirone, quetiapine, sertraline, and Valium. Staff acknowledged these omissions during interviews.
The facility failed to follow its Antibiotic Stewardship Program, as it did not document or evaluate antibiotic use according to the McGeer Criteria for several residents. This included residents prescribed antibiotics for pneumonia, UTIs, and thrush without proper symptom assessment, increasing the risk of unnecessary antibiotic use.
A facility failed to notify a physician and a resident's POA of a change in condition for a resident with severe cognitive impairment and high blood pressure. Despite administering Hydralazine for elevated BP, the resident's condition remained concerning, with no documentation of notification to the physician or POA. The oversight was acknowledged by staff, highlighting a risk for delayed treatment decisions.
The facility failed to provide the required SNF Advanced Beneficiary Notice (ABN) to two residents, which is necessary for informing Medicare beneficiaries about their financial responsibilities when skilled services might not be covered by Medicare. One resident's Medicare Part A services ended, and they were discharged without receiving the SNF ABN, while another resident continued to reside in the facility without receiving the notice. The facility justified the lack of provision by stating that both residents used ten free contract days.
A facility failed to implement its policies on abuse and neglect prevention by not reporting or investigating multiple elopement incidents and a skin injury for a resident with severe cognitive impairment. Despite the resident's conditions, they managed to elope several times, and a skin tear was observed but not reported or investigated. The Director of Nursing acknowledged these failures.
The facility failed to document and communicate the transfer of two residents to the hospital, lacking physician orders and proper notification to the receiving hospital. This involved a resident with high blood pressure and heart failure, and another with sepsis and dementia, both experiencing acute symptoms requiring hospitalization.
The facility failed to notify the State LTC Ombudsman of hospital transfers for two residents. One resident, cognitively intact, was transferred due to symptoms like pain and low blood pressure, while another, with dementia, was transferred due to vomiting and low oxygen levels. Staff interviews confirmed the lack of notification documentation.
The facility failed to provide bed-hold notices to two residents during hospital transfers, as required. One resident, with high blood pressure and heart failure, was hospitalized twice without receiving a notice. Another resident, with sepsis and dementia, was also transferred without a notice. The DON confirmed that notices were only given upon admission, not during each hospital transfer.
The facility failed to create comprehensive care plans for four residents, neglecting to address specific medical needs such as high blood pressure, sleep disturbances, fragile skin, and hearing loss. This oversight led to inadequate management of conditions like hypertension, Alzheimer's, thrombocytopenia, and hearing impairment, as staff did not implement necessary interventions or document care strategies.
A facility failed to administer Hydralazine as needed for a resident with high blood pressure, despite multiple readings showing systolic BP above 160. The MAR indicated an as-needed order for the medication, but there was no documentation of its administration. The Resident Care Manager confirmed the oversight and acknowledged the need for order clarification.
A resident who was cognitively impaired and required assistance with ADLs was not consistently groomed, as evidenced by observations of facial hair over several days. Despite documentation of facial hair removal on certain dates, the resident was repeatedly seen with facial hair. Staff interviews indicated that shaving was done as needed, and the DON recognized the dignity issue of not removing facial hair during bathing.
A facility failed to update a resident's code status from CPR/Full treatment to Do Not Resuscitate/Selective Treatment as requested by the resident's POA. Despite a care conference and documentation of the change, the POLST form and electronic medical record still indicated full CPR, leading to potential risk of unwanted intervention.
The facility failed to implement the bowel protocol for three residents, leading to unmet needs and potential complications. A resident with neurogenic bladder and dementia did not receive prescribed laxatives, and another with a urinary tract infection and dementia experienced similar neglect. Additionally, a resident's bowel protocol was neglected, and the facility failed to monitor them after a fall and skin tear, with no documentation of the incidents or subsequent monitoring.
A facility failed to assess and implement restorative services for a resident with impaired range of motion in their lower extremities. Despite receiving physical therapy and having a history of neuromuscular impairments, the resident was not referred for restorative services to prevent further decline. Observations showed ongoing limitations, and staff interviews confirmed the resident was not on a restorative program, despite previous participation before hospitalization.
A resident with severe cognitive impairments and swallowing difficulties was not adequately supervised during meals, leading to multiple coughing episodes. Staff failed to document these incidents and did not promptly notify therapy and providers for a swallow evaluation, leaving the resident at risk for choking.
A facility failed to ensure timely coordination of controlled substances for a resident at the end of life due to a lack of effective after-hours physician availability. The resident, who required a change from morphine to Dilaudid, experienced delays as the primary physician was unreachable, and the covering NP could not manage controlled substance orders. The DON was unaware of the issue, and no process was in place to ensure prompt physician response.
A facility failed to monitor the effectiveness of sleep medication for a resident with dementia and weakness, who was prescribed Melatonin nightly. Despite receiving the medication, no sleep monitor was in place to assess its effectiveness, as confirmed by an LPN and the DON. This oversight posed a risk of adverse side effects.
The facility failed to consistently monitor refrigerator temperatures in the medication room, risking the efficacy of stored medications like Tubersol and RSV vaccines. Temperature logs were incomplete, and the room lacked a thermometer. The DON acknowledged the oversight and reported notifying maintenance about the issue.
The facility failed to ensure nursing staff had current Washington State Food Worker Cards, with three staff members either having expired cards or no information available. A Nursing Assistant was observed serving meals without a hair covering, and it was noted that nursing assistants served food when dietary staff were unavailable. This posed a potential risk for unsafe food handling practices.
A facility failed to ensure a resident received information and was offered the recommended pneumonia vaccinations. The facility's policy required pneumococcal vaccines to be offered upon admission, with documentation of consent or refusal in the EMR. However, the resident's records showed no documentation of vaccine assessment or offer, and the admission assessment questions about vaccination status were unanswered. This was confirmed by the Infection Preventionist.
Incorrect Transcription and Dosing of Psychotropic Medication
Penalty
Summary
The deficiency involves the facility’s failure to correctly transcribe and administer a prescribed psychotropic medication for a resident admitted with a mental health disorder. On admission, the provider ordered Seroquel 25 mg to be given once daily in the evening. However, when the order was entered into the Medication Administration Record (MAR), it was incorrectly transcribed as Seroquel 25 mg once a day, give 0.5 mg in the evening. As a result of this incorrect transcription, the MAR reflected administration of only 12.5 mg (½ tablet of a 25 mg tablet) instead of the prescribed 25 mg dose. The MAR for January and February showed that the resident consistently received 12.5 mg of Seroquel every evening from early January through early February, rather than the intended 25 mg dose. A facility investigation documented that the pharmacy dispensed 12.5 mg (½ of a 25 mg tablet) based on the incorrect order, and this dose was administered throughout the period. Interviews with the Resident Care Manager and the DNS confirmed that the original provider order was for Seroquel 25 mg every evening and that the order had been transcribed incorrectly into the MAR, resulting in the resident receiving the wrong dose.
Deficiencies in Hand Hygiene, Food Safety, and Storage Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene and the use of hair coverings during food preparation and meal service in both the North and South Dining Rooms. Observations revealed that staff members, including Nursing Assistants and Dietary Aides, did not change gloves or perform hand hygiene between tasks, such as serving food, touching residents, and handling utensils. Additionally, staff members were observed serving food without wearing hairnets, which is a requirement to prevent cross-contamination. The facility also failed to monitor and record the temperatures of all food items being served, particularly mechanical soft and pureed foods. Staff members were observed checking temperatures for regular textured food items but not for mechanical soft and pureed items, which is against the facility's policy. This oversight was acknowledged by the Food Services Director, who stated that all food items should have been checked to prevent illness. Furthermore, the facility did not adhere to proper food storage practices. Observations in the kitchen and nourishment areas revealed uncovered and unlabeled food items, as well as expired products. Staff members acknowledged these issues, noting the importance of labeling and covering food to prevent contamination and ensure food quality. Additionally, there was a lack of competency among staff in preparing thickened liquids, with staff unable to accurately determine the consistency required for residents' diets.
Incomplete Informed Consents for Psychotropic Medications
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, specifically regarding informed consents for psychotropic medications. For Resident 15, the November 2024 Medication Administration Record (MAR) indicated the administration of Nuplazid, Trazodone, and citalopram. However, the consents dated 05/02/2023 for Trazodone and Nuplazid did not specify the drug class categories, and the consent for Nuplazid lacked the symptoms it was prescribed for, only mentioning 'psychosis.' Similarly, Resident 17's November 2024 MAR showed the administration of citalopram, Nuplazid, buspirone, and quetiapine, but the consents for citalopram and buspirone from 01/23/2024 did not identify the drug class categories. For Resident 19, the November 2024 MAR documented the administration of quetiapine, sertraline, Trazodone, and Valium, with consents from 11/22/2023 missing the drug class categories and symptoms for sertraline and quetiapine. Staff C and Staff D, Resident Care Managers, acknowledged the omissions in the consents during interviews, noting that the necessary information should have been included.
Failure to Follow Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its established Antibiotic Stewardship Program (ASP) over a two-month period, as evidenced by a lack of documentation and evaluation of antibiotic use according to the McGeer Criteria. The policy required the facility to assess residents for infections using recognized standards and to reassess the appropriateness of empirically prescribed antibiotics. However, the facility did not document whether residents' signs and symptoms met the surveillance definitions for infections, nor did they evaluate the necessity of antibiotics prescribed upon admission or transfer. Several residents were affected by this deficiency. Resident 12 was prescribed Augmentin for pneumonia without documentation of whether the symptoms met the McGeer Criteria. Resident 28 was admitted with a prescription for Bactrim for cystitis, but there was no documentation of symptom evaluation. Similarly, Resident 17 was prescribed nitrofurantoin for a UTI based on symptoms that did not meet the McGeer Criteria. Resident 2 was given azithromycin and Levaquin for pneumonia without adequate evaluation of symptoms. Resident 29, Resident 7, and Resident 21 also received antibiotics without documented evaluation against the McGeer Criteria. The facility's failure to document and evaluate antibiotic use extended to Resident 24, who was treated for thrush and later a UTI without proper symptom assessment. The Infection Preventionist acknowledged the lack of documentation and evaluation for each resident's clinical signs and laboratory reports to determine if they met the McGeer Criteria for infection. This oversight increased the risk of unnecessary antibiotic use and potential adverse outcomes for residents.
Failure to Notify Physician and POA of Resident's Condition Change
Penalty
Summary
The facility failed to notify the physician and the resident's power of attorney (POA) of a change in condition for a resident with severe cognitive impairment and medically complex conditions, including high blood pressure and arrhythmia. The resident had an as-needed order for Hydralazine if their systolic blood pressure exceeded 160. On a particular day, after being showered, the resident exhibited signs of lethargy and a drooped lip, with a blood pressure reading of 194/95. Despite administering Hydralazine, the resident's blood pressure remained elevated, and there was no documentation of notification to the physician or the resident's representative about the ineffective medication or the continued high blood pressure. The staff documented the resident's condition and the administration of Hydralazine but failed to monitor the resident's status for adverse effects from the elevated blood pressure until 12 hours later. The lack of communication with the physician and the POA was acknowledged by a staff member, who stated that the nurse should have contacted the doctor and informed the POA about the interventions attempted. This oversight placed the resident at risk for delayed treatment decisions by the legal representative and the physician.
Failure to Provide Required Beneficiary Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) to two residents, which is necessary for informing Medicare beneficiaries about their financial responsibilities when skilled services might not be covered by Medicare. Resident 83's Medicare Part A services ended on August 22, 2024, and the resident was discharged on September 4, 2024, without receiving the SNF ABN. The facility justified the lack of provision by stating that the resident used ten free contract days before discharge. Similarly, Resident 1, whose Medicare Part A services ended on June 7, 2024, continued to reside in the facility without receiving the SNF ABN. The facility explained that Resident 1 also utilized ten free days under a contract agreement. The Director of Nursing, Staff B, confirmed that the SNF ABNs were not given due to the contract with the retirement community, which included ten free days, and asserted that the residents were aware of their costs. No additional information was provided.
Failure to Report and Investigate Elopement and Injury
Penalty
Summary
The facility failed to implement its Abuse and Neglect Prohibition Policies and Procedures, specifically in not reporting or investigating elopement episodes and a skin injury for one resident. The facility's policy required immediate investigation and reporting of any suspicion or actual abuse, neglect, or exploitation, with specific time frames for reporting to the Administrator and state agency. However, the facility did not document or report the elopement incidents or the skin injury of Resident 30, nor did it investigate the circumstances surrounding these events to determine if abuse or neglect contributed. Resident 30, who had a traumatic brain injury, restlessness, agitation, and Parkinson's disease, was assessed with severe cognitive impairment. Despite these conditions, the resident managed to elope multiple times, including reaching an independent living area and being found near a maintenance office. Additionally, a skin tear was observed on the resident's elbow, but the facility did not report or investigate this injury. The Director of Nursing acknowledged these failures when the findings were shared, but no further information was provided.
Failure to Document and Communicate Resident Transfers
Penalty
Summary
The facility failed to ensure proper documentation and communication during the transfer of two residents to the hospital, which resulted in a deficiency. Resident 24, who had diagnoses including high blood pressure, heart failure, and thrombocytopenia, was sent to the hospital on two occasions due to complaints of pain and low blood pressure. However, there was no documentation in the resident's medical record indicating that an order was obtained for the transfer or that the receiving hospital was informed of the resident's condition. Interviews with staff revealed that a transfer form should have been completed and that the hospital should have been notified, but this was not done. Similarly, Resident 22, who had diagnoses of sepsis and dementia, was sent to the hospital after experiencing vomiting and low oxygen levels. Again, there was no documentation of a physician's order for the transfer or communication with the receiving hospital. Staff interviews confirmed that a transfer form should have been sent with the resident, but there was no evidence that the hospital was informed of the resident's condition. These failures placed the residents at risk for delays in treatment and unmet care needs.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure that the Office of the State Long-Term Care Ombudsman was notified in writing of hospital transfers for two residents, Resident 24 and Resident 22. Resident 24, who was cognitively intact and had diagnoses including heart failure, pneumonia, and thrombocytopenia, was transferred to the hospital on two occasions due to symptoms such as pain, lethargy, and low blood pressure. Despite these transfers, there was no documentation indicating that the Ombudsman was notified, as confirmed by interviews with staff members including the Medical Records staff, Resident Care Manager, and Director of Nursing. Similarly, Resident 22, who was not cognitively intact and had diagnoses of sepsis and dementia, was transferred to the hospital after experiencing vomiting, abdominal pain, and low oxygen levels. Again, there was no documentation of notification to the Ombudsman regarding this transfer. The lack of notification was acknowledged by staff during interviews, indicating a systemic issue in the facility's process for notifying the Ombudsman of resident transfers.
Failure to Provide Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide a bed-hold notice to residents or their representatives at the time of discharge or within 24 hours of transfer to the hospital, as required by regulations. This deficiency was identified for two residents who were hospitalized. Resident 24, who was cognitively intact and had diagnoses including high blood pressure and heart failure, was sent to the hospital on two occasions due to pain, lethargy, and low blood pressure. However, there was no documentation indicating that a bed-hold notice was provided to the resident during these hospitalizations. Similarly, Resident 22, who had diagnoses including sepsis and dementia, was sent to the hospital after experiencing vomiting, abdominal pain, and low oxygen levels. Again, there was no documentation of a bed-hold notice being provided. During an interview, the Director of Nursing acknowledged that bed-hold notices were only offered upon admission and not each time a resident was transferred to the hospital, which is contrary to the requirements.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their specific medical needs. Resident 15, who was admitted with high blood pressure and arrhythmia, had multiple instances of elevated systolic blood pressure readings, yet there was no care plan developed to manage these conditions. Staff acknowledged the absence of a care plan for these active diagnoses, which should have been in place to guide the management of the resident's health issues. Resident 19, diagnosed with Alzheimer's disease and severe cognitive impairment, was receiving Melatonin as a sleep aid. However, the resident's care plan did not include any interventions or considerations for sleep disturbances, despite the ongoing administration of the medication. Staff confirmed that a care plan addressing the resident's sleep needs should have been developed to ensure appropriate care. Resident 24, with diagnoses including high blood pressure, heart failure, and thrombocytopenia, exhibited significant bruising on their arms due to low platelet count. Despite the high risk for bruising and bleeding, there were no care plan interventions in place to protect the resident's fragile skin. Staff interviews revealed that protective measures such as sleeves and gentle care should have been documented in the care plan. Additionally, Resident 8, with Alzheimer's disease and bilateral hearing loss, had no care plan addressing their hearing aids, which were essential for communication. Observations showed the resident often without their hearing aids, and staff did not assist in managing them, impacting the resident's ability to communicate effectively.
Failure to Administer As-Needed Medication for Elevated Blood Pressure
Penalty
Summary
The facility failed to implement a physician's order for the treatment of elevated blood pressures for Resident 15, who was admitted with medically complex conditions including high blood pressure and arrhythmia. The November 2024 Medication Administration Record (MAR) indicated an as-needed order for Hydralazine every six hours if the resident's systolic blood pressure exceeded 160. However, multiple readings showed the resident's systolic blood pressure was above 160 on several occasions, yet there was no documentation that the staff administered the Hydralazine as ordered. Staff C, the Resident Care Manager, confirmed the lack of documentation and acknowledged that the order required clarification, as there were no instructions to cue the staff on administering the medication when needed.
Failure to Consistently Provide Grooming for a Resident
Penalty
Summary
The facility failed to consistently provide grooming for a resident, identified as Resident 25, who was cognitively impaired and required partial to moderate assistance with activities of daily living, including personal hygiene. According to the resident's care plan, assistance with personal hygiene was necessary. However, observations from December 3 to December 6, 2024, noted that Resident 25 had facial hair approximately a centimeter long, indicating a lack of grooming. Despite documentation showing facial hair removal on specific dates in November and December, the resident was observed with facial hair on multiple occasions. Interviews with staff revealed that shaving was performed as needed, and the Director of Nursing acknowledged that not removing facial hair during bathing was a dignity issue.
Failure to Update Resident's Code Status
Penalty
Summary
The facility failed to follow up on a resident's request to change their code status, which is the level of intervention a resident chooses if their heart or breathing stops. This failure involved Resident 17, who was admitted with medically complex conditions and severe cognitive impairment. During a care conference, the resident's Power of Attorney (POA) requested a change in the code status from CPR/Full treatment to Do Not Resuscitate/Selective Treatment. The facility documented this change and faxed the POLST form to the provider for signature. However, the POLST form in the electronic medical record still indicated full CPR and full treatment, contrary to the POA's decision. Staff M, a Registered Nurse, was unable to confirm the correct code status for Resident 17, as the resident roster did not display code statuses, and the CPR book and electronic medical record both directed staff to initiate CPR. This discrepancy was acknowledged by Staff C, the Resident Care Manager, who confirmed that the electronic medical record and POLST did not reflect the POA's choice. This oversight placed Resident 17 at risk of receiving CPR against the legal representative's wishes.
Failure to Implement Bowel Protocol and Monitor Post-Incident
Penalty
Summary
The facility failed to implement the bowel protocol for the management of constipation for three residents, leading to unmet needs and potential complications. Resident 14, diagnosed with neurogenic bladder and dementia, did not receive the prescribed laxatives as per the bowel protocol during specific periods in November 2024, despite having no bowel movements for several days. The Resident Care Manager confirmed the protocol was not followed, which was necessary to prevent constipation and related complications. Resident 28, with diagnoses including a urinary tract infection and dementia, also did not receive the prescribed laxatives according to the bowel protocol. The resident experienced multiple periods of no bowel movements from November to December 2024, yet there was no documentation of laxative administration during these times. The Resident Care Manager acknowledged the oversight and emphasized the importance of following the protocol to avoid constipation and further medical issues. Resident 30's bowel protocol was similarly neglected, with no documentation of laxative administration despite the absence of bowel movements over several days. Additionally, the facility failed to monitor Resident 30 after a fall and a skin tear, with no documentation of the fall's occurrence, the abrasion's details, or subsequent monitoring. The Director of Nursing confirmed the lack of documentation and expected monitoring for at least 72 hours post-incident.
Failure to Assess and Implement Restorative Services for Resident
Penalty
Summary
The facility failed to assess the need for restorative services for a resident with impaired range of motion in their lower extremities. The resident, who had diagnoses including dementia and abnormalities of gait and mobility, required substantial to total assistance with activities of daily living and had received physical and occupational therapy. Despite a physical therapy evaluation identifying new or worsened neuromuscular impairments and high tone in the resident's bilateral lower extremities, there was no assessment or referral for restorative services to prevent further decline. The resident's care plan lacked interventions related to their lower extremity limitations or directions for range of motion or restorative exercises. Observations of the resident showed their legs stretched out and foot pointing upward while sitting in a wheelchair, indicating ongoing limitations. Interviews with staff revealed that the resident was not on a restorative program, despite having been on one prior to a hospitalization. Staff acknowledged the oversight, noting that the resident should have been placed back on a restorative program after therapy completion to prevent contractures and maintain their current level of functioning.
Inadequate Supervision During Resident's Coughing Episodes
Penalty
Summary
The facility failed to provide adequate supervision during a coughing episode for a resident with severe cognitive impairments and a history of dementia and stroke. The resident required total assistance with eating and was on a mechanical soft diet with nectar thick liquids due to swallowing difficulties. Despite these needs, the resident was observed coughing during meals on multiple occasions without immediate intervention or documentation of the episodes. Staff left the resident alone after a coughing episode, and there was a delay in notifying the appropriate personnel for a swallow evaluation. The resident's care plan required one-to-one feeding assistance and specific instructions for safe swallowing, which were not consistently followed. Staff failed to document the coughing episodes and did not promptly communicate the resident's condition to therapy and providers. The lack of immediate assessment and documentation of the resident's condition after the coughing episodes contributed to the deficiency, as it placed the resident at risk for choking and compromised their quality of life.
Delayed Physician Response for End-of-Life Medication
Penalty
Summary
The facility failed to ensure the timely coordination of controlled substances for a resident at the end of life, due to a lack of an effective system for physician availability after hours. Resident 31, who was readmitted to the facility for comfort care following a rapid health decline, was described as alert but confused and incoherent. The resident was administered morphine to manage symptoms of anxiety and agitation, but the medication was not effective, and a change to Dilaudid was needed. However, the facility's staff encountered delays in obtaining the necessary physician orders for the medication change. Staff F, a registered nurse, attempted to contact the resident's primary physician, Staff I, who was also the facility's Medical Director, but was unable to reach them promptly. Despite leaving messages with the physician's answering service, the nurse was informed that a nurse practitioner was covering for the physician, who could not manage orders for controlled substances. This led to further delays, as Staff I was not able to call in the order to the pharmacy immediately. The Director of Nursing, Staff B, was unaware of the issue and stated that no process was in place to ensure prompt physician response, highlighting a gap in the facility's emergency procedures for medication management at the end of life.
Failure to Monitor Sleep Medication Effectiveness
Penalty
Summary
The facility failed to ensure that sleep medications were consistently monitored for a resident, identified as Resident 183, who was reviewed for unnecessary medications. Resident 183 had diagnoses including dementia and weakness and was prescribed Melatonin for sleep, to be administered every night at bedtime. The medication administration records for November and December 2024 confirmed that the resident received Melatonin nightly. However, interviews with Staff K, an LPN, and Staff B, the Director of Nursing, revealed that a sleep monitor should have been in place to assess the effectiveness of the Melatonin, which was not done. This oversight placed the resident at risk for potential adverse side effects and medical conditions.
Improper Medication Storage Due to Inconsistent Temperature Monitoring
Penalty
Summary
The facility failed to maintain proper storage conditions for medications, as observed during a survey. On December 6, 2024, a Registered Nurse and surveyors found that the refrigerator in the medication room contained a vial of Tubersol and respiratory syncytial virus vaccines. However, the temperature logs for the refrigerator were inconsistently monitored, with only 14 days recorded in September, 16 days in October, and 16 days in November 2024. Additionally, the medication room lacked a thermometer to monitor the storage temperature of medications. During an interview, the Director of Nursing acknowledged that the refrigerator's temperature should have been monitored to ensure medication efficacy and mentioned that maintenance had been notified about the need for a temperature gauge in the medication room. This deficiency placed residents at risk of receiving compromised or ineffective medications.
Deficiency in Food Worker Card Compliance
Penalty
Summary
The facility failed to ensure that nursing staff had the required qualifications, specifically current Washington State Food Worker Cards, for three nursing staff members. This deficiency was identified through observation, interview, and record review. During an observation, a Nursing Assistant, Staff G, was seen serving meals from the steam table without wearing a hair covering. In an interview, a Cook, Staff Z, stated that nursing assistants served food from the steam table when dietary staff were unavailable. Upon request, the facility was unable to provide current Food Worker Cards for the dietary and nursing staff. A review of the dietary cards revealed that Staff N and Staff BB had expired cards, and there was no information available for Staff CC. This lack of proper qualifications posed a potential risk for unsafe food handling practices, which could lead to foodborne illness among residents.
Failure to Offer Pneumonia Vaccination to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 183, received information on and was offered the recommended pneumonia vaccinations as per the Centers for Disease Control and Prevention guidelines. The facility's policy, dated 10/19/2022, required that pneumococcal vaccines be offered to all residents upon admission unless medically contraindicated. The policy also mandated that staff assess residents for vaccine eligibility upon admission and annually, counsel them on the benefits and adverse effects, and document consent or refusal in the electronic medical record (EMR). However, upon review of Resident 183's records, there was no documentation indicating that the resident was assessed for vaccine eligibility or offered the pneumonia vaccine. The comprehensive admission assessment for Resident 183, dated 11/26/2024, included questions about the resident's pneumococcal vaccination status, but these were left unanswered. Additionally, the Immunizations section of the EMR and the Miscellaneous section for uploaded files showed no evidence that the staff assessed the resident's eligibility or offered the vaccine. This oversight was confirmed during an interview with the Infection Preventionist, Staff E, on 12/09/2024, who was unable to provide further information.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Spokane
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spokane Health & Rehabilitation | 1.6 mi | ★★★★★ | 1 | 0 |
| North Central Care Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Spokane Falls Care | 1.9 mi | ★★★★★ | 34 | 0 |
| Spokane Veterans Home | 2.3 mi | ★★★★★ | 1 | 0 |
| South Hill Rehabilitation And Care Center | 2.5 mi | ★★★★★ | 2 | 0 |
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