The Kenney

Missing annual report; annual forward flow test not performed; kitchen sprinkler system not inspected since 2019; wires connected to sprinkler line; blocked sprinkler in dry storage; kitchen suppression systems past due.

Second semi-annual service report missing; kitchen suppression systems past due for service.

Monthly inspection by facility maintenance log not provided.

Monthly 30-second emergency lighting activation testing not performed or documented.

Carbon Monoxide alarms/detectors need to be tested, maintained, and documented on a monthly schedule.

Log of weekly inspections missing; 30-minute full load test for emergency power system performed for only 15 minutes.

Annual report missing; sensitivity testing not performed; covered smoke detector in wood shop.

Annual 90-minute battery-powered emergency lighting power test not performed or documented.

Facility needs to establish a schedule and perform annual inspections of fire doors.

Facility failed to ensure 1 of 3 newly hired staff was screened for TB within 3 days of employment.

Facility failed to ensure 1 of 3 newly hired staff received required specialty dementia training.

Facility failed to ensure 3 of 4 pets had documentation from a veterinarian confirming they were free of disease.

Medication technicians administered blood pressure medications outside of physician-prescribed 'hold' parameters 61 times for one resident.

Facility failed to provide documentation for twelve planned and unannounced fire drills in the previous 12 months; specific drills for Q4 missing for all shifts.

Missing annual reports, 5-year internal pipe testing, 3-year dry system full flow test, annual trip test, forward flow test, and FDC hydro testing. Observed wires connected to sprinkler line on 3rd floor, blocked sprinkler in 2nd floor kitchen storage, and main kitchen system not inspected since 2019.

4th floor double doors outside administrator's office will not latch.

Annual 90 minute power test had not been performed and documented.

Kitchen AL side roll-up fire door is past due for inspection.

Monthly 30-second activation testing had not been performed and documented.

Missing semi-annual service reports. Main and AL kitchen suppression systems are past due.

Missing annual report, sensitivity testing, and monthly alarm tests. Observed covered smoke detector in wood shop.

Missing annual service report, weekly inspection logs, monthly 30-minute load tests, and diesel fuel testing. Facility not performing 30-minute load tests.

Facility has not established or maintained an annual inspection schedule/record for fire doors.

Facility needs to identify and establish a schedule for inspection of Fire-Rated construction; annual inspection needs to be performed and completed.

3rd floor stairwell outside elevator has a penetration through the fire wall.

Missing annual service report, log of weekly inspections, and documentation of diesel fuel testing; 30-minute full load test was performed for only 15 minutes.

Missing first semi-annual servicing documentation; main and AL kitchen suppression systems show past due status.

Missing semi-annual service reports. Suppression systems in main and AL kitchens show as past due.

Missing documentation for annual servicing.

Missing documentation of monthly testing and maintenance for carbon monoxide alarms/detectors.

Annual 90-minute power test not performed and documented.

Facility failed to provide documentation for 12 planned and unannounced fire drills in the previous 12 months, specifically missing drills for all three shifts in the 4th quarter.

Facility has not established a schedule for annual inspection of fire doors.

Monthly 30-second activation testing not performed and documented.

Missing annual report and monthly single/multiple station alarms test records; covered smoke detector observed in wood shop.

Roll-up fire door on the kitchen AL side is past due for inspection.

Missing annual service report, weekly inspection logs, and diesel fuel testing. Facility not performing monthly 30-minute load tests.

Monthly 30-minute full load test was performed for only about 15 minutes.

4th floor double doors outside administrative office will not latch.

Penetration found in the fire wall in the 3rd floor stairwell outside the elevator.

Missing required inspection reports (annual, quarterly, 5-year internal pipe, 3-year dry system full flow, FDC hydro). Observed wires connected to sprinkler line and blocked sprinkler in 2nd floor kitchen storage.

Facility needs to establish a schedule for annual inspection of fire-rated construction.

Failed to ensure system in place to screen 2 of 5 sample staff for tuberculosis within three days of employment.

Failed to ensure 1 of 5 sample staff had the required TB test within three days of hire.

Failed to integrate hospice care information into assessment/service agreements for 2 of 5 sampled residents.

Failed to ensure 1 of 5 sampled staff renewed Washington state background check every two years.

Failed to ensure 1 of 1 sampled staff had a current food worker card.

Failed to ensure 1 of 5 sample staff completed a national fingerprint background check.

Failed to ensure pet had current vaccinations and veterinarian health statement.

Failed to maintain a valid Medical Testing Site Waiver/CLIA certificate.

Three staff members provided care to a COVID-19 positive resident without completing required respirator mask fit-tests, failing to follow CDC, DOH, OSHA, and facility-specific infection control policies.

Failed to document agreed-upon plan to support resident's needs (toileting/transfers) in the record.

Failed to follow criteria for nurse delegation for 1 of 1 sampled resident. Non-licensed staff administered medication without proper delegation training or valid documentation of oversight.

Failed to assess special needs related to dementia and behavior issues for 4 sampled residents.

Failed to identify, evaluate, and act on changing needs of residents (Resident 1 low pulse, Resident 7 bathing/toileting needs).

Failed to notify physician or perform evaluation after repeated medication refusals for 1 of 1 sampled resident (Resident 5).

Failed to develop/document behavioral interventions in NSAs for 5 of 5 sampled residents, failed to document a plan for use of a medical device (transfer) for 1 of 1 sampled resident, and failed to define roles for a private companion for 1 of 1 resident.

Failed to update Negotiated Service Agreement for resident to reflect current care needs.

Facility failed to ensure 3 of 4 sampled agency staff members had valid background checks, placing residents at risk.

Failed to obtain medications in a timely manner for 2 of 7 sampled residents (Residents 1 and 6), resulting in missed doses.

Failed to annually assess personal care needs for 1 resident.

Disaster manual was incomplete, lacking on-duty staff responsibilities, alternative resident accommodations, and provisions for essential needs during emergencies.

Facility failed to implement a Respiratory Protection Program including respirator mask fit-testing for staff.

Facility failed to ensure staff consistently and accurately documented medication services in eMARs. Initials used for medication administration could not be identified by management, placing residents at risk.

The licensee failed to implement the Federal and State regulated standards of a Respiratory Protection Program (RPP) by respirator mask fit-testing for staff.