Alaska Gardens Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Tacoma, Washington.
- Location
- 6220 South Alaska Street, Tacoma, Washington 98408
- CMS Provider Number
- 505483
- Inspections on file
- 32
- Latest survey
- October 9, 2025
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Alaska Gardens Health And Rehabilitation during CMS and state inspections, most recent first.
A resident who required CPR did not receive immediate basic life support due to unclear protocols, staff confusion about code status verification, and delays in initiating emergency procedures. Crash carts were found with missing or expired supplies, inconsistent checklists, and incomplete documentation. The system for maintaining and accessing POLST forms was disorganized, with forms missing or filed incorrectly, leading to uncertainty among staff about residents' code status.
Two nursing staff members, an LPN and an RN, were found to have expired CPR certifications and demonstrated insufficient knowledge regarding CPR procedures and required equipment. Facility policy required current CPR certification for all licensed nurses, but interviews and record reviews revealed lapses in compliance and knowledge, placing residents at risk for unmet care needs.
A nurse was employed and worked full time without holding a valid multistate license to practice in the state. The nurse provided care to a resident who experienced a change in condition and required CPR, despite only being licensed in another state. Staff responsible for verifying licensure could not explain how the nurse was allowed to work without proper authorization.
Multiple residents reported disrespectful and unprofessional behavior from staff, including negative interactions, demeaning attire, and lack of communication about medications. Delays in call light response times were also noted, with some residents waiting up to two hours for assistance and feeling ignored or devalued. These issues were acknowledged by facility leadership.
The facility did not timely issue refunds to two residents or their representatives after discharge or death, resulting in significant delays and miscommunication. One resident's refund was delayed due to billing errors and mailing issues, while another resident's trust fund balance was not promptly conveyed after death, contrary to policy and regulatory requirements.
Surveyors found that two medication storage refrigerators containing lorazepam were left unlocked, with narcotic lock boxes either open or inoperable. Additionally, two medication carts contained multiple opened but undated eye medications and an insulin pen, which staff confirmed were being administered to residents. Facility policy requires these medications to be secured and dated upon opening, but these procedures were not followed.
The facility did not identify or investigate multiple allegations of abuse and neglect, including delayed pain medication administration by an LPN, a resident-to-resident incident during activities, and concerns about the administrator's behavior causing residents to feel unsafe or avoidant. These incidents were not documented or reported according to policy, and no investigations were initiated.
A resident with diabetes and dementia, who was assessed as having impaired vision and without corrective lenses, did not have a baseline care plan developed to address their vision needs within 48 hours of admission. The care plan lacked interventions to obtain eyeglasses or arrange for new ones, despite the resident expressing this need.
Three residents did not have care plans that accurately reflected their current medical needs or timely care conferences. One resident with respiratory failure lacked a care plan for their condition, another was not informed about their care and missed a scheduled care conference, and a third had a care plan that did not match the updated fluid restriction order. Staff confirmed these deficiencies and acknowledged that care plans and conferences were not managed as required.
A resident with aphasia and hearing impairment was left without a required whiteboard for communication, as specified in their care plan. Despite staff awareness of the need for the device, it was missing for several days and not replaced, resulting in the resident being unable to effectively communicate with staff.
Two residents dependent on staff for ADL support were not consistently offered shaving or dressed in clean clothing. One resident with upper extremity impairment was repeatedly observed with facial hair and reported not being offered shaving, while another was seen wearing a visibly soiled shirt for several days due to a lack of clean clothes. Staff interviews confirmed these lapses in care and a lack of adherence to facility expectations.
Two residents with renal disease and physician-ordered fluid restrictions received fluids in excess of their prescribed limits due to inconsistent documentation, lack of communication between nursing and dietary staff, and failure to notify the provider when restrictions were exceeded. Staff interviews and record reviews revealed that fluid intake was not accurately tracked, dietary staff were unaware of restrictions, and residents' meal trays did not reflect fluid limitations.
A resident with a history of diabetes, depression, and muscle weakness experienced broken and missing teeth and reported oral pain. Despite referrals from an RDH for dental care, there was no documentation in the EHR of a dental visit or follow-up, and required dental reports were not reviewed or signed by nursing staff. The facility failed to obtain and include dental visit documentation, resulting in unmet dental needs and incomplete records.
A resident with diabetes and renal failure, who was missing upper and lower teeth and requested dental care, was referred by an RDH for dental and denturist services. However, the referral was not promptly acted upon, with no documentation of follow-up or scheduled dental visits, and staff were unaware of the referral until later interviews.
Staff failed to ensure that equipment and surfaces remained cleanable, as evidenced by a resident's wheelchair with a torn armrest exposing uncleanable foam padding and numerous stained shoelaces tied to a bathroom handrail. Both an LPN and the DON acknowledged these items did not meet expectations for cleanable surfaces.
A resident with end stage renal disease and diabetes, who required two-person assistance for bed mobility per their care plan, was assisted by only one CNA during repositioning. This led to the resident falling from the bed and sustaining a fractured arm. Staff and leadership confirmed that the care plan was not followed, resulting in harm.
The facility failed to provide adequate nutrition and hydration, resulting in severe health issues for several residents. One resident was hospitalized with aspiration pneumonia and severe dehydration due to inadequate care planning and monitoring. Another resident experienced repeated hospitalizations for dehydration and uncontrolled blood sugars, with significant delays in addressing critical lab values. A third resident suffered a significant weight loss without proper monitoring or timely intervention. The facility's deficiencies in care planning and monitoring placed residents at risk for further health complications.
The facility failed to implement effective fall prevention measures for three residents, leading to multiple falls and injuries. A resident with a history of falls experienced three falls, resulting in a hip fracture and over-sedation. Another resident fell twice in one night, with incomplete investigations and untimely care plan updates. A third resident fell from their bed, with inadequate post-fall monitoring and communication of interventions to staff.
The facility failed to provide adequate pain management for three residents, leading to significant harm. One resident experienced harm due to delayed pain medication administration and lack of monitoring for opioid use, resulting in hospital transfer and surgical intervention. Another resident's pain complaints were unaddressed, leading to a hospital transfer for a hip fracture. A third resident did not receive scheduled pain medications due to communication failures, and their pain was not adequately assessed or documented.
The facility failed to implement baseline care plans within 48 hours of admission for several residents, leading to unmet care needs and potential health risks. Residents with complex medical conditions, such as heart failure and post-surgical needs, did not receive comprehensive care plans, resulting in inadequate care and communication issues. This deficiency highlights the facility's inability to provide timely and effective care planning.
The facility failed to ensure effective use of resources and maintain compliance due to inadequate administrative oversight in the absence of the DNS and Regional President of Clinicals. The lack of an ADNS and the RCM not being appointed as acting DNS led to the Administrator assuming responsibility for clinical oversight. This resulted in repeated citations for Quality of Care and Significant Medication Errors, and an Immediate Jeopardy related to nutritional care for 11 residents. Additionally, the facility failed to implement a QAPI program and educate staff on its goals.
The facility's QAPI Committee failed to identify and address deficiencies, including medication errors, nutrition monitoring, fall care plan implementation, and training compliance. The committee did not recognize issues in the new resident admission process, leading to medication availability problems. Additionally, the facility did not ensure proper nutrition for tube feeding-dependent residents or track CNA training hours.
The facility failed to thoroughly investigate incidents and alleged violations involving three residents, leading to unaddressed falls, neglect allegations, and unreported wounds. A resident with cognitive issues experienced multiple falls without proper documentation or investigation. Another resident faced neglect allegations due to inadequate care and unexpected death, while a third resident was discharged with unreported wounds. The facility's investigations were incomplete, lacking necessary documentation and analysis.
The facility failed to meet professional standards by not holding anti-hypertensive medications when vital signs were outside parameters, delaying lab specimen collection and reporting, and lacking consistent documentation for skilled nursing care. These deficiencies affected multiple residents, potentially impacting their quality of care.
A facility failed to provide adequate care for residents, including not conducting weekly skin checks, failing to monitor surgical wounds, and not following heart failure management protocols. This led to unreported wounds, infections, and multiple rehospitalizations.
A facility failed to ensure residents were free from significant medication errors, affecting 12 residents. Errors included lack of medication reconciliation, incorrect transcription, and untimely administration. Residents experienced missed doses, unavailability of medications, and unreported errors, leading to risks of adverse events and diminished care quality.
The facility failed to provide required annual training for four NACs, as outlined in their Facility Assessment. Missing documentation for trainings in Resident Rights, Change of Condition, Person-Centered Care, and Activities of Daily Living was confirmed by the Staff Development Coordinator and the Regional President of Clinicals. This deficiency placed residents at risk for unmet care needs.
The facility failed to provide mandatory QAPI training to four CNAs, as confirmed by interviews and record reviews. Staff R admitted to not knowing about the QAPI committee, and the Staff Development Coordinator confirmed the lack of training for Staff Q. The facility could not provide documentation for the required annual training for Staff R, S, and T, and no specific QAPI curriculum was available.
A facility failed to notify a resident's court-appointed guardian of a new antibiotic order for a skin infection. The resident, who was moderately cognitively impaired, had a communication deficit and required assistance with personal care. Staff A confirmed the order but did not inform the guardian, while Staff B was unaware of the order, leading to a lack of communication and documentation.
A facility failed to document and monitor a resident's hematoma on their left leg, lacking measurable and descriptive baselines. Despite orders to monitor and notify the provider of changes, records only indicated monitoring without detailed documentation. Staff interviews confirmed no treatments or measurements were performed, and the DON acknowledged the lack of documentation hindered the ability to assess the hematoma's progression.
A resident with COPD did not receive their prescribed respiratory medication, Trelegy, for eight days due to unavailability and lack of communication with the medical provider. The resident experienced distress and shortness of breath during this period. The DNS noted that staff should have taken steps to address the medication's unavailability, including contacting the pharmacy and notifying the doctor.
The facility failed to notify the DPOA for two residents about changes in their medication orders, including morphine for a resident receiving hospice care and an increased dose of Depakote for another resident with dementia. Despite staff expectations to inform and document such changes, there was no record of notification to the residents' representatives.
Failure to Ensure Immediate CPR and Maintain Crash Cart Readiness
Penalty
Summary
The facility failed to ensure that basic life support, including CPR, was initiated immediately and according to policy for a resident who experienced an unexpected death. The facility did not have a clear, written policy or protocol outlining the procedures, documentation expectations, or staff responsibilities during a cardiac or respiratory arrest event. Staff interviews revealed confusion regarding who was responsible for initiating CPR, how to verify code status, and how to call a Code Blue. There were also inconsistencies in staff statements about the sequence of events, with delays in recognizing the resident's unresponsiveness, checking for a pulse, and notifying a nurse. Additionally, some staff members were not current in their CPR certification, and there was uncertainty about whether nursing assistants could initiate CPR if they were certified and knew the resident's code status. The facility's crash carts were not consistently stocked with required, unexpired supplies and equipment necessary for immediate use during a code event. Observations showed missing or expired items such as blood glucose test strips, non-rebreather masks, oral airways, and oxygen tanks that were not full. There were discrepancies between different crash cart checklists, leading to confusion about what items should be present and how equipment should be set up. Some crash carts lacked essential documentation forms, and daily checks were not consistently documented or performed as required. The facility also had an AED that was not readily accessible or in a designated location for emergency use. The system for maintaining and accessing residents' Physician Orders for Life-Sustaining Treatment (POLST) was disorganized and unreliable. POLST forms were missing, filed under incorrect room numbers, or not updated to reflect residents' current locations. There were inconsistencies between posted code status lists and the actual POLST forms in the binders. Staff were unclear about where to find residents' code status information, with some relying on electronic records, binders, or posted lists, and others unsure of the process. These failures placed numerous residents with current POLSTs requesting CPR at serious risk for adverse outcomes.
Removal Plan
- Audited the records of all residents
- Audited the POLST binders
- Audited and stocked the crash carts
- Updated the facility CPR policy
- Educated staff on the facility's CPR Policy and Code Blue Emergency process during CPR
- Audited and ensured licensed staff had current CPR training
- Implemented a plan of correction to sustain ongoing compliance
Expired CPR Certifications and Inadequate Staff Competency
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate knowledge, competencies, and skill sets necessary to provide nursing and related services, including Cardio-Pulmonary Resuscitation (CPR), as required by facility policy and regulatory standards. Specifically, two staff members, an LPN and an RN, were found to have expired CPR certifications upon review. During interviews, the LPN was unable to identify the necessary equipment for responding to respiratory arrest or performing CPR, only mentioning 'hands' and failing to name other required equipment. The RN stated they had received CPR training and claimed to have current certification, but documentation showed their certification was also expired. Additionally, the facility's policy required all licensed nurses to maintain current CPR certification, with routine reviews to validate compliance. However, interviews with administrative staff revealed that while CPR certification was mandatory for nurses, it was only recommended for nursing assistants, and there were ongoing efforts to schedule another CPR class. These findings demonstrate that the facility did not ensure all nursing staff maintained the required competencies and certifications to provide safe and effective care, as evidenced by expired certifications and lack of knowledge regarding emergency procedures.
Nurse Employed Without Valid State License
Penalty
Summary
The facility failed to ensure that a registered nurse (Staff C) employed at the facility held a valid multistate license authorizing practice in the state where the facility is located. Staff C was hired with only a California State RN license, which did not permit practice in the facility's state. Staff C worked full time and was involved in the care of a resident who experienced a change in condition and subsequently coded, requiring CPR and emergency medical intervention. Record review and staff interviews confirmed that Staff C was not authorized to practice in the state, and staff responsible for license verification were unable to explain how this oversight occurred.
Failure to Maintain Resident Dignity and Timely Response to Needs
Penalty
Summary
The facility failed to ensure that care and services were provided in a manner that maintained and promoted dignity and respect for eight of nine residents interviewed. Multiple residents reported negative interactions with staff, including a nursing assistant who responded to a resident's apology by loudly calling for another aide and leaving the resident exposed, as well as wearing attire perceived as demeaning. Residents described staff as disrespectful, belittling, and unprofessional, with one resident sharing that staff wore a shirt with an offensive caption and another stating that staff acted as if they were more important than the residents. Several residents also reported significant delays in call light response times, ranging from 30 minutes to two hours, and described staff as dismissive or unresponsive to their needs, including requests for pain medication. Residents expressed frustration and feelings of being ignored or devalued, with some stating that staff did not inform them about the medications being administered and others noting that their requests were not fulfilled even after long waits. These findings were acknowledged by the facility's administrator and director of nursing services.
Delayed Refunds to Residents and Representatives After Discharge or Death
Penalty
Summary
The facility failed to provide timely refunds to two residents or their representatives following discharge or death, as required by policy and regulation. For one resident who was discharged, the facility overbilled and delayed issuing a refund of $489.72. The refund process was prolonged due to miscommunication, changes in billing services, and errors in mailing the check, resulting in the resident's representative not receiving the funds until several months after discharge. The representative reported inconsistent information from the facility regarding the status of the refund, and the check was ultimately picked up at the facility after multiple reissuances. For another resident who passed away, the facility did not promptly convey the trust fund balance of $530.58 to the appropriate party. Staff waited for direction from the resident's representative regarding the use of the funds for funeral services, and after declining, the facility prepared to send the refund to the Office of Financial Recovery. These delays in refunding owed amounts did not comply with the facility's admission agreement or regulatory requirements, placing resident families and representatives at risk for financial hardship.
Failure to Secure Controlled Substances and Date Opened Medications
Penalty
Summary
Surveyors observed that the facility failed to properly secure controlled substances and to date medications as required by policy and regulation. Specifically, two of three medication storage refrigerators (ASSISI and Long-Term Care) were found unlocked while containing lorazepam, a Schedule IV controlled substance. In both cases, the narcotic lock boxes within the refrigerators were also left open or inoperable, and staff confirmed that these should have been locked and functional whenever controlled substances were present. Additionally, two of three medication carts (ASSISI and Long-Term 2) contained multiple opened but undated medications, including various ophthalmic drops and an insulin injector pen. Staff acknowledged that these medications were being administered to residents and should have been dated upon opening, in accordance with facility policy and manufacturer recommendations. The facility's own policies require that all medications, especially controlled substances, be stored securely and that medications be dated when opened to ensure their integrity and safe administration. During interviews, staff and the Director of Nursing Services confirmed that the observed practices did not meet these requirements. The deficiencies were identified through direct observation, staff interviews, and review of facility policies, with no mention of specific residents affected or adverse outcomes at the time of the survey.
Failure to Identify and Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and investigate allegations of abuse and neglect for four out of seven sampled residents. For one resident with a history of peritoneal abscess, ovarian cancer, muscle weakness, anxiety, and depression, there were repeated delays or omissions in administering PRN pain medication by an LPN, despite the resident communicating their needs to both CNAs and a nurse supervisor. The medication administration record showed a lack of timely pain medication administration during specific shifts, and the issue was not reported or investigated as required by facility policy. Another resident with bipolar disorder and borderline personality disorder reported being touched by another resident during an activity, which caused distress and led to withdrawal from activities. The incident was reported to the activity director, who spoke to the other resident but did not document the event or report it as required. There was no record of the incident in the grievance or incident logs, and the required investigation was not initiated. Additional concerns involved a resident with adjustment disorder and anxiety who reported fear and perceived retaliation from the administrator after filing a grievance, leading to self-isolation. Another resident with COPD and depression described the administrator as rude and avoided interactions. Multiple residents expressed concerns about the administrator's behavior, but these were not logged or investigated as potential abuse or neglect. The facility's failure to identify, document, and investigate these allegations did not meet the expectations outlined in their abuse and neglect policy.
Failure to Develop Baseline Care Plan for Vision Needs
Penalty
Summary
The facility failed to develop a baseline care plan with specific goals and interventions to address the immediate needs of a newly admitted resident within 48 hours of admission. The resident, who had diagnoses including diabetes and dementia and was able to communicate needs, was assessed as having impaired vision and did not have corrective lenses available at the facility. Despite the resident expressing a desire to have their eyeglasses brought from home, the care plan did not include any interventions or plans to obtain the eyeglasses or arrange for new ones. The omission was confirmed by review of the care plan and by interview with the Director of Nursing Services, who acknowledged that the baseline care plan should have addressed the resident's vision needs.
Failure to Revise and Update Care Plans and Conduct Timely Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected the care needs of three residents, and that care conferences occurred in a timely manner. For one resident with pulmonary fibrosis and chronic respiratory failure with hypoxia, there was no care plan addressing their respiratory conditions, despite the resident requiring oxygen therapy and having recent respiratory symptoms. Both a registered nurse and a care coordinator confirmed that a care plan for these conditions should have been in place upon admission. Another resident with multiple diagnoses, including heart, kidney, and liver disease, as well as diabetes and depression, reported being unaware of their medical plan of care and stated that staff had not discussed their medications, therapy, or treatments for some time. The social services director acknowledged that a scheduled care conference had been missed due to a glitch in the electronic health record system, and the director of nursing services confirmed that care conferences are typically organized by social services in coordination with nursing staff. A third resident, who was dependent on dialysis and had a fluid restriction order, had a care plan that did not reflect the most current provider order for fluid restriction. The care plan listed a 1000 ml per day restriction, while the provider's order had been updated to 1200 ml per day. Staff interviews confirmed that the care plan had not been revised to match the new order, and the director of nursing services stated that the care plan did not meet expectations.
Failure to Provide Communication Device for Resident with Aphasia
Penalty
Summary
The facility failed to maintain a resident's ability to communicate as outlined in their care plan. The resident, who had diagnoses including aphasia and adult failure to thrive, was admitted with the ability to communicate needs and was identified as hard of hearing. The care plan specified the use of a dry erase board to facilitate communication. However, during multiple observations, the resident was found in bed without a whiteboard present, despite signage indicating its use for communication. Staff interviews confirmed that the whiteboard, previously used to communicate with the resident, had been missing for some time and had not been replaced. Further interviews revealed that staff were aware of the care plan intervention but did not report the missing communication device, resulting in the resident being unable to effectively communicate with facility staff. The resident confirmed that staff did not use writing to communicate with them. The Director of Nursing Services acknowledged that communication devices should be kept at the bedside and missing devices should be reported, but this protocol was not followed in this instance.
Failure to Provide ADL Support: Residents Not Shaved or Dressed in Clean Clothing
Penalty
Summary
The facility failed to provide necessary care and services to ensure that two residents dependent on staff for activities of daily living (ADLs) were properly groomed and dressed in clean clothing. One resident, who had upper extremity impairment and required assistance with personal hygiene, was observed on multiple occasions with long facial hair around the chin area. The resident reported not always being offered shaving and expressed a desire to have facial hair removed, stating they had never refused when offered. Staff interviews revealed uncertainty about whether they could shave the resident, and the Director of Nursing Services was unaware that the resident had not been offered shaving, which did not meet facility expectations. Another resident, dependent on staff for personal hygiene and dressing due to conditions including COPD, dementia, and muscle weakness, was observed over several days wearing the same visibly soiled shirt. Staff confirmed that the resident received a bed bath but was not changed into clean clothes because their shirts had not returned from the laundry. Staff stated that the expectation was for residents to wear clean clothing at all times, and if clean clothes were unavailable, items from donations should be used. These findings were based on observations, interviews, and record reviews.
Failure to Monitor and Document Fluid Restrictions for Residents with Renal Disease
Penalty
Summary
The facility failed to monitor and accurately document fluid intake for two residents with physician-ordered fluid restrictions, resulting in the residents receiving fluids in excess of their prescribed limits. One resident, with a history of diabetes, renal failure, and dependence on dialysis, had a fluid restriction order of 1200 ml per 24 hours. However, documentation showed that on multiple occasions, the resident was provided with fluids exceeding this limit, with totals ranging from 1312 ml to 1672 ml in a 24-hour period. The provider was not notified when the fluid restriction was exceeded, and documentation was inconsistent or missing in several records, including the medication administration record (MAR), treatment administration record (TAR), and electronic health record (EHR). Staff interviews confirmed that the fluid restriction orders did not clearly specify the amount of fluid to be provided by dietary services, and that documentation of fluid intake was not consistently accurate or complete. Another resident, also dependent on dialysis and diagnosed with end stage renal disease, had a fluid restriction order of 1500 ml per 24 hours, with specific amounts to be provided by dietary and nursing staff. Review of records showed discrepancies between the fluids documented by nursing and those recorded by nursing assistants, with intake amounts documented as high as 1280 ml in a single shift. Additionally, the resident's meal tray ticket did not indicate a fluid restriction, and the dietary supervisor was unaware of the restriction, resulting in the kitchen not being informed of the need to limit fluids. Observations confirmed that the resident had access to multiple cups of fluid at the bedside, and staff interviews revealed a lack of awareness and communication regarding the fluid restriction. The deficiency was further evidenced by the lack of coordination between nursing and dietary departments, incomplete or inaccurate documentation of fluid intake, and failure to notify the provider when fluid restrictions were exceeded. Staff acknowledged that the orders were not followed as written, and that the documentation and communication processes did not meet expectations for ensuring compliance with physician-ordered fluid restrictions.
Failure to Provide Prompt Dental Care and Documentation
Penalty
Summary
The facility failed to provide prompt dental care and obtain post-visit dental documentation for one resident. The resident, who had a history of diabetes, depression, and muscle weakness, was observed to have broken and missing teeth and reported occasional oral pain. The resident had been referred by a Registered Dental Hygienist (RDH) for dental care on two separate occasions due to pain, but there was no documentation in the electronic health record (EHR) that the resident had been seen by a dentist or that a follow-up appointment was scheduled. The care plan indicated the need for dental care coordination, but this was not effectively carried out. Staff interviews revealed that the RDH's referrals were not properly communicated or documented, and the dental reports were not reviewed or signed by nursing staff as required. Although a dental appointment was scheduled and later confirmed to have occurred, the facility failed to obtain and include the dental visit documentation in the resident's EHR. The Social Services Director and Administrator both acknowledged that the expected documentation and follow-up were not present, and the dental summary report obtained later was unclear regarding the care provided. This lack of timely dental care and documentation did not meet facility expectations and requirements.
Failure to Provide Prompt Dental Services Following Referral
Penalty
Summary
A deficiency occurred when the facility failed to provide prompt dental services for a resident who was readmitted with diagnoses including diabetes and renal failure. The resident, who was able to communicate needs, was observed to have missing upper and lower teeth and expressed a desire to see a dentist for extractions and to obtain dentures or partial dentures. The resident's care plan included an intervention to refer to a facility dentist or dental hygienist as needed. Documentation showed that the resident was seen by a Registered Dental Hygienist (RDH), who referred the resident to a dentist and denturist after the resident requested dental care. Despite the RDH's referral, there was no evidence that the referral was acted upon in a timely manner. Staff interviews revealed that the RDH's report and referral were not noted by nursing staff or a provider, and there was no documentation explaining why the resident had not seen a dentist. The Social Services Director reported submitting a referral through a dental portal but could not provide documentation of the submission or any follow-up. The administrator confirmed the lack of documentation and was unable to explain the delay in dental care, noting that this did not meet expectations.
Failure to Maintain Cleanable Equipment and Surfaces
Penalty
Summary
Facility staff failed to maintain essential equipment in a manner that allowed for proper disinfection on one of five sampled halls. Observations revealed that a resident was using a wheelchair with a torn left-hand armrest, where the vinyl covering had worn away, exposing the underlying foam padding. This exposed foam was not a cleanable surface. The resident confirmed that the armrest had been damaged for some time, and subsequent observations showed the damage persisted over several days. Additionally, in another room, approximately 25 shoelaces were found tied to the handrail next to the toilet. These shoelaces were stained with brown material and were not cleanable. The shoelaces remained in place over multiple days. Interviews with staff, including an LPN/Care Coordinator and the DON, confirmed that both the damaged wheelchair armrest and the stained shoelaces did not meet facility expectations for cleanable surfaces and should have been reported for repair or removal.
Failure to Provide Two-Person Assistance for Bed Mobility Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, admitted with end stage renal disease and diabetes and receiving dialysis, did not receive the required level of assistance for bed mobility as specified in their care plan. The care plan, updated on 11/20/2024, indicated that the resident required two-person extensive assistance for repositioning and turning in bed. However, on 04/12/2025, the resident was assisted by only one CNA during bed mobility, contrary to the care plan instructions. As a result of this deviation from the care plan, the resident slid from the bed while being changed, fell to the floor, and sustained a fractured right humerus. Interviews with staff and facility leadership confirmed that staff are expected to follow the care plan and use the Kardex to determine the required number of staff for such tasks. The incident investigation determined that the CNA performed bed mobility alone, which was not in accordance with the resident's documented needs.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
The facility failed to ensure residents received adequate nutrition and hydration, leading to significant health issues for multiple residents. Resident 20 was admitted to the hospital with aspiration pneumonia, sepsis, severe dehydration, severe malnutrition, and acute kidney injury. The facility did not accurately assess and develop a care plan to prevent aspiration pneumonia, failed to monitor and document nutritional status, and did not provide physician-ordered oral care. Additionally, the facility did not maintain the head of the bed elevation as required, contributing to the resident's condition. Resident 22 experienced repeated hospitalizations due to dehydration and uncontrolled blood sugars. The facility failed to assess the resident's feeding tube status, did not develop care plan interventions to prevent dehydration, and delayed implementing physician orders to correct electrolyte imbalances. The resident's tube feeding was not documented for 18 days, and there was a significant delay in addressing critical lab values, leading to further deterioration of the resident's health. Resident 40 suffered a significant unplanned weight loss of 20 pounds in two weeks. The facility did not develop a person-centered nutrition care plan, failed to monitor weights consistently, and did not evaluate oral intake. The resident's responsible party was not informed of the weight loss, and there was a delay in starting ordered IV fluids for rehydration. The facility's lack of timely intervention and monitoring placed the resident at risk for further health complications.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to develop and implement a resident-centered fall prevention care plan for three residents, leading to multiple falls and injuries. Resident 1, who had a history of falls and was at high risk due to conditions such as Parkinson's disease and atrial fibrillation, experienced three falls. The facility did not consistently monitor Resident 1 for post-fall injuries, update their care plan in a timely manner, or ensure that interventions were communicated to staff. After the third fall, Resident 1 was found to have a hip fracture and was over-sedated due to psychotropic medications. Resident 8, who had moderate cognition problems and required assistance for activities of daily living, experienced two falls in one night. The facility's investigation into these falls was incomplete, lacking details about the circumstances and necessary interventions. The care plan was not updated with timely interventions, and there was no consistent post-fall monitoring or documentation of physician notification. Resident 11, who had cognition problems and required assistance with activities of daily living, fell from their bed. The facility did not document consistent post-fall monitoring or notify the physician and responsible party. The care plan interventions were not effectively communicated to staff, as evidenced by the lack of implementation of specific interventions such as placing the bed in the lowest position and against the wall.
Inadequate Pain Management Leads to Harm in Residents
Penalty
Summary
The facility failed to provide adequate pain management for three residents, leading to significant harm. Resident 2 experienced harm due to the facility's failure to accurately transcribe and clarify admission orders for pain medications, resulting in delayed administration of scheduled pain medications. The facility also failed to evaluate the underlying cause of Resident 2's sudden onset of severe chest pain and shortness of breath after open-heart surgery. This resident was not monitored for adverse effects of opioid use and was transferred to the hospital in acute respiratory failure, where it was discovered that they had broken chest wires requiring surgical intervention. Resident 1 suffered harm when their complaints of pain were not addressed, and their behavioral signs of pain were not evaluated. The facility did not monitor Resident 1 for post-fall injuries, and they were transferred to the hospital, where a new hip fracture requiring surgical intervention was discovered. The facility's pain care plan for Resident 1 lacked person-centered interventions, and there was no evidence of non-medication interventions or PRN pain medications being provided. Resident 13, who was non-English speaking and required an interpreter, did not receive their scheduled pain medications due to a failure in communication with the pharmacy. The facility did not implement non-medication pain interventions, and Resident 13's pain was not adequately assessed or documented. The lack of translation services further hindered the staff's ability to assess and manage Resident 13's pain effectively.
Failure to Implement Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for five residents, which is a requirement to address their immediate health and safety needs. This deficiency was observed in the cases of Residents 1, 2, 8, 19, and 13, where the facility did not provide written summaries of the baseline care plans to the residents or their responsible parties in a language they understood. The absence of these care plans led to a lack of clear instructions for direct care staff, resulting in unmet care needs and potential risks to the residents' health and safety. Resident 2, who was admitted with chronic heart failure and post-surgical needs, did not receive a comprehensive care plan that included necessary instructions for diet, heart failure management, and other critical care needs. The resident reported not receiving expected care, such as proper wound care and blood sugar monitoring, which contributed to their rehospitalization. Similarly, Resident 8, who had specific needs related to a stroke and tube feeding, did not have these needs addressed in their care plan, and their responsible party confirmed the absence of a baseline care plan. Resident 19's care plan was incomplete, lacking instructions for their immediate healthcare needs, and Resident 1's care plan did not address essential health and safety instructions related to their medical conditions. Resident 13, who required communication assistance due to a language barrier, did not have a care plan that included communication strategies or tools, leaving staff without guidance on how to meet their needs. These deficiencies highlight the facility's failure to ensure timely and effective care planning, placing residents at risk for adverse outcomes.
Inadequate Administrative Oversight and QAPI Program
Penalty
Summary
The facility failed to ensure effective and efficient use of resources to maintain residents' highest practical physical, mental, and psychosocial well-being, as well as compliance with state and federal regulations. This deficiency was primarily due to inadequate clinical administrative oversight in the absence of both the Director of Nursing (DNS) and the Regional President of Clinicals. The facility did not have an Assistant Director of Nursing (ADNS) to fill in, and the Resident Care Manager (RCM), who was the only Registered Nurse (RN) available, was not appointed as the acting DNS. Consequently, the Administrator assumed responsibility for ensuring physician orders were implemented, which contributed to the facility's inability to maintain substantial compliance with regulatory requirements. The facility's historical surveys revealed ongoing non-compliance, with repeated citations for Quality of Care and Significant Medication Errors. An Immediate Jeopardy was identified related to the facility's failure to ensure 11 residents received care to maintain acceptable nutritional status. Additionally, the administration failed to develop, implement, and monitor a Quality Assurance Process Improvement (QAPI) program, and staff were not educated on the QAPI goals. These deficiencies placed residents at risk for adverse events, substandard quality of care, rehospitalization, and diminished quality of life.
Ineffective QAPI Committee and Deficient Practices
Penalty
Summary
The facility failed to maintain an effective Quality Assurance/Performance Improvement (QAPI) Committee, which did not self-identify deficient practices or implement corrective actions for identified deficiencies. The QAPI committee did not recognize issues in the new resident admission process, specifically the failure to ensure that newly admitted residents' medications were available in a timely manner and that orders were accurate, complete, and reconciled. This oversight led to a citation for significant medication errors, as the facility did not have medications available for residents. Additionally, the facility did not identify failures in ensuring residents received necessary nutrition and monitoring their response to interventions, particularly for tube feeding-dependent residents. The facility also failed to consistently implement fall care plans, initiate incident reports, or document monitoring following resident falls. Furthermore, the facility did not comply with training requirements, as they did not track annual in-service hours for CNAs, which was not self-identified by the QAPI committee.
Inadequate Investigation of Incidents and Alleged Violations
Penalty
Summary
The facility failed to conduct thorough investigations into incidents, accidents, and alleged violations involving three residents, which placed them at risk for abuse, neglect, and diminished quality of care. Resident 1, who had moderate cognitive problems and a history of falls, experienced multiple falls during their stay. The facility did not document or investigate these falls adequately, failing to identify root causes or unmet care needs. Additionally, an allegation of neglect was made by Resident 1's family member, but the facility's investigation lacked interviews, witness statements, and a thorough clinical chart review. Resident 8, who had moderate cognitive problems and required assistance with activities of daily living, experienced falls and an allegation of neglect was reported. The facility's investigation into these incidents was incomplete, lacking documentation to rule out neglect. The resident's responsible party reported issues with call light accessibility, long wait times, and inadequate care, including unaddressed urinary problems and insufficient nutrition despite a feeding tube. The facility failed to provide a thorough investigation into the circumstances leading to Resident 8's unexpected death. Resident 38, who had severe cognitive problems and was at risk for pressure injuries, was discharged with unreported wounds. The facility did not conduct a thorough investigation into the allegation of neglect reported by the resident's caregiver at the receiving facility. The caregiver discovered multiple wounds upon admission, which were not documented or treated by the facility. The lack of a comprehensive investigation into these incidents highlights the facility's failure to ensure resident safety and proper care.
Deficiencies in Medication Management, Lab Processing, and Documentation
Penalty
Summary
The facility failed to ensure that care and services provided met professional standards of practice for eight out of twelve sample residents. Specifically, the facility did not hold anti-hypertensive medications when vital signs were outside the ordered parameters for three residents. This oversight occurred despite clear physician orders to withhold medication if the systolic blood pressure was below 110 or the heart rate was below 60. The medications were administered to residents even when their vital signs indicated that the medication should have been withheld, potentially placing them at risk for adverse events. Additionally, the facility did not ensure timely collection and reporting of lab specimens for four residents. There were significant delays in collecting STAT lab orders, and in some cases, lab results were not communicated to the physician in a timely manner. For instance, one resident's critical lab result was not reported to the physician until two days after it was obtained, and another resident's urine specimen was not collected until 15 hours after the order was updated. These delays in lab processing and communication could have contributed to inadequate medical management and delayed treatment. Furthermore, the facility failed to provide consistent monitoring and documentation for residents requiring skilled nursing care. The documentation for four residents did not consistently reflect the need for skilled nursing services, nor did it adequately document changes in condition or events that occurred. This lack of thorough and timely documentation did not meet the Medicare requirements for skilled nursing care and could have impacted the quality of care provided to these residents.
Deficiencies in Wound and Heart Failure Care
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice and quality care to meet the physical, mental, and psychosocial needs of several residents. For Resident 38, the facility did not conduct weekly skin checks as ordered, failed to document a new skin impairment, and did not perform a skin check upon discharge. This resulted in the resident being discharged with multiple unreported wounds, including a Stage II pressure ulcer and deep tissue injuries, which were only discovered after the resident returned home. Resident 2 experienced a lack of consistent monitoring and care for a surgical wound on their left leg. Despite having a surgical wound with staples, there were no directives for care or monitoring in the care plan, and the dressing was not changed for several days, leading to an infection. The resident reported pain and drainage, but the facility did not address these concerns promptly, resulting in delayed healing and ongoing wound care needs. For Resident 10, the facility did not follow hospital discharge orders for heart failure management, including daily weights and monitoring for edema. The resident was not weighed daily, and their care plan did not include instructions for managing their heart and respiratory conditions. This lack of monitoring and adherence to care protocols contributed to multiple rehospitalizations for respiratory failure and heart failure exacerbations.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that 12 sampled residents were free from significant medication errors. These errors included the failure to conduct thorough medication reconciliations upon admission, verify allergies before administering medications, clarify duplicate or questionable orders, and correctly transcribe orders into the electronic Medication Administration Record (MAR). Additionally, medications were not administered timely in accordance with professional standards of practice, and identified medication errors were not reported or investigated. This placed residents at risk for adverse events, rehospitalization, poorly managed health conditions, and diminished quality of care and life. Resident 26, who had a history of stroke and heart attack, was not given their prescribed blood thinner, dabigatran, after admission, leading to a hospital transfer for neurologic changes. Resident 2, who was allergic to Lantus insulin, was administered the medication despite the allergy, and their pain medications were not accurately transcribed or administered timely. Resident 22 did not receive their prescribed insulin and blood sugar checks due to a lack of medication reconciliation on readmission. Resident 13 did not receive any of their ordered medications upon admission due to unavailability, and the physician was not notified. Other residents, such as Resident 10, experienced missed doses of critical medications like diuretics and pain patches due to unavailability, with no physician notification. Resident 38 continued to receive medications that were ordered to be stopped, and Resident 14's insulin orders were not clarified, leading to poorly controlled blood sugars. Resident 8's insulin and oxygen orders were not properly reconciled, and Resident 17's inhalant medication was unavailable without provider notification. Late medication administration was a recurring issue for Residents 23, 34, 10, and 15, with medications often given hours after the scheduled time, compromising their treatment efficacy.
Deficiency in Staff Training Documentation
Penalty
Summary
The facility failed to ensure that staff were educated on all required topics as specified in their Facility Assessment. This deficiency was identified for four sampled staff members, all of whom were Nursing Assistant Certified (NAC). The facility's assessment, dated February 27, 2025, outlined mandatory annual trainings, including Resident Rights and Facility Responsibilities, Change of Condition, Person-Centered Care Competencies, and Activities of Daily Living Competencies. However, upon review of employee files and interviews, it was found that Staff Q, who was hired on January 24, 2024, did not receive training in Resident Rights, Change of Condition, Person-Centered Care, or Activities of Daily Living. The Staff Development Coordinator, Staff P, confirmed the absence of documentation for these trainings. Further investigation revealed that training records for Staff R, Staff S, and Staff T, all NACs hired between March 2022 and December 2023, were also missing. During interviews, the Administrator and the Regional President of Clinicals acknowledged the existence of an in-service calendar intended to ensure mandatory trainings were conducted, but the calendar was not provided upon request. The Regional President of Clinicals also confirmed that competencies for the requested staff could not be found. This lack of training documentation placed residents at risk for unmet care needs and inadequate quality of care.
Failure to Provide Mandatory QAPI Training to CNAs
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to four Certified Nursing Assistants (CNAs), identified as Staff Q, R, S, and T. During an interview, Staff R, a CNA, admitted to not knowing what the QAPI committee was or the meaning of QAPI, indicating a lack of training. Staff R mentioned that they would report concerns to their nurse. The Staff Development Coordinator, Staff P, confirmed through a review of training records that Staff Q had not received QAPI training. Additionally, the facility could not provide documentation proving that Staff R, S, and T had received the required annual QAPI training. The facility's training program included a component called 'Stop and Watch,' which instructed staff to report observations and document them in the computer, but no specific QAPI curriculum was available.
Failure to Notify Guardian of New Medication Order
Penalty
Summary
The facility failed to notify the responsible party of a new medication order for a resident, identified as Resident 2, who was moderately cognitively impaired and had a court-appointed guardian. The resident was admitted with diagnoses including a communication deficit and a genetic-related intellectual disability, requiring assistance with personal care. On December 30, 2024, a physician ordered an antibiotic to treat a skin infection on the resident's leg, which was confirmed by Staff A, a Resident Care Manager (RCM). However, there was no documentation in the progress notes indicating that the resident's guardian was informed of this new medication order. Interviews with staff revealed a lack of communication and understanding of responsibilities regarding notification of new orders. Staff A stated that they confirmed pending orders each morning but did not notify the resident or their responsible party unless they were under their care management. Staff B, another RCM, was unaware of Staff A's actions and believed that whoever received or confirmed an order should inform the resident and their responsible party, documenting it in a progress note. This miscommunication and lack of notification prevented the guardian from being involved in the care planning process and being informed about the resident's medications.
Failure to Monitor and Document Skin Impairment
Penalty
Summary
The facility failed to document a measurable and descriptive baseline and routinely monitor the progression of a skin impairment for a resident with a hematoma on their left lower leg. Upon admission, the resident was noted to have a large hematoma on the left lateral calf, but there were no documented measurements or additional details describing the hematoma. Subsequent weekly skin checks also lacked documented measurements or detailed descriptions, and there was no indication of whether the hematoma was improving or worsening. Despite physician orders to monitor the hematoma and notify the provider of any delayed healing or worsening, the treatment administration record only showed that the hematoma was being monitored each shift without corresponding documentation in the electronic medical record. Interviews with staff revealed that no treatments, observations, or measurements were performed on the hematoma, and the Director of Nursing Services acknowledged that the lack of documentation meant staff would not have known if the hematoma was worsening or improving.
Failure to Administer Prescribed Respiratory Medication
Penalty
Summary
The facility failed to ensure the administration of a prescribed respiratory medication, Trelegy, for a resident diagnosed with chronic obstructive pulmonary disease (COPD) and respiratory failure. The medication was not administered on eight occasions over a period spanning late December 2024 to early January 2025. The medication administration records indicated that there should have been progress notes explaining the missed doses, but the notes revealed issues such as the medication not being located, waiting for a pharmacy refill, and the pharmacy stating it was too early for a refill. On two occasions, no progress notes were written. There was no documented communication with the resident's medical provider regarding the unavailability of the medication during this period. The resident experienced shortness of breath and was in obvious distress during the time the medication was unavailable. A collateral contact observed the resident struggling to breathe, describing the resident as "like a fish out of water." The Director of Nursing Services (DNS) stated that staff should have contacted the pharmacy, notified the doctor, requested alternative treatment orders if necessary, and informed the DNS when the medication was unavailable. The DNS also mentioned that the facility could have paid for an early refill if insurance coverage was an issue, but this step was not taken.
Failure to Notify DPOA of Medication Changes
Penalty
Summary
The facility failed to notify the designated Durable Power of Attorney (DPOA) for two residents regarding changes in their medication orders, which is a requirement for ensuring that residents' representatives are included in the plan of care. Resident 1, who was admitted to the facility and had a diagnosis of Alzheimer's dementia, began receiving hospice care and was prescribed morphine, an opioid pain medication, on 07/27/2024. Despite the administration of morphine on multiple occasions, there was no documentation indicating that Resident 1's DPOA was informed of this new medication order. Similarly, Resident 2, who also had a diagnosis of dementia, experienced a change in their medication regimen with an increased dose of Depakote, a medication for seizures, on 07/18/2024. The medical record showed that the increased dose was administered starting that evening, but there was no documentation that Resident 2's DPOA was notified of this change. Interviews with facility staff, including LPNs and the Director of Nursing Services, confirmed that the expectation was to notify the resident and their responsible party of medication changes and document these communications, which was not done in these cases.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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