Alderwood Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Spokane, Washington.
- Location
- 3600 East Hartson Avenue, Spokane, Washington 99202
- CMS Provider Number
- 505257
- Inspections on file
- 40
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Alderwood Manor during CMS and state inspections, most recent first.
A resident with a history of diabetes, peripheral vascular disease, and recent finger amputation did not receive consistent monitoring or documentation of their surgical wound. Although wound care was marked as completed on the TAR, there was little to no documentation in nurse notes about the wound's condition or changes. The resident developed a blister and infection, which was not adequately tracked, resulting in hospitalization and further amputation. Staff interviews revealed inconsistent wound monitoring practices and unclear responsibilities.
The facility failed to ensure proper hand hygiene and hair coverings during food service, risking foodborne illness. A Dietary Aide had visible facial hair without a beard covering, and a Cook wore a bandana that did not contain their hair. The Cook also engaged in improper hand hygiene, such as wiping their head with gloved hands and washing hands inadequately. The facility's policy required head and beard coverings and thorough handwashing, which were not followed.
The facility failed to obtain accurate and timely consents for psychotropic medications for several residents. A resident received sertraline with an incorrect consent, another was given lorazepam without prior consent, and a third had medications consented by a cognitively impaired representative. Additionally, a resident received Trazodone before signing the consent. These oversights were acknowledged by facility staff.
The facility failed to provide adequate ADL assistance for four residents, leading to deficiencies in cleanliness and grooming. A resident reported receiving fewer baths than care planned, while another with severe cognitive impairment received only weekly showers instead of twice-weekly. Observations noted unshaven facial hair and unkempt hair. Another resident had unclean nails and protruding nasal hair, and a fourth resident reported fewer showers than planned. Staff interviews highlighted inconsistencies in care delivery.
The facility failed to properly assess and implement interventions for residents at risk of elopement, as several residents were not included in the Elopement Book, leading to staff unawareness. Additionally, a resident with a history of falls did not receive updated care plan interventions after multiple falls, and two residents were observed smoking unsupervised despite a non-smoking policy, with care plans lacking clear instructions for supervision and storage of smoking materials.
The facility failed to properly store and dispose of medications and medical supplies, with expired medications found in carts, anti-anxiety meds not secured behind two locks, and incomplete narcotic logs. Unsecured lab supplies were found in The Bistro, and temperature logs for storage rooms were incomplete, risking medication effectiveness. Staff acknowledged these issues.
A resident's preferences for waking and bedtime hours were not accommodated or documented in their care plan, despite the facility's policy requiring person-centered planning. The resident expressed a desire to be woken up early to remove bi-pap equipment and preferred an early bedtime, but these preferences were not reflected in the care plan, leading to a risk of diminished quality of life.
A resident with dementia and depression reported missing jewelry, highlighting the facility's failure to provide secure storage for valuables. The facility's policy did not address securing personal belongings, and not all rooms had locked drawers. Staff interviews revealed inconsistencies in offering lock boxes to residents, and the grievance logs lacked documentation of the resident's concerns.
A facility failed to report and investigate abuse allegations as per its policies, involving a resident with verbal and behavioral symptoms. Despite multiple incidents of verbal aggression, the facility did not document investigations or implement protective measures, placing residents at risk for repeated abuse.
A facility failed to notify the State Long-Term Care Ombudsman of a resident's hospital transfer, as required. The resident, who was cognitively intact and had anxiety and opioid dependence, was sent to the hospital after exhibiting severe symptoms. Staff interviews revealed that the necessary transfer notification form was not completed or sent, resulting in a deficiency.
A resident was transferred to the hospital without receiving a required bed-hold notice, which informs them of their right to pay to hold their room/bed during hospitalization. Despite being cognitively intact and having conditions like anxiety and opioid dependence, the resident's record lacked this documentation. Interviews with the DON and Medical Records staff confirmed the oversight.
A facility failed to incorporate PASARR Level 2 recommendations for a resident with bipolar disorder, neglecting to implement environmental and communication strategies to support mental health needs. The care plan lacked documentation of these recommendations, and an observation showed missing items like a visible clock and schedule.
The facility failed to complete required PASARR Level 1 screenings for two residents, risking inappropriate placement and unmet mental health needs. One resident's PASARR was outdated and did not reflect current diagnoses, while another's PASARR did not indicate the need for a Level II evaluation despite documented mental health conditions. The oversight was acknowledged by the facility's administration.
A resident with dementia and paralysis exhibited possible seizure activity, but the facility failed to notify the provider. The incident was not documented in the communication binder, and no vital signs were recorded in the EMR. Staff interviews revealed uncertainty about whether the provider was informed, and the notification sheet was missing. The provider was scheduled to evaluate the resident ten days later.
A resident with a history of paralysis and a fractured femur developed an unstageable pressure ulcer on their left heel due to the facility's failure to monitor and document skin assessments. The resident was resistant to care, and refusals were not documented, leading to a delay in identifying the ulcer. Hospital records indicated pre-existing wounds, but the facility was unaware, contributing to the deficiency.
A facility failed to implement and monitor orthotic devices for a resident with a progressive neurological condition, leading to the use of rolled washcloths instead. The resident experienced discomfort with the prescribed splints, and staff used washcloths to prevent nails from digging into palms. The care plan required orthotics for six hours daily, but there was no documentation of application, monitoring, or management of refusals. The DON acknowledged the lack of monitoring and documentation.
A resident with a history of stroke and moderate cognitive impairment did not receive necessary care to maintain bowel and bladder functions. Despite assessments indicating the need for a timed voiding program, the facility failed to implement such a program, resulting in frequent incontinence. The resident expressed a preference for using the bathroom but was hindered by delayed staff response and lack of structured toileting support. The care plan lacked interventions, and therapy referrals did not address incontinence issues.
The facility failed to maintain clean respiratory equipment for two residents, risking respiratory complications. A resident with heart failure and sleep apnea had an unclean CPAP mask, while another with chronic respiratory failure had a dusty oxygen concentrator filter. The DON confirmed the importance of regular cleaning to prevent breathing issues.
The facility failed to provide consistent dialysis care for two residents. One resident was not consistently evaluated post-dialysis, missing nine evaluations in two months, while another did not receive morning medications on dialysis days, with no blood sugar checks performed. Staff acknowledged the importance of these evaluations and medication administration, but the facility's practices did not align with its policies.
The facility failed to provide trauma-informed care for two residents with histories of trauma. For one resident, the facility did not identify potential triggers or develop a comprehensive care plan, leading to an incident with a male staff member that was not promptly addressed. The other resident, with a history of mental illness, exhibited disruptive behaviors, but the facility did not document specific triggers or involve family in the evaluation process. The care plans lacked guidance for staff to prevent re-traumatization.
Two residents received medications without proper monitoring of vital signs, contrary to prescribed parameters. One resident was given metoprolol despite a low pulse, and another received Carvedilol without documented blood pressure or heart rate checks. The facility's MAR lacked sections for vital sign documentation, leading to these oversights.
The facility failed to develop a complete water management plan to mitigate Legionnaire's Disease risks and did not ensure proper handling of soiled linens. Additionally, a resident with chronic respiratory failure was exposed to infection risks when their nasal cannula was placed back in use after being on the floor without cleaning or replacement.
The facility failed to maintain clean wheelchairs for two residents, one with a history of stroke and hemiplegia and another with heart failure and diabetes. Observations over several days revealed unclean conditions, including food debris and substances on the wheelchairs. The DON confirmed that wheelchairs should be cleaned weekly, and failure to do so was a dignity issue.
A resident with a history of stroke required substantial assistance for transfers, as per their care plan. However, a staff member attempted to transfer the resident alone, resulting in the resident being assisted to the floor and sustaining a fractured arm and clavicle. The staff member did not review the resident's Kardex, which specified the need for two staff members for transfers.
Residents in the facility reported ongoing issues with the dietary services, including not receiving meals according to their preferences and being served items they disliked or were allergic to. Despite attending food committee meetings and filing grievances, residents felt their concerns were not resolved, leading to dissatisfaction and some resorting to buying their own food. Staff interviews revealed communication issues and a lack of effective resolution to the dietary complaints.
The facility failed to thoroughly investigate allegations of abuse and neglect for four residents, including grievances about rough treatment, inadequate staffing, and delayed responses to call lights. Despite residents' complaints, there was no documentation of comprehensive investigations, placing residents at risk for further abuse and neglect.
Failure to Monitor and Document Surgical Wound Leading to Infection and Hospitalization
Penalty
Summary
The facility failed to adequately monitor and document the condition of a surgical wound for one resident who had undergone amputation of the right fingertips due to dry gangrene. Upon admission, the resident had a dressing on the right hand that was not to be removed until a follow-up with the surgeon. After the initial follow-up, daily wound care was ordered and documented as completed on the Treatment Administration Record (TAR), but there was no corresponding documentation in the nurse progress notes regarding the wound's condition or any changes observed during this period. Subsequent surgical follow-ups revealed the development of a large blister and signs of soft tissue infection on the resident's right hand, leading to new wound care orders and antibiotics. While the TAR indicated that wound care was performed, there was no documentation showing that the wound was monitored for increased redness or signs of worsening infection as ordered. Nurse notes contained only brief references to the wound's appearance and infection status, with no detailed assessments or ongoing monitoring documented, especially in the days leading up to the resident's transfer to the hospital for a worsened infection. Interviews with facility staff revealed inconsistent practices and a lack of clarity regarding wound monitoring responsibilities, particularly for surgical wounds. Staff members were either unfamiliar with the resident's wound or had not observed it directly, and the Director of Nursing stated that wound observation forms were not used for surgical incisions at the time. The lack of thorough assessment and documentation contributed to the resident's condition worsening, ultimately resulting in hospitalization and further amputation.
Improper Hand Hygiene and Hair Covering in Food Service
Penalty
Summary
The facility failed to ensure proper hand hygiene and hair coverings were worn and implemented during food service, which placed residents at risk for foodborne illness. Observations revealed that a Dietary Aide, Staff Z, participated in the breakfast tray line with visible facial hair and no beard covering. Additionally, a Cook, Staff Y, was observed with a pink bandana that failed to contain their hair, allowing hair to flow down their forehead and around the sides and back of their head. Staff Y was also seen engaging in improper hand hygiene practices, such as wiping their head with gloved hands, using the same gloves to take food temperatures, and washing their hands for only seven seconds before using a paper towel to wipe down the steamer table. The facility's policy required kitchen staff to always wear head and beard coverings, regardless of their activities, and to wash hands thoroughly for at least 30 seconds. However, Staff Y did not adhere to these guidelines, as evidenced by their inadequate handwashing and improper use of a paper towel. The Dietary Manager, Staff X, confirmed the requirement for head and beard coverings and proper hand hygiene, acknowledging that Staff Y's actions did not comply with the facility's standards. Further observation showed Staff Y wearing a hairnet incorrectly, with hair exposed below the hairnet line.
Failure to Obtain Accurate and Timely Medication Consents
Penalty
Summary
The facility failed to ensure that psychotropic medication consents were accurate and obtained prior to administration for several residents. For Resident 3, the consent form for the medication sertraline was inaccurately documented as being used for somatization instead of depression, as per the physician's order and care plan. This discrepancy was acknowledged by the facility's administrator. Resident 13 was administered lorazepam for anxiety related to dialysis without a consent form being signed prior to the medication's initiation. The consent was only obtained nearly two months later, which was confirmed by the Director of Nursing. This oversight meant that the resident's representative was not informed of the medication's risks and benefits before administration. For Resident 27, the consent for medications Lexapro and Zyprexa was signed by a representative who was also a resident of the facility and had moderate cognitive impairments. This representative was unaware of the medications and their associated risks and benefits. Additionally, Resident 39 received Trazodone for insomnia before the consent was signed, which was acknowledged as a mistake by the Resident Care Manager and the Director of Nursing.
Deficiencies in ADL Assistance and Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for four residents, leading to deficiencies in cleanliness and grooming. Resident 44, who was cognitively intact and dependent on staff for bathing, reported receiving baths only once a week despite a care plan indicating twice-weekly baths. Documentation confirmed the lack of adherence to the care plan, with no records of baths on specified dates. Resident 37, with severe cognitive impairment and paralysis, required assistance for personal hygiene and showering. The care plan specified twice-weekly showers, but records showed only weekly showers were provided. Additionally, Resident 37 was observed with unshaven facial hair and unkempt hair, despite expressing a preference for being clean-shaven with a mustache. Staff interviews revealed inconsistencies in shower scheduling and shaving practices. Resident 9, with moderate cognitive impairments, required substantial assistance for personal hygiene, including nail care. Observations noted unclean nails with a brown substance and protruding nasal hair, which the resident was unaware of. Resident 19, cognitively intact, also reported receiving fewer showers than care planned, with documentation supporting this claim. Staff interviews highlighted the importance of regular showers for hygiene and dignity, yet the facility failed to meet these standards.
Deficiencies in Elopement, Fall Prevention, and Smoking Supervision
Penalty
Summary
The facility failed to ensure that residents identified at risk for elopement were accurately assessed and interventions implemented to prevent elopement for four of five sampled residents. Specifically, Residents 7, 27, 25, and 254 were not properly included in the Elopement Book, which is used to alert staff of residents at risk for elopement. Despite care plans indicating these residents were at risk, the Elopement Books at various locations in the facility did not contain their information, leading to a lack of awareness among staff about their elopement risk. Additionally, the facility did not provide adequate supervision and interventions to prevent falls for Resident 41. The resident, who had a history of falls and was identified as having poor balance and safety awareness, experienced multiple falls outside the facility. Despite these incidents, the care plan was not updated with new interventions to prevent further falls, and there was no documentation of a referral to therapy services to address the resident's mobility and safety issues. The facility also failed to supervise two residents, Residents 24 and 41, who were identified as smokers. Despite the facility's non-smoking policy, these residents were observed smoking outside the facility without staff supervision. Resident 24, who had limited mobility, was seen smoking in unsafe areas, and Resident 41, who was cognitively intact but had physical limitations, was observed smoking on the main road and in the facility's driveway. The care plans for these residents did not provide clear instructions on the supervision required or the safe storage of smoking materials.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and timely disposal of medications and medical supplies, as observed in two medication carts and two medication storage rooms. Expired medications, including insulin pens and allergy nasal spray, were found in the medication carts, and some insulin pens lacked usage dates. Additionally, anti-anxiety medications were not stored behind the required two locks, and the narcotic logs were not consistently signed by nursing staff at shift changes. These lapses in protocol placed residents at risk of receiving compromised or ineffective medication and increased the potential for drug diversion. In a room called The Bistro, unsecured lab supplies, including intravenous needles and unsealed bottles of red liquid used for stool sample transport, were found in unlocked cabinets and drawers. The room was used for family visits, staff breaks, and corporate visits, and although no residents were wandering in the area, the unsecured items posed a potential safety risk. Furthermore, the temperature logs for the medication storage rooms had multiple omissions, which could affect the effectiveness of stored vaccines. Staff interviews confirmed awareness of these issues, acknowledging the importance of proper storage and monitoring to ensure medication viability and safety.
Failure to Accommodate Resident's Bedtime Preferences
Penalty
Summary
The facility failed to accommodate the bedtime routine preferences of a resident, identified as Resident 44, which was a violation of their right to self-determination and choice. The facility's policy on Person Centered Planning required the development of a care plan that included the resident's goals, preferences, values, and practices, with the resident's participation. However, the care plan for Resident 44 did not reflect their stated preferences for waking and bedtime hours. The resident expressed a desire to be woken up at or before 6:00 AM to remove their bi-pap equipment and preferred to go to bed around 8:00 PM. Despite this, the quarterly assessment and activities evaluation indicated different preferred times, and these preferences were not documented in the care plan. Interviews with staff, including Staff L, the Activities Coordinator, confirmed that the process for identifying and documenting resident preferences was not followed in this case. Staff L acknowledged that although they were responsible for gathering information on resident preferences and adding it to the care plan, Resident 44's care plan did not include instructions for their preferred waking or bedtime hours. This oversight placed the resident at risk for a diminished quality of life, as their preferences were not accommodated or communicated to the staff.
Failure to Provide Secure Storage for Resident Valuables
Penalty
Summary
The facility failed to provide a secure place for residents to store their valuables, as evidenced by the case of a resident who reported missing jewelry. The resident, who had dementia and depression, expressed the importance of having a secure place for their belongings. Upon admission, the facility's policy required personal clothing to be marked and returned to the resident, but it did not address the security of other personal belongings. The resident reported missing a wedding ring and two diamond bracelets, which were not documented on the personal belonging inventory sheet. The resident mentioned the possibility of losing the jewelry at dialysis but was unsure of its whereabouts. Interviews with staff revealed that not all rooms had locked drawers, and newer residents were asked if they wanted a lock box, but this was not consistently communicated to all residents. The resident's room was inspected, and it was confirmed that there were no lock boxes or locking mechanisms available for securing personal items. The staff acknowledged the oversight and indicated that arrangements would be made to provide a lock for the resident's belongings. The grievance logs did not contain any entries related to the missing jewelry, indicating a lack of documentation and follow-up on the resident's concerns.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its Abuse and Neglect Prohibition Policies and Procedures, specifically in reporting allegations of abuse to the State Agency (SA) within the required timeframe and conducting thorough investigations. This deficiency was identified in the case of one resident, who was cognitively intact but exhibited verbal and behavioral symptoms such as yelling, threatening, and making disruptive sounds. Despite these behaviors, the facility did not document investigations into the psychological impact on other residents or implement protective measures to prevent recurrence. The facility's policies required immediate reporting of abuse allegations to the SA, but incidents involving the resident's verbal aggression were not logged or reported within the specified timeframe. Progress notes indicated multiple instances of verbal aggression and disruptive behavior, yet there was no documentation of investigations or measures taken to address these incidents. The facility's failure to follow its policies placed the resident and others at risk for repeated abuse, as acknowledged by the facility's administrator.
Failure to Notify Ombudsman of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman about a hospital transfer for one of the residents, identified as Resident 51. This deficiency was identified through interviews and record reviews. Resident 51, who was cognitively intact and had diagnoses including anxiety and opioid dependence, was observed in the early morning hours to be pulling their hair and experiencing severe jerking movements. Following an assessment and direction from the on-call provider, the resident was transferred to the hospital for evaluation. However, there was no documentation indicating that the Ombudsman had been notified of this transfer. Interviews with facility staff revealed a breakdown in the process of notifying the Ombudsman. Staff E, responsible for medical records, stated that the Notice of Transfer or Discharge form should have been filled out and sent to the Ombudsman by Staff F, the receptionist. Upon reviewing Resident 51's record, both Staff E and Staff F confirmed that the form was missing. Staff F explained that once the form was sent to the Ombudsman, it was supposed to be filed in the resident's record, but this step was not completed for Resident 51.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide a bed-hold notice to a resident or their representative at the time of discharge or within 24 hours of transfer to the hospital. This deficiency was identified for one of the two sampled residents, who was reviewed for hospitalization. The resident, identified as Resident 51, was cognitively intact and had diagnoses including anxiety and opioid dependence. On the early morning of August 29, 2024, the resident exhibited severe jerking movements and was observed pulling their hair, leading to a hospital transfer for evaluation as directed by the on-call provider. Upon review of Resident 51's records, it was found that there was no documentation of a bed-hold notice being provided, as required. Interviews with the Director of Nursing and Medical Records staff revealed that bed-hold notices were supposed to be completed upon admission and again when a resident was transferred to the hospital. However, the Medical Records staff confirmed that the electronic form for the bed-hold notice was not present in the resident's record, indicating it was not completed.
Failure to Implement PASARR Level 2 Recommendations
Penalty
Summary
The facility failed to incorporate specific recommendations from a PASARR Level 2 evaluation for a resident with medically complex conditions, including depression and bipolar disorder. The PASARR Level 2 evaluation recommended environmental and communication strategies to support the resident's mental health needs, such as keeping the room free of obstacles, ensuring it is well-lit during the day, and maintaining a quiet, dark, and cool environment at night. Additionally, the evaluation advised on clear communication, monitoring for changes in behavior, and early intervention to prevent manic episodes. Despite these recommendations, the facility did not document or implement them in the resident's care plan. An observation of the resident's room revealed the absence of a clock or daily schedule in a visible location, as suggested by the PASARR Level 2 evaluation. The deficiency was acknowledged by the facility's administrator, who confirmed that the recommendations should have been incorporated into the care plan.
Failure to Complete Required PASARR Screenings
Penalty
Summary
The facility failed to ensure that a PASARR Level 1 screening was completed as required for two residents, placing them at risk for inappropriate placement and not receiving necessary mental health services. Resident 3 was readmitted to the facility with complex medical conditions, including depression and anxiety disorder, but the medical record lacked a current PASARR Level 1. An outdated PASARR Level 1 from 2020 was presented, which did not recognize the resident's current diagnoses. The administrator and director of nursing acknowledged the oversight and the need for an updated PASARR Level 1. Resident 27 was admitted with diagnoses of depression, anxiety, and dementia. Although a PASARR was completed prior to admission, it failed to indicate the need for a Level II evaluation despite documenting anxiety and a mood disorder. The absence of a Level II evaluation was confirmed by the administrator, who acknowledged the necessity of a referral to meet the resident's care needs.
Failure to Notify Provider of Possible Seizure Activity
Penalty
Summary
The facility failed to notify the provider when a resident, who had no previous diagnosis of seizures, exhibited possible seizure activity. The incident involved a resident with dementia and paralysis from a stroke, who was observed having seizure-like movements while in the dining room with family. Despite the resident's vital signs being within normal limits, there was no documentation of these vital signs in the electronic medical record for the date of the incident. Furthermore, the provider was reportedly notified via a communication binder, but no entry was found in the binder, and no provider progress notes were documented after the incident. Staff interviews revealed that the absence of the notification document made it difficult to confirm whether the provider was aware of the resident's possible seizure. Staff acknowledged that a seizure would constitute a change of condition requiring provider notification. The Director of Nursing later confirmed that the notification sheet could not be located, and the provider was scheduled to evaluate the resident ten days after the initial event. This oversight placed residents at risk of not being assessed for potential decline by their provider, leading to unintended health consequences and decreased quality of life.
Failure to Monitor and Document Pressure Ulcer Development
Penalty
Summary
The facility failed to identify and monitor a pressure ulcer for a resident who was at risk due to decreased mobility and a history of paralysis and a fractured femur. Upon admission, the resident had no pressure ulcers, but a significant change assessment later documented an unstageable pressure ulcer on the resident's left heel. The care plan included interventions such as providing a pressure-relieving mattress and wheelchair cushion, conducting weekly skin checks, and notifying relevant staff if the resident refused care. However, the facility did not document refusals of care or skin assessments, and the pressure ulcer was not identified until a nurse noticed it weeks after admission. The resident had a history of refusing care and was resistant to skin checks, which was not adequately documented by the facility. Hospital records indicated the presence of wounds on both heels prior to admission, but the facility staff were unaware of these wounds. The resident's care plan was updated to address the unstageable pressure ulcer, but the lack of initial documentation and monitoring contributed to the deficiency. The resident's refusal to wear foam boots and the discomfort caused by a leg brace further complicated the situation, leading to the development of the pressure ulcer. Interviews with staff revealed that the resident's refusals were not documented, and the facility did not have a complete understanding of the resident's condition upon admission. The Director of Nursing acknowledged the lack of documentation and stated that a full skin assessment was conducted only after the wound was identified. The facility's failure to document refusals and monitor the resident's skin condition led to the deficiency, as the pressure ulcer was not addressed in a timely manner.
Failure to Implement and Monitor Orthotic Devices for Resident
Penalty
Summary
The facility failed to properly implement and monitor the use of orthotic devices for a resident, identified as Resident 10, who was at risk for contractures due to a progressive neurological condition. Despite being part of a Restorative Nursing Program, Resident 10 was observed using rolled washcloths instead of the prescribed orthotic devices. The resident reported discomfort with the splints, leading to the use of washcloths, which were not consistently effective as one often fell out of the resident's hand. Staff interviews confirmed the use of washcloths to prevent the resident's nails from digging into their palms and to cushion their arms. The care plan for Resident 10 included instructions to apply orthotics to both hands for up to six hours a day, with skin checks each shift. However, there was no documentation of the application, monitoring, or management of the orthotics, nor any record of the resident's refusals or the reasons for them. The Director of Nursing acknowledged the lack of monitoring and documentation regarding the orthotics and the absence of an order in the treatment administration record to ensure compliance with the care plan.
Failure to Implement Toileting Program for Resident
Penalty
Summary
The facility failed to provide necessary care and services to Resident 18, who was admitted with a stroke and moderate cognitive impairment, to maintain and avoid loss of bowel and bladder functions. The resident required substantial assistance for toileting and was frequently incontinent of bowel and bladder. Despite assessments indicating the need for a timed or scheduled voiding program, no such program was implemented. Observations revealed that the resident was often left in bed without timely assistance to use the bathroom, leading to incontinence episodes. The resident expressed a preference for using the bathroom but was unable to do so due to delayed staff response and lack of a structured toileting program. The facility's documentation showed inconsistencies in the assessment of the resident's incontinence and the interventions provided. Various assessments identified different types of incontinence, such as urge, functional, and stress incontinence, but failed to result in a consistent care plan. Although referrals to occupational and physical therapy were made, there was no documentation of evaluations or interventions to address the resident's incontinence. The care plan did not include interventions for a timed or scheduled voiding program, despite the resident meeting the criteria for such a program in multiple evaluations. The Director of Nursing acknowledged the lack of interventions and the conflicting assessment results.
Failure to Maintain Clean Respiratory Equipment
Penalty
Summary
The facility failed to maintain clean oxygen delivery equipment for two residents, leading to potential risks of respiratory complications and infection. Resident 19, who had heart failure and obstructive sleep apnea, required a CPAP machine. Despite a physician's order to clean the CPAP mask daily, observations revealed that the mask was unclean with white splatter inside, and the resident reported that staff had not been cleaning it. The CPAP was also stored in a drawer full of crumbs, indicating a lack of proper hygiene and maintenance. Resident 38, diagnosed with chronic respiratory failure and asthma, required oxygen therapy. The physician's order specified that the oxygen concentrator filter should be cleaned weekly. However, an observation found the filter covered in thick dust debris. The Director of Nursing confirmed the importance of cleaning the equipment to prevent interruptions in oxygen flow and potential breathing difficulties. These observations highlight the facility's failure to adhere to prescribed cleaning protocols for respiratory equipment.
Inconsistent Dialysis Care for Two Residents
Penalty
Summary
The facility failed to provide consistent dialysis care in accordance with professional standards for two residents. Resident 13, who had paralysis and end-stage kidney disease, was not consistently evaluated post-dialysis. The facility's policy required staff to check vital signs and document the resident's status in the Dialysis Communication Binder after each session. However, there were nine instances in September and October 2024 where the post-dialysis evaluation was not completed. Staff D, the Resident Care Manager, acknowledged the importance of these evaluations to monitor for adverse reactions and maintain communication with the dialysis center. Resident 19, diagnosed with heart failure and end-stage kidney disease, did not receive their morning medications on dialysis days. The care plan required blood sugar checks and medication administration at least two hours before or after dialysis. However, the October 2024 medication administration record showed no blood sugar checks before dialysis and inconsistent medication administration on dialysis days. Staff B, the Director of Nursing, confirmed the necessity of monitoring blood sugars and administering medications appropriately. The dialysis clinic stated they did not check blood sugars unless symptomatic and did not administer facility-prescribed medications.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for two residents, Resident 3 and Resident 25, who were reviewed for trauma-informed care. For Resident 3, the facility did not adequately assess and identify potential triggers that could re-traumatize the resident, nor did it develop and implement a comprehensive Trauma Informed Care Plan. Despite Resident 3's history of physical assault and severe human suffering, the facility's evaluation did not list any triggers, and staff were unaware of what could trigger re-traumatization. An incident involving a male staff member who exhibited intimidating behavior was reported, but the facility did not monitor Resident 3 for adverse reactions until two days later. Resident 25, who was assessed as cognitively intact and had a history of mental illness, also did not receive adequate trauma-informed care. The facility's evaluations identified that Resident 25 had experienced a very stressful event but failed to document what the event was or identify specific triggers. The resident exhibited several disruptive behaviors, including yelling, banging, and verbal aggression, but the care plan lacked trigger-specific interventions to prevent re-traumatization. The facility did not involve family members or representatives in the evaluation process, and the care plan did not provide guidance to staff on how to address the resident's reactions. The deficiencies were acknowledged by the facility's Administrator and Director of Nursing, who recognized the lack of interventions and guidance in the care plans for both residents. The facility's failure to identify triggers, coping mechanisms, and strategies to manage re-traumatization placed the residents at risk for re-traumatization and a diminished quality of life.
Failure to Monitor Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to ensure proper monitoring of blood pressures and heart rates, leading to the administration of medications against prescribed parameters for two residents. Resident 10 had an order for metoprolol, which was to be held if the pulse was below 60 beats per minute. Despite this, the medication was administered on multiple occasions when the resident's pulse was below the threshold. This oversight was acknowledged by Staff D, a Registered Nurse/Resident Care Manager, who confirmed that the medication should have been withheld on those days. Resident 22, who had diagnoses including hypertensive kidney disease and dementia, was prescribed Carvedilol with instructions to hold the medication if the systolic blood pressure was less than 110 or the heart rate was below 60 beats per minute. However, the facility's Medication Administration Record (MAR) lacked a section for documenting vital signs, and the resident received the medication without proper monitoring. Staff J, an LPN, confirmed that there was no place to document the vital signs on the MAR, and vital signs were only taken every other day. Staff D admitted that the monitoring requirement had been overlooked, leading to the administration of the medication without verifying the necessary parameters.
Inadequate Infection Control and Water Management
Penalty
Summary
The facility failed to develop a comprehensive water management plan to address the risk factors associated with Legionnaire's Disease. The plan, last reviewed on March 11, 2024, was incomplete, lacking essential components beyond identifying the facility's water source, contacts, and characteristics. This deficiency was confirmed by the facility's administrator, who acknowledged the need for a more detailed plan. Additionally, the facility did not ensure proper handling of soiled linens, as observed when a nursing assistant transported a soiled gown without placing it in a bag, contrary to infection control protocols. Furthermore, the facility failed to maintain sanitary conditions for oxygen administration for a resident with chronic respiratory failure. The resident's nasal cannula was found on the floor, and a nursing assistant placed it back in the resident's nose without cleaning or replacing it, which was identified as an infection control concern by the infection preventionist.
Failure to Maintain Clean Wheelchairs for Residents
Penalty
Summary
The facility failed to maintain wheelchairs in a clean manner for two residents, which was observed during a survey. Resident 14, who had a history of stroke and hemiplegia, was noted to have moderate cognitive impairments and required substantial to total assistance for all care. Observations on multiple occasions revealed that the resident's wheelchair was unclean, with the left armrest covered in sheepskin and netting that had brown and red substances on it. Additionally, food debris was crusted on the cushion and bottom of the chair. These observations were made over several days, indicating a persistent issue with maintaining cleanliness. Similarly, Resident 19, who was cognitively intact and required substantial to total assistance, was observed with an unclean wheelchair containing food debris. This was noted on several occasions over a few days. An interview with the Director of Nursing confirmed that wheelchairs were supposed to be cleaned weekly, and failure to do so was considered a dignity issue for the residents. The lack of cleanliness in the wheelchairs for these residents was a deficiency in maintaining a safe and dignified environment.
Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident was transferred according to their care plan, resulting in harm. The resident, who had a history of a stroke affecting their right side and required substantial assistance with transfers, was supposed to be transferred by two staff members using a gait belt or a sit-to-stand lift. However, Staff A attempted to transfer the resident alone using a gait belt. During the transfer, the resident's legs gave out, and Staff A assisted them to the floor. The wheelchair brake was inadvertently released, causing the wheelchair to slide back, and the resident landed on the floor. Initially, the resident did not report any pain or abnormalities, but later complained of pain, and an x-ray revealed a fractured right arm and clavicle. Staff B, a Registered Nurse, confirmed that Staff A did not review the resident's Kardex, which indicated the need for two staff members for transfers. The Director of Nursing acknowledged that Staff A did not follow the care plan, leading to the resident's injuries.
Failure to Address Dietary Grievances
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances related to dietary issues for eight out of nine residents. Residents reported that their food preferences, as indicated on meal cards, were not being honored. This included not receiving the food they ordered, being served items they disliked, and in some cases, receiving food they were allergic to. Despite attending food committee meetings and voicing their concerns, residents felt that their grievances were not addressed, leading to ongoing dissatisfaction with the dietary services provided. Interviews with residents revealed consistent issues with the facility's food service. Residents expressed frustration over not receiving the meals they selected, with some resorting to purchasing their own food due to dissatisfaction. Specific grievances included being served cold food, not receiving required dietary supplements, and experiencing rude behavior from staff when rejecting meals. The facility's grievance records corroborated these complaints, showing repeated concerns about the kitchen staff not adhering to residents' meal preferences and dietary needs. Staff interviews indicated a lack of effective communication and follow-through on resolving the dietary issues. The Dietary Manager acknowledged the problems but attributed them to misunderstandings about menu processes and a lack of time for cooks to review individual dislikes. Despite attempts to educate staff and involve them in food committee meetings, the issues persisted, with residents continuing to feel that their concerns were not being adequately addressed.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and/or neglect for four residents, which placed them at risk for further abuse and/or neglect. Resident 4, who had heart disease, filed a grievance about a Licensed Practical Nurse (LPN) being rough and rude. The Director of Nursing (DNS) documented speaking with the resident and ruling out abuse/neglect, but there was no evidence of a thorough investigation, including interviews with the resident and staff. Resident 5, diagnosed with diabetes and paraplegia, reported grievances about two nurses being rude and not being assisted out of bed for three days due to staff unavailability and lack of training with the Hoyer lift. The facility's response involved speaking with the resident and adjusting staffing, but there was no documentation of a comprehensive investigation into the allegations. Similarly, Resident 6, with respiratory disease, reported a lack of staff availability when they were sick, but the facility's response did not include a thorough investigation. Resident 7, with a central nervous system disease, filed a grievance about inadequate staffing and a delayed response to their call light. The facility's response indicated that staffing was adequate, but there was no documentation of a detailed investigation. Interviews with staff revealed that grievances were logged and assigned to relevant departments, but allegations of abuse and/or neglect were not investigated as required, and the grievances were not treated as such.
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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