Americana Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Longview, Washington.
- Location
- 917 7th Avenue, Longview, Washington 98632
- CMS Provider Number
- 505361
- Inspections on file
- 20
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Americana Health And Rehabilitation during CMS and state inspections, most recent first.
Several residents did not receive timely bowel interventions as ordered, with staff failing to administer or document required steps such as laxatives, suppositories, or enemas after multiple days without a bowel movement. Staff interviews confirmed that the bowel management protocol was not consistently followed or documented, resulting in prolonged periods without appropriate care.
Surveyors found that two residents receiving IV therapy did not have their PICC lines properly assessed or monitored according to facility policy and professional standards. Orders were incomplete, lacking details such as PICC type and required monitoring, and documentation was missing for key assessments like external length and arm circumference measurements, as well as for needleless cap changes and daily site checks. The DON confirmed these deficiencies in documentation and order completeness.
A resident's trust account balance was not transferred to the Office of Financial Recovery within the required 30-day period following the resident's death. The funds remained in the facility's account for several months before being conveyed, as confirmed by the Business Office Manager.
A resident's bed was placed against the wall, constituting a potential physical restraint, without a documented Safety Device Evaluation, consent, or physician's order. The resident, who was moderately cognitively impaired, reported no discussion about the bed placement. Staff interviews confirmed that required documentation and consent were missing, in violation of facility policy.
A resident's admission MDS assessment was not completed within the required 14-day timeframe, with the assessment being finalized 20 days after admission. The MDS Coordinator confirmed the delay during an interview, and records supported the finding.
Two residents had inaccurate MDS assessments: one with a terminal diagnosis receiving hospice care was not coded as having a terminal prognosis, and another's frequency of care refusals was underreported compared to medication and meal records. The MDS Coordinator confirmed both assessments were inaccurate.
Care plans for three residents were not updated to include treatment for an anal fissure, constipation, or the presence and management of PICC lines for IV therapy. The DON confirmed that these care needs should have been addressed in the care plans.
Nursing staff did not consistently follow or clarify physician orders for three residents, including failing to notify providers of significant weight changes, improperly holding prescribed medication despite vital signs being within parameters, and not clarifying PICC line flush orders. These actions resulted in incomplete documentation and lack of required provider notifications.
A resident assessed to need a passive ROM Restorative Nursing Program (RNP) five times weekly received the intervention only about once per week over a 52-day period, far less than prescribed. The DON confirmed the RNP was not provided at the required frequency.
The facility failed to label and date food items in the kitchen and nourishment refrigerators, leading to the disposal of undated and expired items. The Dietary Manager and Director of Nursing acknowledged the oversight, which included unlabeled celery and carrot sticks, expired pumpkin pie, cake, sour cream, and other items. This failure to adhere to facility policy posed a risk to resident safety.
The facility failed to label medications with the date first accessed in two medication storage areas and did not secure medications for a resident. Multi-dose vials of insulin and a TB test solution were found without access dates, and a resident's medications were left unsecured on a bedside table. Staff acknowledged the need to discard undated medications and ensure medication security.
A resident, who was moderately cognitively impaired, received an influenza vaccination without a signed consent from the resident or their representative. The facility's policy requires documentation of consent or declination in the EHR, but a review showed no signed consent. Staff confirmed the absence of consent, acknowledging that it should have been obtained yearly before vaccination.
A facility failed to ensure residents were free from physical restraints, as a resident's bed was repeatedly observed against the wall, potentially restricting movement. Staff acknowledged the need for consent and care plan inclusion, but these were not in place. The DON confirmed the bed should not have been positioned against the wall, highlighting a lapse in monitoring and adherence to care plans.
A facility failed to develop a comprehensive care plan for a resident on Apixaban, an anticoagulant, for paroxysmal atrial fibrillation. The care plan lacked documentation for monitoring side effects, despite facility policy requiring such monitoring. The resident was observed with discoloration of the lower extremities, a potential side effect, but staff could not provide documentation of a care plan addressing anticoagulant therapy and side effect monitoring.
A facility failed to initiate bowel interventions for a resident who did not have a bowel movement for over four days on two occasions. The facility's bowel protocol requires intervention after three days without a bowel movement, but records showed no such actions were taken. Staff interviews confirmed the oversight, with the LPN acknowledging the resident should have been on the list for interventions, and the DON unable to provide documentation of any actions taken.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic wound, as required by CMS guidelines. Despite the resident having a right heel wound needing daily dressing changes, no EBP signage or PPE was observed. The Infection Preventionist stated EBP was unnecessary due to the lack of drainage, contradicting CMS recommendations. A nurse confirmed using only gloves during wound care, increasing the risk of infection transmission.
A resident with moderate persistent asthma experienced respiratory failure due to the facility's failure to notify the physician of significant respiratory changes and obtain necessary medications. Despite administering oxygen and other treatments, the facility did not document physician notification or orders, leading to the resident's hospitalization and intubation.
Failure to Initiate and Document Bowel Interventions per Physician Orders
Penalty
Summary
The facility failed to initiate and document bowel interventions as ordered for five residents who were reviewed for quality of care. According to the facility's bowel protocol and physician orders, licensed nurses were required to monitor bowel movements daily and administer specific interventions if a resident had not had a bowel movement for three days. These interventions included administering milk of magnesia on day four, followed by a stimulant laxative suppository or oral tablet if there was no result, then an enema if still no result, and notifying the physician if all interventions failed. However, record reviews showed that these steps were not followed for multiple residents. For example, one resident went approximately 139 hours without a bowel movement, and another went about 228 hours, with no documentation of any bowel interventions during these periods. Another resident experienced a gap of 110 hours between bowel movements, again with no evidence of interventions being administered as per protocol. Additionally, a resident reported experiencing constipation and hard stools, with records confirming that staff did not administer the required interventions on the fourth day without a bowel movement. In another case, a resident went seven days without a bowel movement, and although some interventions were attempted, staff failed to follow through with the full protocol as ordered. Interviews with staff, including the Resident Care Manager, LPN, and DON, confirmed that the bowel management protocol was not consistently followed or documented. Staff acknowledged that alerts should have triggered interventions and that the protocol should have been initiated and documented per policy. However, they were unable to provide documentation of successful bowel interventions for the affected residents during the periods in question.
Failure to Properly Assess and Monitor IV Access Devices
Penalty
Summary
The facility failed to ensure that intravenous (IV) access devices were assessed, maintained, and monitored according to professional standards of practice for two residents who were receiving IV therapy. The facility's policy required staff to measure the external length of a Peripherally Inserted Central Catheter (PICC) and the resident's arm circumference upon admission or insertion, and then weekly with dressing changes. However, for both residents reviewed, there was no documentation that these measurements were obtained at admission or during their stay. Additionally, staff did not consistently document the changing of needleless injection caps with dressing changes or daily assessment of the PICC insertion site for signs of complications. For one resident with diagnoses of intervertebral discitis and osteomyelitis who was receiving IV antibiotics, physician orders for PICC maintenance and monitoring were incomplete. The orders did not specify whether the PICC was valved or non-valved, the number of lumens, or the location of the line, and directed staff to use a flush protocol that was inconsistent with facility policy. The resident's care plan did not address the type, location, or required maintenance and monitoring of the PICC. Medication and treatment administration records indicated that staff signed off on daily flushing of the PICC, but it was unclear which protocol was followed, and there was no documentation of required cap changes or site assessments. For another resident with a diagnosis of left lower extremity cellulitis who was also receiving IV antibiotics, physician orders similarly lacked direction for daily monitoring of the PICC insertion site and did not require measurement of the PICC external length upon admission or weekly. The orders also failed to specify whether the PICC was valved or non-valved and the number of lumens. Documentation showed that staff signed for dressing changes and arm circumference measurements, but there was no place to record the actual measurements, and no documentation was found that these assessments were performed. The Director of Nursing Services confirmed the lack of documentation and incomplete orders for both residents.
Delayed Conveyance of Resident Funds After Death
Penalty
Summary
The facility failed to ensure that resident funds were conveyed to the Office of Financial Recovery (OFR) within 30 days of a resident's death or discharge, as required. Specifically, review of records showed that a resident was transferred to the hospital and subsequently passed away on the same day. Despite this, the resident's trust account balance of $60 remained in the facility's account from March through August, and was not conveyed to the OFR until several months after the resident's death. During an interview, the Business Office Manager confirmed that the funds were not transferred within the required timeframe.
Failure to Obtain Consent and Evaluation for Bed Placement as a Physical Restraint
Penalty
Summary
The facility failed to obtain a Safety Device Evaluation, consent, and/or a physician's order for the use of a physical restraint for one resident. Specifically, the resident's bed was positioned with the right side against the wall, which is considered a potential restraint. There was no documentation in the resident's electronic health record of an evaluation, consent, or physician's order related to this bed placement. The resident, who was moderately cognitively impaired according to the most recent assessment, stated that her bed had always been positioned this way and that no one had discussed the reason for it with her. Interviews with facility staff, including an LPN and the DON, confirmed that facility policy requires resident consent and an evaluation before implementing any type of restraint or safety device. Both staff members were unable to locate any documentation or consent for the bed placement for this resident. The facility's policy also requires that the care plan be updated and evaluated regularly for device use, but there was no evidence that these steps were followed in this case.
Late Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete the admission Minimum Data Set (MDS) assessment within the required 14 days for one resident. Specifically, a review of records showed that the resident was admitted on a certain date, but the admission MDS was not completed until 20 days after admission, exceeding the regulatory timeframe. During an interview, the MDS Coordinator confirmed that the assessment was not completed by the 14th calendar day as required. This deficiency was identified through both interview and record review, and it was noted that such delays could place residents at risk for unidentified or unmet care needs.
Inaccurate Resident Assessments Documented in MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the health status and care needs of two residents. For one resident with a terminal diagnosis of severe COPD, respiratory failure, and hypoxia, hospice intake paperwork and ongoing hospice documentation confirmed a life expectancy of less than six months and continuous hospice services. However, multiple Quarterly Minimum Data Set (MDS) assessments did not indicate the resident's terminal prognosis, despite the resident remaining on hospice care throughout the period. The MDS Coordinator confirmed that these assessments were inaccurate and should have reflected the terminal prognosis. For another resident, the Quarterly MDS assessment documented that the resident rejected care on 1-3 days during the assessment period. However, a review of the Medication Administration Record and meal monitor showed that the resident refused medications and alternative meals on five of seven days during the same period. The MDS Coordinator acknowledged that the MDS was inaccurate and required modification to reflect the correct frequency of care rejection. These inaccuracies in resident assessments were identified through interviews and record reviews.
Care Plans Not Updated to Reflect Residents' Clinical Needs
Penalty
Summary
The facility failed to ensure that care plans were reviewed, revised, and accurately reflected the care needs of three residents. For one resident, there was an order to cleanse and treat an anal fissure, but the comprehensive care plan did not address this condition. Additionally, this resident was noted to be constipated according to the Minimum Data Set, but no care plan was developed or implemented for constipation. The Director of Nursing Services acknowledged that both the anal fissure and constipation should have been included in the care plan but were not. Another resident was admitted with a peripherally inserted central catheter (PICC) and an order for intravenous antibiotics due to septic arthritis and spondylodiscitis, but the care plan did not address the type, location, number of lumens, or maintenance and monitoring instructions for the PICC. Similarly, a third resident had a PICC for IV infusions to treat muscle calcification, but the care plan lacked documentation regarding the PICC's type, location, number of lumens, and maintenance and monitoring instructions. In each case, the DON confirmed that these aspects should have been included in the residents' care plans.
Failure to Follow and Clarify Physician Orders and Notify Providers
Penalty
Summary
Nursing staff failed to follow and/or clarify physician orders and did not notify providers as required for three residents. For one resident, daily weights were ordered, but significant weight variances exceeding three pounds in 24 hours were not reported to the provider on multiple occasions, and there was no documentation of such notifications. Another resident had an order for metoprolol with specific parameters for holding the medication and notifying the physician; however, staff held the medication multiple times when the resident's vital signs were within the ordered parameters, and did not notify the physician as required. Additionally, this resident experienced a weight loss of 5.8 pounds in 24 hours, but there was no documentation that the physician was notified as ordered. For a third resident, there was an order to flush a PICC line with normal saline and, if non-valved, with heparin. The order was transcribed without specifying whether the PICC was valved or non-valved, making it unclear if the appropriate flushes, including heparin, were administered. The DON confirmed that the documentation did not clarify this and that staff did not seek clarification of the order.
Failure to Provide Prescribed Passive ROM Program
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received the prescribed treatment and services to maintain or improve ROM. The resident, who was cognitively intact, was assessed to require a passive ROM Restorative Nursing Program (RNP) to both lower extremities, consisting of two sets of 15 repetitions (hip flexion, hip abduction, heel sliders, and ankle pumps) five times a week. However, review of restorative flowsheets showed that over a 52-day period, the passive ROM RNP was only offered or provided on eight out of 36 scheduled days, averaging approximately 1.1 times per week, which was significantly less than the care plan required. The Director of Nursing Services confirmed that the RNP was not provided at the assessed frequency.
Failure to Label and Date Food Items in Refrigerators
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in both the kitchen and nourishment refrigerators, as observed during a survey. In the kitchen walk-in refrigerator, undated and unlabeled items such as a plastic bag of celery sticks, a plastic bag of carrot sticks with a received date, and a cardboard box containing rosemary were found. The Dietary Manager, Staff N, acknowledged that these items should have been dated and was unable to determine how long they had been stored. Consequently, these items were discarded as they were deemed unsafe for consumption. In the nourishment refrigerator/freezer located in the central supply room, several items were found to be undated or expired, including a pumpkin pie, a quarter sheet of cake, a jar of sour cream, a plastic container of coffee creamer with an illegible expiration date, a partially consumed ice cream shake, and a ziplock bag containing unknown food items. Staff N confirmed that it was the responsibility of the kitchen staff to manage the items in the fridge and admitted that the items in question were not safe to consume, leading to their disposal. The Director of Nursing Services, Staff B, stated that she expected all food items to be dated and labeled according to facility policy.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to properly label medications with the date they were first accessed in two of three medication storage areas, specifically in the Ocean Side medication storage room and medication cart. During an observation, a multi-dose vial of purified protein derivative used for TB skin tests was found in the medication refrigerator without a date indicating when it was first accessed. Additionally, two multi-dose vials of insulin, Humulin and Lispro, were observed on the medication cart without dates showing when they were first accessed. Staff members acknowledged that medications without open dates should be discarded to prevent administering potentially unsafe medications. Furthermore, the facility did not ensure the security of medications for a resident, as observed when a medicine cup containing various pills was left on the resident's bedside table while she was eating breakfast. The Resident Care Manager and LPN stated that the nurse should have remained with the resident until all medications were ingested or secured them if the resident was not ready to take them. The Director of Nursing Services confirmed that it was expected that nurses do not administer medications without a date showing when they were first accessed and that such medications should be discarded.
Failure to Obtain Consent for Influenza Vaccination
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed and provided consent before administering an influenza vaccination. This deficiency was identified for one of the five sampled residents reviewed for the right to be informed to make treatment decisions. Specifically, Resident 24, who was moderately cognitively impaired, received an influenza vaccination on 10/04/2024 without a signed consent from the resident or the resident's representative. The facility's policy, updated on 01/04/2023, requires documentation in the Electronic Health Record (EHR) of consent or declination for each resident. However, a review of Resident 24's EHR showed no signed consent for the vaccination. Staff C, an Infection Preventionist and RN, confirmed the absence of a signed consent, and Staff B, the Director of Nursing Services and RN, acknowledged that a consent should have been signed yearly before administering the influenza vaccination.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints, as evidenced by the case of Resident 19. Resident 19, who was moderately cognitively impaired, was observed multiple times with their bed positioned against the wall, which could potentially restrict movement. Staff K, an MDS Coordinator and RN, acknowledged that such a setup should have a consent, an order, and be part of the care plan. However, Staff E, a Resident Care Manager and LPN, admitted that there was no consent found, and it was not included in the care plan. Furthermore, Staff B, the Director of Nursing Services, confirmed that Resident 19's bed was not supposed to be against the wall and emphasized that staff should monitor bed placements and adhere to the care plan. This oversight placed residents at risk for injury and decreased quality of life.
Failure to Develop Comprehensive Care Plan for Anticoagulant Monitoring
Penalty
Summary
The facility failed to develop a comprehensive care plan for monitoring the side effects of anticoagulant therapy for Resident 150, who was on Apixaban for paroxysmal atrial fibrillation. Despite the facility's policy requiring monitoring for complications from anticoagulant medications, Resident 150's care plan, dated 11/21/2024, did not include documentation for anticoagulant therapy or side effect monitoring. Additionally, the electronic health record lacked orders addressing anticoagulant side effect monitoring. On 12/12/2024, Resident 150 was observed with significant discoloration of the lower extremities, a potential side effect of anticoagulant therapy, but the resident was unable to provide further information. Staff M, an LPN, confirmed that residents on anticoagulants were monitored daily for issues like bruising and bleeding, and that such monitoring should be part of the care plan. However, Staff M and Staff B, the Director of Nursing Services, were unable to provide documentation of a care plan for anticoagulant therapy and side effect monitoring for Resident 150.
Failure to Initiate Bowel Protocol for Resident
Penalty
Summary
The facility failed to initiate bowel interventions for a resident, identified as Resident 35, who was reviewed for quality of care related to constipation. According to the facility's bowel protocol, if a resident does not have a bowel movement for three days, the nurse is required to administer the physician-ordered bowel program. In the absence of a specific bowel program, the protocol dictates the administration of Milk of Magnesia on the fourth day, followed by a stimulant laxative suppository if there are no results, and an enema if necessary, with physician notification if there is still no result. However, the records for December 2024 showed that Resident 35 did not have a bowel movement for over four days on two separate occasions, yet the bowel protocol was not initiated as required. Interviews with staff revealed that the Licensed Practical Nurse, Staff M, acknowledged the oversight, stating that Resident 35 should have been on the list for bowel interventions and had not been given Milk of Magnesia since September. The Director of Nursing Services, Staff B, confirmed that the bowel protocol should have been initiated according to the facility's policy but was unable to provide documentation showing that the necessary interventions were carried out for Resident 35. This failure to follow the bowel protocol placed the resident at risk for discomfort and health complications.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for a resident, identified as Resident 33, who was reviewed for infection prevention and control. According to the Centers for Medicare and Medicaid Services (CMS) Memorandum, EBP should be employed for residents with chronic wounds or indwelling medical devices during high-contact care activities, regardless of their multidrug-resistant organism status. Resident 33 had a right heel wound that required daily dressing changes, yet there was no EBP signage or personal protective equipment (PPE) observed on the resident's door or room entrance during multiple observations. Staff C, the Infection Preventionist and Registered Nurse, stated that if wounds are contained, residents do not necessarily require precautions, and since Resident 33's wound did not have drainage, EBP was deemed unnecessary. However, this contradicts the CMS guidelines that recommend EBP for residents with open wounds. Staff G, a Licensed Practical Nurse, confirmed changing the dressing without using additional PPE beyond gloves. This oversight in implementing EBP placed residents at risk for contracting infectious diseases and decreased their quality of life.
Failure to Notify Physician of Respiratory Changes
Penalty
Summary
The facility failed to ensure timely physician consultation and notification regarding a significant change in a resident's respiratory status, which led to harm. A resident with a history of moderate persistent asthma and status asthmaticus experienced respiratory failure requiring hospitalization and intubation. The facility did not notify the physician of the need for oxygen administration orders or obtain necessary seasonal allergy and asthma medications in a timely manner. The resident was admitted with diagnoses including moderate persistent asthma and was alert and oriented. Despite experiencing respiratory symptoms such as shortness of breath and wheezing, the facility did not document physician notification after administering medications like Albuterol and Guaifenesin. The resident's oxygen saturation levels were below normal, and although oxygen was administered, there was no documentation of physician notification or orders for oxygen administration. Staff interviews revealed a lack of clarity and follow-through in the process of obtaining physician orders and addressing the resident's respiratory symptoms. The resident requested an Advair inhaler, which was not provided due to an expired medication and lack of response from the physician. The resident was eventually found unresponsive with critically low oxygen saturation levels, leading to emergency hospitalization.
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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