Arlington Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Arlington, Washington.
- Location
- 620 South Hazel Street, Arlington, Washington 98223
- CMS Provider Number
- 505351
- Inspections on file
- 31
- Latest survey
- January 26, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Arlington Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to adhere to professional food safety standards, with observations revealing undated and unlabeled food items in the kitchen and nourishment refrigerators. Spoiled cucumbers and improper labeling practices were noted, posing risks of food contamination and foodborne illnesses. Staff interviews confirmed that open food items should be dated and discarded if not compliant.
Two residents in a facility were administered psychotropic medications without appropriate diagnoses or documentation of non-pharmacological interventions. One resident received Seroquel without a valid diagnosis, and the facility failed to limit PRN use to 14 days. Another resident was given Lorazepam and Seroquel for reasons not aligned with the orders, and non-pharmacological interventions were not documented. Staff interviews revealed confusion and lack of documentation regarding medication use and interventions.
The facility failed to complete comprehensive Resident Assessment Instruments (RAIs) and Care Area Assessments (CAAs) for several residents, including those with psychotropic drug use, stroke, diabetes, dementia, and severe cognitive impairment. The assessments lacked necessary summaries and analyses of residents' goals, preferences, strengths, or needs, crucial for updating care plans. Staff interviews revealed confusion over responsibilities and incomplete documentation, impacting the quality of care provided.
The facility failed to implement comprehensive care plans for residents, leading to deficiencies in individualized care. A resident with dementia was at risk for wandering, yet their care plan lacked interventions. Another resident used a positioning wedge not reflected in their care plan. A resident with chronic conditions reported not having a shower, and their care plan lacked person-centered interventions. A resident with severe cognitive impairment struggled to eat independently, and their care plan did not reflect the need for feeding assistance. Another resident's care plan did not accurately reflect their activity preferences or the need for heel floating.
The facility failed to provide adequate care and communication for several residents, including a resident with CHF who experienced significant weight gain without provider notification, leading to hospitalization. Another resident with swallowing difficulties did not receive a full evaluation, and a resident with insomnia was not given prescribed medication due to a pharmacy issue. Additionally, a resident with ongoing diarrhea continued to receive a stool softener, and a resident did not have timely follow-up with an infectious disease doctor.
The facility failed to comply with Infection Prevention and Control Guidelines, with staff not adhering to Enhanced Barrier Precautions, proper hand hygiene, and catheter care protocols. A resident with a cholecystostomy tube did not receive appropriate peri-care, and a resident with multi-drug resistant bacteria had improper wound care. Miscommunication about precautionary measures and inadequate signage further contributed to the risk of infection transmission.
A facility failed to provide proper respiratory care for a resident with COPD, as the oxygen concentrator was set incorrectly at 2.5 lpm instead of the ordered 2 lpm. The resident's nasal cannula was improperly positioned or not in use during observations. The LPN did not verify the concentrator settings, and the DON confirmed the expectation to ensure settings matched physician orders.
A facility failed to develop a comprehensive dementia care plan for a resident, lacking specific interventions and personalized goals to address their physical, mental, and psychosocial needs. The resident exhibited anxiety and wandering behaviors, but the care plan did not include strategies to manage these issues. Staff interventions, such as encouraging phone calls to the resident's daughter and engaging in music, were not documented in the care plan, placing the resident at risk for unmet needs.
A resident with a left hip fracture requiring assistance for transfers did not receive scheduled showers since admission, despite being on a shower schedule. Staff interviews revealed a lack of documentation and follow-up on bathing tasks, leading to a deficiency in providing necessary ADL care.
The facility failed to properly store and dispose of medications, with expired lorazepam found in the medication room and an open bottle of Acidophilus requiring refrigeration left unrefrigerated in a medication cart. An LPN noted that the night shift was responsible for these tasks, but inconsistencies in adherence to protocols were evident.
The facility failed to serve meals in a timely manner and at appropriate temperatures, impacting food palatability and safety. Meal trays were observed sitting in the hallway of South Hall, with oatmeal found at 124°F, below the recommended 165°F. The Resident Council reported consistent issues with cold and late food, especially on weekends.
A facility failed to coordinate effectively with a hospice provider for a resident, resulting in the absence of a hospice care plan in the resident's EHR. The resident, with a terminal prognosis, showed signs of confusion and agitation, and the lack of a coordinated care plan placed them at risk of unmet care needs. Facility staff were unaware of the missing care plan until prompted by surveyors.
The facility failed to update care plans for two residents, leading to potential risks. One resident experienced multiple falls without adequate care plan revisions, while another had incorrect medication categorization and outdated interventions. Staff acknowledged errors but had not addressed them, risking residents' health and quality of life.
Two residents were found self-administering medications without proper assessment or documentation. One resident had eye drops without a physician's order or a self-medication program in their care plan, while another had an inhaler at their bedside without a safety evaluation or documentation. Staff were unaware of these medications, contrary to facility policy requiring an interdisciplinary assessment and prescriber's order for self-administration.
The facility failed to provide the correct beneficiary notices for two residents regarding Medicaid/Medicare coverage. One resident received an incorrect form for the SNF ABN, while another received the NOMNC only 24 hours before the last covered day, instead of the required 48 hours. The Social Service Director was unaware of the updated form requirement and could not explain the timing error.
The facility failed to promptly address grievances for two residents, leading to unresolved issues. A resident reported missing clothing, but no grievance was logged, and the issue remained unaddressed. Another resident reported broken blinds, which were acknowledged but not documented or repaired. These deficiencies highlight a breakdown in the grievance process.
A facility failed to report alleged financial exploitation of a resident, who believed they had paid their child's mortgage, to the state agency and law enforcement. Despite being aware of the concerns, the Social Service Director did not ensure a report was made or documented conversations with APS. This deficiency was a repeat issue.
A resident with a history of atrial fibrillation and other conditions experienced ongoing abdominal pain and discomfort, which was not adequately assessed or communicated to the physician by the LTC facility staff. Despite the resident's worsening condition, including vomiting and restlessness, the staff failed to conduct timely assessments or notify the physician appropriately, leading to the resident's hospitalization and subsequent death.
A resident with a history of atrial fibrillation, anticoagulant use, diabetes, and stroke experienced increased abdominal pain, but staff failed to conduct thorough assessments or notify the physician promptly. The resident was left in pain during the night shift, and vital signs were not checked. Despite the resident's distress, staff did not perform additional assessments or notify the physician until hours later. The resident was found in distress and later passed away in the hospital. Interviews revealed staff awareness of the resident's condition but inadequate actions were taken.
The facility failed to conduct thorough investigations into incidents involving residents, including an unexpected death and allegations of abuse by a nursing assistant. Investigations were delayed, lacked key witness interviews, and did not notify physicians or families. Care plans did not address potential psychosocial harm, indicating significant lapses in the facility's response to these serious incidents.
A resident with intact cognition was sent to the hospital after a change in condition and passed away unexpectedly. The LTC facility failed to report the death to the state agency as required by the Purple Book guidelines. The DNS and Administrator were unaware of the reporting requirements, and the investigation summary indicated the resident did not receive timely care.
Deficiency in Food Safety Practices
Penalty
Summary
The facility failed to ensure that resident meals were prepared and stored in accordance with professional standards of food safety. During an observation, it was noted that the facility kitchen refrigerator contained undated and unlabeled food items, including applesauce, cottage cheese, and freezer jam. Additionally, a cabinet labeled as a Fruit Bar contained trays of salad dressings without preparation dates. Furthermore, a refrigerator located outside the building contained cucumbers that were visibly spoiled, with black circles and a mushy texture. Staff interviews revealed that all open food items should be dated, and undated items should be discarded. In another observation, a refrigerator/freezer in a small dining room/conference room contained snacks and sandwiches for residents, which were also undated and unlabeled. Items included a fast-food bag with a roast beef sandwich, opened egg nog, a gallon of milk, a med pass supplement, and a coconut drink, all without open dates. The freezer had a note indicating no ice packs, yet contained one. Staff interviews indicated that nourishment refrigerators were checked weekly, and opened items should be discarded after three days. These lapses in food safety practices left residents at risk for food contamination and foodborne illnesses.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications, which placed them at risk for adverse events and diminished quality of care. For Resident 22, the facility did not have appropriate diagnoses for the use of Seroquel, an anti-psychotic medication, and failed to implement non-medication interventions before administering the medication. The resident's care plan did not address the PRN use of anti-psychotics, and there was no documentation of non-medication interventions prior to giving the PRN dose of Seroquel. Additionally, the facility did not limit the PRN use of psychotropic medications to 14 days as required, and there was confusion between the hospice agency and the facility regarding the management of these medications. Resident 1 was administered Lorazepam and Seroquel without appropriate diagnoses or documentation of non-pharmacological interventions. The resident's care plan indicated the use of Lorazepam for terminal agitation, but the medication was administered for reasons not aligned with the order, such as inability to sleep and pain. The facility also failed to document non-pharmacological interventions before administering these medications, and the PRN order for Seroquel exceeded the 14-day limitation. Staff interviews revealed a lack of understanding and documentation regarding the use of these medications and the required interventions. The facility's policy on psychotropic medications was not followed, as evidenced by the lack of appropriate diagnoses, failure to implement non-medication interventions, and inadequate monitoring and updating of care plans. The facility's staff, including the Director of Nursing and Director of Operation, acknowledged the deficiencies and the confusion between the hospice agency and the facility regarding the management of psychotropic medications. These failures highlight significant gaps in the facility's medication management practices, particularly concerning the use of psychotropic medications for residents in hospice care.
Incomplete Resident Assessments and Care Area Analyses
Penalty
Summary
The facility failed to ensure that the Resident Assessment Instrument (RAI) and Care Area Assessments (CAAs) were comprehensively completed for several residents, which is necessary to holistically analyze and update the plan of care based on each resident's individualized needs. This deficiency was identified for five residents, including those with conditions such as psychotropic drug use, stroke, diabetes, dementia, and severe cognitive impairment. The assessments lacked comprehensive summaries or analyses that included the residents' current goals, preferences, strengths, or needs, which are crucial for determining if updates to the care plans were needed. For Resident 1, the psychotropic drug use CAA was incomplete, lacking necessary summaries and analyses. Staff interviews revealed confusion over responsibility for completing the psychotropic medication reviews, with the Licensed Practical Nurse (LPN)/MDS Coordinator and Social Service Director both indicating that the other was responsible. Similarly, for Resident 16, the pressure ulcer/injury CAA was not comprehensive, and the LPN/MDS Coordinator admitted to relying solely on medical records for information, with some sections left for social services to complete. Resident 22's cognition/dementia and communication CAA also lacked comprehensive summaries, and the same issue was noted for Resident 32, who had severe cognitive impairment and communication issues. Staff interviews indicated that the LPN/MDS Coordinator was only completing parts of the CAA worksheets, unaware that other areas needed addressing. For Resident 12, the pressure ulcer/injury CAA was incomplete, despite the resident being at high risk for pressure ulcers, as indicated by the Brayden Scale. The LPN/MDS Coordinator admitted to copying and pasting information without addressing all necessary areas.
Deficiencies in Care Plan Implementation and Individualized Care
Penalty
Summary
The facility failed to review, revise, and implement comprehensive care plans for several residents, leading to deficiencies in individualized care. Resident 22, diagnosed with dementia, was at risk for wandering, yet their care plan lacked documented interventions for a wandering incident. Observations showed Resident 22 entering rooms other than their own, and staff were unaware of the need for updated interventions. Additionally, the care plan did not include person-centered information or goals related to their dementia, despite significant cognitive changes noted in assessments. Resident 16, with a history of stroke and diabetes, had a care plan that did not include the use of a green positioning wedge, which the resident used to relieve pressure. The resident was resistant to repositioning, preferring to lie on their back, yet this behavior and the use of wedges were not reflected in the care plan. Staff were unaware of these omissions, indicating a lack of communication and updates to the care plan. Resident 40, with multiple chronic conditions, reported not having a shower since breaking their leg, and their care plan lacked person-centered interventions for bathing preferences. Additionally, the care plan did not address the use of antibiotics or insulin, nor did it include non-pharmacological interventions for pain management. Resident 33, with severe cognitive impairment, was observed struggling to eat independently, yet their care plan did not reflect the need for feeding assistance. The resident experienced significant weight loss, and staff were unaware of the need for one-to-one feeding, as it was not documented in the care plan. Resident 34, also with severe cognitive impairment, had a care plan that did not accurately reflect their activity preferences or the need for heel floating, leading to inconsistencies in care delivery.
Inadequate Care and Communication in Resident Treatment
Penalty
Summary
The facility failed to ensure that several residents received care and treatment in accordance with professional standards of practice, leading to unmet care needs and potential medical complications. Resident 13, who was admitted with conditions including congestive heart failure and peripheral artery disease, had orders for daily weight monitoring with specific instructions to notify the provider of significant weight gains. However, there were multiple instances where weight gains were not communicated to the physician, resulting in the resident experiencing severe respiratory distress and requiring hospitalization for possible pneumonia and fluid overload. Additionally, Resident 13 was observed not wearing prescribed heel boots, and there was a lack of documentation regarding the resident's refusal to wear them. Resident 19, diagnosed with vascular dementia and heart failure, experienced a change in condition requiring additional assistance with meals. Despite a request for a speech-language pathology evaluation due to concerns about swallowing, only a screening was conducted, which did not identify any issues. The resident continued to exhibit signs of difficulty, such as pocketing food, but no further evaluation was pursued. This oversight in addressing the resident's swallowing difficulties could have led to further complications. Resident 260, who had a history of insomnia, was not provided with their prescribed sleep medication, Ambien, due to a pharmacy issue. The lack of medication availability was not communicated to the provider, and the resident reported poor sleep as a result. Similarly, Resident 40, who had ongoing diarrhea, continued to receive a stool softener without the administration of Imodium, despite family requests to stop the medication. Lastly, Resident 20 did not have timely follow-up with an infectious disease doctor as required, and there was a significant delay in obtaining necessary documentation from the clinic. These deficiencies highlight a pattern of inadequate communication and follow-up on medical orders and resident needs.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure compliance with Infection Prevention and Control Guidelines, leading to multiple deficiencies across various areas. Staff did not adhere to Enhanced Barrier Precautions (EBP) in three out of four hallways, and there were lapses in personal care and wound care procedures. For instance, a Nursing Assistant Certified (NAC) did not use a gown during high-contact peri-care for a resident with a cholecystostomy tube and failed to perform hand hygiene between glove changes, citing the time it takes for hands to dry. Similarly, a Licensed Practical Nurse (LPN) conducted wound care for a resident with multi-drug resistant bacteria without changing gloves between different wound sites, potentially contaminating supplies and surfaces. The facility also demonstrated a lack of proper signage and understanding of EBP requirements. A resident with a history of respiratory MRSA was not placed under EBP, and there was confusion among staff regarding the meaning of door jamb indicators. Additionally, a resident with a gastrostomy tube was not recognized as needing precautions, leading to staff entering the room without performing hand hygiene or using PPE. This miscommunication and lack of adherence to protocols increased the risk of infection transmission. Further deficiencies were observed in catheter care and hand hygiene practices. A resident's catheter bag was repeatedly found touching the floor or garbage, contrary to CDC guidelines, and staff were unaware of the correct procedures. Housekeeping staff also failed to perform hand hygiene between glove changes, which was against the facility's policy. These failures, combined with improper handling of enteric contact precautions, such as not washing hands with soap and water, contributed to the overall risk of infection spread within the facility.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident, identified as Resident 40, who was reviewed for respiratory care. The deficiency was observed when Resident 40, who had a physician order for oxygen therapy at two liters per minute (lpm) as needed to maintain oxygen saturation above 90%, was found with the oxygen concentrator set incorrectly at 2.5 lpm. Additionally, the nasal cannula was not properly positioned in the resident's nostrils during an observation, and on another occasion, the nasal cannula was found on the floor, not in use, while the concentrator remained set at 2.5 lpm. Resident 40 had a medical history that included diabetes type two, chronic obstructive pulmonary disease, and high blood pressure. Despite the physician's order for oxygen therapy, the nursing staff, including a Licensed Practical Nurse (LPN) identified as Staff DD, did not verify the settings on the oxygen concentrator, which was a part of their responsibility. The Director of Nursing Services, identified as Staff B, confirmed that the nursing staff was expected to ensure the oxygen settings matched the physician's orders. This oversight placed Resident 40 at risk for unmet needs and potential negative outcomes.
Inadequate Dementia Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive dementia care plan for Resident 22, who was diagnosed with dementia and admitted to the facility. The care plan did not adequately address the resident's physical, mental, and psychosocial needs, nor did it establish personalized and achievable goals or identify specific interventions to promote a person-centered environment. The care plan lacked detailed information on how Resident 22's dementia manifested, what situations increased or decreased their stress and anxiety, and the role of family support in their overall cognition. Observations and interviews revealed that Resident 22 exhibited behaviors such as anxiety, self-propelling in the hallways, and calling out for their daughter. Despite these behaviors, the care plan did not include specific strategies to address them. Staff interventions included encouraging phone calls to the resident's daughter and engaging in storytelling and music, but these were not documented in the care plan. Additionally, the resident was noted to be essentially blind, making music an important aspect of their care, yet this was not reflected in the care plan. The lack of a detailed and personalized care plan placed Resident 22 at risk for unmet needs and decreased quality of life.
Failure to Provide Scheduled Bathing for Resident
Penalty
Summary
The facility failed to provide necessary activities of daily living care for Resident 263, specifically in the area of bathing. Resident 263, who was admitted with a left hip fracture and required two-person maximum assistance for transfers, reported not having received a shower since admission. Despite being alert and able to verbalize needs, the resident's requests for a shower were not fulfilled, and there was no documentation of bathing or refusal in the clinical records for the past 14 days. Interviews with staff revealed that the resident was placed on a shower schedule for Tuesdays and Thursdays, but there was no follow-up to ensure the showers were provided. Staff members admitted to not auditing or checking if residents received their showers and acknowledged the lack of a system to document refusals. The oversight in providing showers and the absence of documentation contributed to the deficiency, as observed by the surveyors.
Improper Storage and Disposal of Medications
Penalty
Summary
The facility failed to ensure proper storage and timely disposal of drugs and biologicals, as observed in two medication carts and one medication room. Specifically, three vials of lorazepam with an expiration date of October 2024 were found in the medication room refrigerator, and a bag labeled Promethegan had its expiration date altered from 2023 to April 2025 by hand. Additionally, an open bottle of Acidophilus, which required refrigeration after opening, was found in the medication cart on the Medicare Hall, indicating a lack of adherence to storage instructions. Staff interviews revealed that the night shift was responsible for removing and destroying or returning expired medications, but this process was not effectively implemented. Staff U, an LPN, acknowledged the expired lorazepam and the altered expiration date on the Promethegan, stating that the latter came from the emergency kit. Furthermore, Staff U noted that the night shift was also responsible for ensuring proper storage of medications, but the Acidophilus found in the North Hall cart was replaced with a new brand that did not require refrigeration, indicating a lack of consistent oversight and adherence to medication storage protocols.
Failure to Serve Meals Timely and at Safe Temperatures
Penalty
Summary
The facility failed to ensure that meals were served in a timely manner and at appropriate temperatures, impacting the palatability and safety of the food provided to residents. On the morning of January 31, 2025, a full cart of meal trays was observed in the hallway of South Hall, with none of the trays having been served. Staff I, an LPN, mentioned that the carts had arrived a few minutes prior, and there were two nursing aides working on the South Hall, with another aide expected to arrive. Staff D, a Nursing Aide Certified, began distributing the meal trays at 8:52 AM, indicating that the trays had been sitting for a few minutes. However, the dietary manager, Staff HH, noted that the trays were sent out at around 8:15 AM, and upon checking, found the oatmeal on one of the trays to be at 124 degrees Fahrenheit, which was below the recommended temperature of 165 degrees Fahrenheit for hot foods. The Resident Council reported that the food was consistently cold and late, particularly on weekends when the dietary manager was absent. The facility's policy outlined the recommended temperature ranges for safe food holding, storage, and serving, which were not met in this instance. The dining times indicated that meals should be provided between 7:45 AM and 8:45 AM, but the delay in serving and the inadequate temperature of the food suggest a failure to adhere to these guidelines, potentially affecting the residents' nutritional status and meal acceptance.
Failure to Coordinate Hospice Care Plan
Penalty
Summary
The facility failed to ensure effective communication and coordination of care between the facility and the hospice provider for a resident receiving hospice services. The facility did not obtain or maintain a copy of the resident's current hospice coordinated plan of care, nor was it integrated into the facility's care plan. This oversight placed the resident at risk of not receiving necessary care and services. The facility's contract with hospice required coordination regarding the plan of care, but this was not adhered to, as evidenced by the absence of the hospice care plan in the resident's electronic health record (EHR). The resident, who had a terminal prognosis related to an end-stage disease process, was admitted to hospice care, but the hospice plan of care was missing from their EHR. Despite multiple hospice notes being present, there was no indication that they were reviewed by facility staff. The resident exhibited confusion and agitation, with behaviors such as self-propelling up and down halls and calling out for their daughter. Interviews with facility staff revealed a lack of awareness regarding the missing hospice care plan, which was only located and provided after the surveyor's inquiry.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to adequately review and revise care plans for two residents, leading to potential risks for unmet care needs. Resident 40, who was admitted with conditions including diabetes, COPD, and high blood pressure, experienced multiple falls. Despite having a care plan that identified them as a fall risk, the plan was not updated to reflect the resident's recent falls and was inconsistent with the Care Area Assessment. The care plan included interventions such as using a fall mat and ensuring the call light was within reach, but these measures were not effectively preventing falls, as evidenced by the incident reports. Resident 1, who was under palliative care with severe cognitive impairment, was receiving both antidepressant and antipsychotic medications. However, their care plan incorrectly combined these two categories of psychotropic medications, leading to confusion in monitoring and interventions. Additionally, the resident's care plan included a wander guard intervention, but there was no recent wandering risk assessment, and the wander guard was found not in use, indicating a lack of proper review and revision of the care plan. Interviews with staff revealed that there were errors in the care planning process, such as incorrect categorization of medications and outdated interventions. Staff acknowledged the need for updates and corrections in the care plans, but these deficiencies had not been addressed at the time of the survey, placing residents at risk for adverse health effects and diminished quality of life.
Failure to Assess Residents for Safe Self-Medication Administration
Penalty
Summary
The facility failed to ensure that two residents, Resident 5 and Resident 263, were properly assessed for the safety of self-medication administration. Resident 263, who was alert and oriented, was observed with an eye drop container labeled Pataday Ophthalmic Solution on their overbed table and stated they self-administered the eye drops daily. However, there was no physician order for the eye drops, and the resident's care plan did not include a self-medication program. Staff members were unaware of the eye drops in the resident's room, and the facility's policy required an interdisciplinary team assessment and a prescriber's order for self-administration, which was not followed. Similarly, Resident 5, a long-term resident with no cognitive issues, was observed with an inhaler at their bedside after returning from a doctor's appointment. The resident stated they used the inhaler as needed, but there was no self-medication assessment or documentation in the care plan for keeping the inhaler at the bedside. Staff interviews revealed a lack of awareness and adherence to the facility's policy, which required a doctor's order and a safety evaluation for residents to have medications at the bedside. The Director of Nursing Services acknowledged the oversight and indicated that the medication should be removed until proper procedures were followed.
Failure to Provide Correct Beneficiary Notices
Penalty
Summary
The facility failed to provide the required beneficiary notice for two residents regarding Medicaid/Medicare coverage and potential liability for services not covered. For Resident 47, the facility used an incorrect form, CMS form R-131, instead of the required CMS-10055 form for Skilled Nursing Facilities (SNF) Advance Beneficiary Notice of Non-coverage (ABN). This discrepancy was acknowledged by the Social Service Director, who was unaware of the updated form requirement. For Resident 265, the Notice of Medicare Non-Coverage (NOMNC) was provided only 24 hours before the last covered day of Medicare Part A services, instead of the required 48 hours, as per guidelines. The Social Service Director, responsible for issuing these notices, could not explain the timing error.
Failure to Address Resident Grievances Promptly
Penalty
Summary
The facility failed to promptly initiate, resolve, and document resident grievances for two residents, leading to delays in addressing their concerns. Resident 45, who was cognitively intact, reported missing clothing items, including two pairs of socks and one pair of pants, since September. Despite informing nurses and laundry staff, no grievance was logged, and the resident had not received any communication or resolution regarding the missing items. Interviews with staff revealed a lack of awareness and uncertainty about whether a grievance form was filled out, indicating a breakdown in the grievance process. Resident 25, who was alert but forgetful, reported during a Resident Council meeting that the blinds in their room had holes. Although the Maintenance Manager acknowledged the issue and promised to order replacements, the maintenance log did not reflect this concern, and the blinds remained unrepaired. The facility's grievance log also did not document this issue, highlighting a failure to properly record and address the resident's grievance. These deficiencies in handling grievances resulted in unresolved issues and potential frustration for the residents involved.
Failure to Report Financial Exploitation Concerns
Penalty
Summary
The facility failed to adhere to its policies and procedures for timely reporting of alleged financial exploitation concerning a resident. Specifically, the facility did not report to the state agency and law enforcement when a resident expressed concerns about their financial affairs. The resident, who had a history of hypertension, stroke, and type two diabetes mellitus, believed they had paid their child's mortgage, which raised concerns about potential financial exploitation. Despite these concerns, there was no documentation of a report being made to the appropriate authorities, as required by the facility's policy and the Nursing Home Guidelines, The Purple Book. Interviews with facility staff revealed that the Social Service Director was aware of the concerns regarding the resident's funds being used by their child but did not ensure a report was made to the department. The Social Service Director also failed to document conversations with the Adult Protective Services (APS) investigator about these concerns. The facility administrator acknowledged that new or additional information about a resident should prompt a report, but this was not done in this case. This deficiency was noted as a repeat issue from a previous survey.
Failure to Provide Timely Assessment and Treatment Leads to Resident's Death
Penalty
Summary
The facility failed to provide timely assessments and treatment for a resident experiencing ongoing abdominal pain and discomfort, leading to an unexpected hospitalization and subsequent death. The resident, who had a history of atrial fibrillation, long-term anticoagulant use, diabetes, and a previous stroke, was admitted with intact cognition and was dependent on staff for personal care. Despite the resident's POLST form indicating a preference for selective treatment and hospital transfer if necessary, the facility did not adequately respond to the resident's acute change in condition. Over the course of several days, the resident experienced persistent abdominal discomfort, which was documented in nursing progress notes. However, there was a lack of thorough assessment and communication with the physician. The resident's condition worsened, with symptoms including restlessness, crying out in pain, and vomiting a dark coffee-colored substance. Despite these alarming signs, the nursing staff failed to conduct a comprehensive assessment or notify the physician in a timely manner, resulting in a delay in treatment. Interviews with staff revealed a lack of adherence to the facility's notification policy and inadequate monitoring of the resident's condition. The resident's vital signs were not assessed regularly, and the physician was only notified by fax, which is not appropriate for urgent situations. The failure to recognize the severity of the resident's condition and take prompt action constituted an immediate jeopardy, ultimately leading to the resident's hospitalization and death.
Neglect in Resident Care Due to Inadequate Assessment and Communication
Penalty
Summary
The facility failed to provide necessary care and services to prevent neglect for a resident who experienced a significant change in condition. The resident, who had a history of atrial fibrillation, long-term use of anticoagulants, diabetes, and a history of stroke, was admitted to the facility and was dependent on staff for toileting and personal care. The resident experienced increased abdominal pain over several days, but the licensed staff did not conduct a thorough assessment or consult with the physician in a timely manner. This lack of action resulted in the resident being left alone in their room in pain during the night shift. The medical records indicated that the resident's vital signs were not checked during the night shift, and the resident continued to experience abdominal discomfort without relief from antacids. Despite the resident's persistent calls for assistance and visible distress, the staff did not perform additional assessments or notify the physician until hours later. The resident was eventually found covered in dark brown vomit with right lower abdominal pain and decreased breath sounds, leading to their transfer to the hospital where they later passed away. Interviews with staff revealed that the Nursing Assistant Certified (NAC) and Licensed Practical Nurse (LPN) were aware of the resident's discomfort but failed to take appropriate actions. The NAC reported the resident's distress but did not re-enter the room after being told by the LPN that they would handle the situation. The LPN admitted to not assessing the resident's vitals or notifying the physician promptly, instead sending a fax about the resident's condition. The Director of Nursing Services (DNS) confirmed that the staff did not meet the facility's expectations for assessing and communicating changes in the resident's condition.
Inadequate Investigations into Resident Incidents
Penalty
Summary
The facility failed to conduct thorough investigations into several serious incidents involving residents, leading to deficiencies in care and oversight. Resident 1 experienced a significant change in condition and was sent to the hospital, where they passed away shortly after. The investigation into this unexpected death was inadequate, lacking crucial details about the nurse's delayed response and inappropriate communication method with the physician. The investigation did not address whether abuse or neglect contributed to the resident's death, despite evidence of the resident's distress and pain prior to hospitalization. In another incident, Resident 2 alleged abuse by a nursing assistant who refused to assist them with incontinence care. The investigation was delayed and incomplete, failing to interview a key witness, Resident 4, who overheard the interaction. The investigation also did not notify the resident's physician or family and lacked documentation of monitoring for potential psychosocial harm. The care plan for Resident 2 did not reflect the incident or address potential harm, indicating a lack of comprehensive follow-up. Similarly, Resident 3 reported rough handling by the same nursing assistant during care. The investigation was again insufficient, with no interviews conducted with other staff or witnesses, and no notification to the resident's physician or family. The care plan did not address potential psychosocial harm, and the investigation relied on a generic questionnaire rather than specific inquiries into the nursing assistant's conduct. These failures in investigation and documentation highlight significant lapses in the facility's response to allegations of abuse and neglect.
Failure to Report Unexpected Death
Penalty
Summary
The facility failed to ensure timely reporting of an unexpected death of a resident, which is a requirement under their policies and procedures for abuse and neglect. The resident, who had intact cognition and no refusals of care, experienced a change in condition and was sent to the hospital, where they passed away hours later. Despite the unexpected nature of the death, the facility did not report the incident to the state agency, as required by the Nursing Home Guidelines, The Purple Book. The Director of Nursing Services (DNS) and the Administrator were unaware of the reporting requirements outlined in the Purple Book, which mandates reporting unexpected deaths to the Department of Social and Health Services (DSHS) hotline, logging the incident on the state reporting log, and notifying law enforcement and the coroner. The facility's investigation summary indicated that the resident did not receive timely or thorough care and services, contributing to the deficiency in reporting the unexpected death.
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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