Aurora Valley Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Spokane, Washington.
- Location
- 414 S University Rd, Spokane, Washington 99206
- CMS Provider Number
- 505114
- Inspections on file
- 51
- Latest survey
- September 15, 2025
- Citations (last 12 mo.)
- 45
Citation history
Health deficiencies cited at Aurora Valley Care during CMS and state inspections, most recent first.
A resident who required extensive assistance with toileting was found in a urine-soaked bed after returning from the emergency room. The resident did not use the call light for help, and a Nursing Assistant did not provide care, assuming no assistance was needed. The LPN responsible did not ensure the resident's needs were met, and the Director of Nursing stated that residents should be checked every two hours.
A resident with right-sided hemiplegia and hemiparesis required assistance with eating, particularly when in bed, due to severe osteoarthritis and a torn rotator cuff. Despite this, the care plan inaccurately stated they could eat independently, leading to inadequate care. Staff communication about the resident's needs was not documented in the care plan, resulting in a lack of guidance for proper care.
A resident with a history of anxiety, mild dementia, and stroke was identified with moderate depression symptoms, but the facility failed to seek timely mental health services. The resident exhibited refusals of care, including medication and repositioning, leading to deteriorating health and worsening wounds. Despite an order for a behavioral health evaluation, the facility did not follow through, and staff were unaware of the need for such an evaluation. The resident's family expressed concerns about the decline, resulting in a hospital evaluation request.
A resident with ill-fitting dentures causing an open sore did not receive timely follow-up for necessary dental services. Despite a dental exam indicating the need for a denture adjustment, no further action was documented. Staff interviews confirmed the lack of follow-up, and the resident was later discharged to the hospital.
The facility failed to address substance use disorders in the care plans of two residents, leading to potential accident hazards. One resident was hospitalized after being found intoxicated following a fall, while another resident with opioid dependence had no safety interventions in place. The administrator acknowledged the need for care planning and monitoring, but this was not implemented.
A resident with Wernicke's Encephalopathy and adult failure to thrive was neglected in terms of incontinence and hygiene care, leading to their removal from the facility AMA. Family members repeatedly found the resident in unsanitary conditions, but staff failed to document or address these concerns adequately. The facility's management was unaware of the situation, highlighting a communication breakdown.
A facility failed to report allegations of potential neglect to the State Agency. A resident left the facility AMA after their family raised concerns about neglect, including the resident being undressed and having urine everywhere. Despite being aware of these concerns, the Social Services Director and Resident Care Manager did not report them to the Administrator or the State Agency, and no report was submitted.
During a COVID-19 outbreak, the facility failed to follow quarantine and isolation precautions, affecting several residents and involving improper PPE use by a staff member. Residents with COVID-19 had open doors against CDC guidelines, and a staff member did not wear the required PPE in a quarantine room. Interviews revealed a lack of documentation and communication regarding precautions.
A resident with end-stage renal disease, diabetes, and seizures experienced vomiting and missed seizure medication doses, but the medical provider was not notified. Staff interviews revealed a lack of communication and documentation regarding the resident's condition changes, leading to a seizure and hospital transport.
The facility failed to implement effective discharge planning for three residents, resulting in unsafe discharges and unmet care needs. One resident was discharged without proper documentation of their urinary status, another left AMA multiple times due to inadequate monitoring of behaviors, and a third resident discharged AMA without proper education on risks. The facility's discharge planning process was insufficient, leading to these deficiencies.
The facility failed to adequately address the risks of elopement and substance use for residents with substance use disorders. A resident with severe cognitive impairment and a history of substance abuse frequently left the facility without staff knowledge and was found with drug paraphernalia. Another resident, initially unresponsive, had an incomplete care plan that did not address elopement or substance use risks. A third resident, with moderate cognitive impairment and alcohol abuse history, had a care plan that failed to address substance use disorder. Staff were unsure of processes for dealing with substance use emergencies.
A resident with an indwelling urinary catheter due to acute urinary retention was not properly assessed or managed by the facility. The facility failed to follow its policy requiring comprehensive assessment and medical justification for catheter use. Despite hospital orders for continued catheter use and a urologist follow-up, the facility did not schedule the appointment and canceled the consult without proper documentation. Staff interviews revealed a lack of clarity and communication regarding catheter management, leading to the resident's discharge with the catheter still in place.
A resident experienced ongoing mouth pain due to the facility's failure to schedule a dental appointment for necessary extractions. Despite being cognitively intact and requesting the appointment, the resident's pain persisted, reaching severe levels. Staff responsible for scheduling acknowledged the oversight, and the DON confirmed the need for the appointment.
The facility failed to ensure timely physician visits for several residents, with gaps exceeding the required intervals. This deficiency was identified through interviews and record reviews, revealing that residents with various diagnoses, including depression, stroke, and diabetes, did not have documented physician visits within the mandated timeframes. The facility's recent switch to a new provider group contributed to the lack of proper tracking and documentation.
A LTC facility failed to administer medications as ordered for three residents, leading to significant medication errors. One resident missed multiple doses due to unavailability and dialysis scheduling conflicts. Another resident missed doses while at dialysis, and a third experienced a delay in receiving a post-surgery antibiotic due to communication issues with an oral surgeon's office.
The facility failed to ensure proper hand hygiene and PPE use during medication administration and wound care, and did not implement Enhanced Barrier Precautions for residents at risk of infection. A resident with MRSA was not placed on EBP, and another resident on EBP did not receive care in accordance with these precautions. Additionally, the facility's water management plan was outdated and inadequately maintained.
The facility failed to provide a dignified dining experience by not offering clothing protectors per residents' preferences, leading to food stains on their clothing. Despite residents being cognitively intact and expressing a preference for clothing protectors, the facility removed them to transition to a fine dining experience. Staff interviews confirmed that residents preferred the protectors, and their removal resulted in soiled clothing, contradicting the facility's policy on dignity.
The facility failed to obtain consent for psychotropic medications before administration for three residents, including one with moderate cognitive impairment and another who was severely cognitively impaired. Staff interviews confirmed that consents should be obtained before the first dose and when doses change, but this was not done for medications like Seroquel and Effexor.
The facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents, one of whom received it 19 days late and another who did not receive it at all. This oversight was due to the Business Office Manager missing a resident and not following the established process, as acknowledged by the Executive Director.
The facility failed to maintain the privacy of residents' mail, as several residents reported receiving opened mail. A cognitively intact resident and others confirmed that their mail was opened before delivery. Staff interviews indicated that mail was sorted by a Business Office Manager, who was on leave during the investigation, leading to confusion about which mail was for residents. The Executive Director acknowledged the issue and confirmed that residents' mail should remain unopened.
A resident with diabetes and quadriplegia reported their cell phone stolen and had not received reimbursement, despite being told it was in process. The facility's logs showed no record of the missing phone, and the Executive Director admitted to not submitting the reimbursement request timely.
The facility failed to complete and implement PASARR for two residents. One resident, admitted with depression, did not receive recommended behavioral health services, and another was admitted without a PASARR completed prior to admission. These oversights risked the residents' mental health and quality of life.
The facility failed to follow care plan interventions for three residents, leading to unmet care needs and discomfort among others. A resident with paralysis was not assisted into a wheelchair as planned, with no documentation of attempts or refusals. Two residents with cognitive impairments engaged in public displays of affection and entered each other's rooms, contrary to their care plans, causing discomfort among other residents. Staff interviews revealed inconsistencies in following these care plans.
Two residents in an LTC facility were not provided with adequate assistance for activities of daily living. One resident, with multiple health issues, received insufficient showers and nutritional support, leading to weight loss and hygiene concerns. Another resident, with amputations and necrosis, reported receiving only one shower in 45 days, with no documentation of scheduled showers. Staff interviews revealed a lack of awareness and communication regarding care plans and resident needs.
A resident with severe cognitive impairment and physical limitations was not provided with activities that matched their interests, leading to social isolation. Despite expressing interest in various activities, the resident was mainly left to watch TV in their room, as staff failed to assist them in attending activities or provide reading materials.
The facility failed to implement a bowel management protocol for two residents, leading to extended periods without bowel movements. One resident, with cognitive impairment and a history of stroke, did not receive prescribed laxatives for six days. Another resident, on opioid medication, experienced multiple periods without bowel movements, with no documentation of offered or refused medications. Staff interviews revealed non-compliance with the protocol.
A resident, who was cognitively intact, informed staff of the need for a vision appointment, which was not scheduled. The resident experienced eye pain and required retinal surgery, but due to communication lapses, the necessary follow-up was not arranged. Staff responsible for appointments acknowledged the oversight, and the DON confirmed the process could have been improved.
A resident with obstructive uropathy was admitted with a urinary catheter, which was supposed to be removed for bladder training as per hospital orders. Despite the resident's cognitive ability to communicate and express discomfort, the catheter was not removed, leading to increased risk of infection. Facility staff confirmed the oversight.
A resident with bipolar disorder and substance abuse in remission missed a crucial behavioral health appointment due to the facility's failure to provide transportation. The appointment was essential for medication review, and the resident was unable to reschedule due to a no-show fee. The facility did not place the appointment on the calendar in time to arrange transportation, despite the resident notifying staff a week in advance.
A facility failed to maintain a medication error rate below five percent, resulting in a 9.38 percent error rate. Two residents received incorrect insulin administration due to staff not following proper procedures, such as cleaning the pen tip and priming the insulin pen. Additionally, one resident did not use their inhaler as documented. The Director of Nursing confirmed the errors.
The facility failed to properly store and handle medications, including controlled substances and expired medications, in two medication rooms and a cart. An insulin pen had conflicting expiration dates, and a refrigerator lock was not engaged, leaving Lorazepam unsecured. Expired medications and unlabeled tablets were found in a medication cart. Staff interviews revealed lapses in securing the emergency kit and removing expired medications.
The facility did not ensure the Dietary Manager had the necessary Food Service Manager certification, as revealed in interviews and record reviews. The Dietary Manager admitted to lacking the certification, and the RD was only part-time. The Executive Director and DON acknowledged these issues, which did not meet regulatory requirements, potentially affecting the nutritional services provided to residents.
The facility failed to provide meals at a safe and appetizing temperature, affecting several residents. Issues included cold food due to a broken plate warmer, lack of fresh fruits and vegetables, and limited meal substitutions. Residents with various medical conditions expressed dissatisfaction with the dining experience. Staff interviews revealed challenges in obtaining necessary ingredients and concerns about reheating food due to cross-contamination.
A resident with end-stage renal disease, diabetes, and heart disease did not receive evening meals on days they returned late from dialysis appointments. Despite requests, the facility failed to hold meals, providing only a sack lunch during appointments. Staff interviews revealed a lack of communication and adherence to meal-holding procedures, risking the resident's nutritional health.
A resident under hospice care did not receive bathing services for over seven weeks due to a scheduling error and lack of communication between the facility and hospice provider. The resident, who required maximum assistance with personal hygiene, was mistakenly removed from the hospice's bath aide schedule. Facility staff believed hospice was providing the baths, but records confirmed the last bath was given over seven weeks prior. The facility's leadership acknowledged the oversight.
The facility failed to ensure a safe discharge for a resident who left AMA without notifying APS, despite safety concerns involving the resident's spouse. Another resident experienced delays in discharge planning, despite expressing a desire to move to another state. Staff interviews revealed lapses in following discharge procedures and timely planning.
A resident in an LTC facility experienced verbal abuse and psychosocial harm due to a roommate's aggressive behavior. Despite being aware of the situation, staff delayed moving the resident to a different room, leading to the resident feeling unsafe and discharging against medical advice. The roommate, with a history of stroke and dementia, exhibited frequent verbally aggressive behaviors, which were not adequately addressed by the facility.
A resident with severe cognitive impairment experienced multiple falls due to the facility's failure to implement and document effective fall prevention strategies. Despite being at high risk, the facility did not consistently revise care plans or add new interventions after falls, leading to repeated incidents. Staff interviews indicated awareness of the need for prompt intervention, but actions did not reflect this understanding.
A resident with PTSD and a history of domestic violence was admitted to a facility without a proper trauma-informed care plan. The care plan lacked specific interventions to address the resident's trauma history, and the resident was placed with a verbally aggressive roommate, leading to a distressing incident. Staff interviews revealed a lack of awareness and documentation of the resident's trauma history and potential triggers.
A facility failed to implement a person-centered care plan for a resident with dementia, leading to increased agitation and combativeness. Despite the resident's history of stroke and dementia, the care plan lacked individualized non-pharmacological interventions. Staff interviews revealed frequent verbal outbursts and the absence of effective behavioral interventions, with pain management not adjusted. The facility's inaction resulted in unmet needs and diminished quality of life for the resident.
The facility failed to report several incidents of potential abuse and misappropriation to the State Survey Agency. A resident with a history of verbal aggression verbally abused their roommate, and another resident with cognitive impairment physically aggressed towards their roommate. Additionally, a resident's missing wallet was not reported as potential misappropriation. These incidents were not documented or reported as required.
Two residents were discharged AMA without proper documentation or valid reasons. One resident, admitted for wound care and antibiotics, was discharged without completing treatment, and their PICC line was removed without a provider order. Another resident, with a history of stroke and overdose, left during an outing and did not return. The facility failed to document the AMA process or send medications with the residents.
The facility failed to consistently monitor a resident's tolerance to dialysis treatments and collaborate with the dialysis center. The resident, who had end-stage renal disease, had significant gaps in the documentation of dialysis communication forms, vital signs, and weights from February to April 2024. The Director of Nursing confirmed that the required dialysis physician orders were only sporadically present, making it difficult to determine if the resident was being adequately monitored.
The facility failed to ensure accurate submission of direct care staffing information to CMS for Q3 2023. The Human Resources Manager did not include agency staff and incorrectly calculated nurse hours, leading to reported staffing levels lower than required. The Administrator, in training at the time, was unsure if the data was reviewed before submission.
The facility failed to timely assess fall risk and implement safety interventions for two residents, leading to repeated falls without appropriate preventive measures. Staff interviews revealed missing information on required assistance levels and delayed initiation of fall care plans.
Failure to Assist Resident with Toileting Needs
Penalty
Summary
The facility failed to provide necessary care and services to a dependent resident who required assistance with toileting. Resident 1, who was cognitively intact and required extensive assistance for bathroom use, was found by Staff C, an LPN, lying in a urine-soaked bed and clothing. This occurred after the resident returned from the emergency room and was transferred back into bed with a transfer sheet still under them. The resident did not use their call light to request assistance during the night shift, and Staff E, a Nursing Assistant, did not provide any care, assuming the resident did not need help. The facility investigation revealed that Staff D, another LPN assigned to the resident, was not interviewed or followed up with regarding the incident. Staff D's medication administration record showed a code indicating that tasks were not completed. Interviews with the resident and staff indicated that the resident typically received assistance before midnight and in the early morning but did not on this occasion. The Director of Nursing stated that residents should be checked every two hours during the night, and it was the responsibility of the night shift nurse to ensure all ADL tasks were completed by the nursing assistant.
Failure to Update Care Plan for Resident's Eating Assistance Needs
Penalty
Summary
The facility failed to revise and implement a comprehensive care plan for a resident who had specific needs related to their ability to eat. The resident, who was admitted with right-sided hemiplegia and hemiparesis following a stroke, malnutrition, and wounds on their left foot, was documented in the care plan as being able to eat independently. However, progress notes from nursing staff indicated that the resident required assistance with eating, particularly when in bed, due to their inability to raise their left arm high enough and lower their head without pain. This discrepancy between the care plan and the resident's actual needs placed the resident at risk of receiving inappropriate and inadequate care. Interviews with staff revealed that the occupational therapist had verbally communicated the resident's need for assistance when eating in bed to the Resident Care Manager, but this information was not documented in the resident's care plan. Additionally, the care plan did not include the resident's diagnoses of severe osteoarthritis and a torn rotator cuff in the left shoulder, which contributed to their difficulty in feeding themselves while in bed. The lack of updated and accurate information in the care plan failed to provide staff with the necessary guidance to meet the resident's individualized needs and preferences.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to meet the behavioral health needs of a resident who was identified as having symptoms of moderate depression. Despite a depression screening indicating moderately severe depression symptoms, the facility did not seek mental health services in a timely manner. The resident's medical record showed a history of anxiety, mild dementia, and a stroke, with additional diagnoses including malnutrition and osteomyelitis. The resident exhibited refusals of care, including medication and repositioning, which were documented in nursing progress notes. These refusals were not addressed with person-centered interventions by the interdisciplinary team. The resident's condition deteriorated, with documented weight loss, poor food intake, and worsening wounds. Despite an order for a behavioral health evaluation due to labile behaviors, the facility did not follow through with the evaluation or referral. The resident's care plan was updated to reflect resistive behaviors but lacked interventions for the diagnosed mild dementia, positive depression screen, or the ordered mental health evaluation. Interviews with staff revealed a lack of awareness and communication regarding the need for a behavioral health evaluation. The resident's family expressed concerns about the resident's physical and mental decline, leading to a request for hospital evaluation. The facility's failure to address the resident's behavioral health needs and implement appropriate interventions contributed to the resident's declining condition and quality of life. The lack of timely mental health services and communication among staff and with the resident's family were significant factors in the deficiency.
Failure to Follow Up on Dental Services for Resident
Penalty
Summary
The facility failed to follow up on necessary dental services for a resident who had ill-fitting dentures causing an open sore. The resident, who was admitted with conditions including right-sided weakness and paralysis after a stroke, severe malnutrition, dysphagia, and chronic ulcers, complained of mouth pain and refused to remove their upper denture. A dental appointment was initially scheduled but was canceled and rescheduled. A dental exam revealed an open sore and the need for a denture adjustment, but no further documentation was found regarding the adjustment or monitoring of the sore. Interviews with staff revealed that a request for a denturist appointment was made, but there was no follow-up on the request. The Director of Nursing confirmed the lack of follow-up, and the Administrator acknowledged that the appointment was not pursued further. The resident was eventually discharged to the hospital, and the staff member responsible for the follow-up was no longer employed at the facility.
Failure to Address Substance Use Disorders in Resident Care Plans
Penalty
Summary
The facility failed to identify, evaluate, and implement safety interventions for residents with substance use disorders, leading to potential accident hazards. Resident 1 was admitted with a diagnosis of COVID-19 and an unspecified alcohol-induced disorder, yet their care plan did not include interventions for substance use disorder. This oversight resulted in an incident where Resident 1 was found intoxicated after a fall, with a blood alcohol level of 297 mg/dL, necessitating hospitalization for observation. Similarly, Resident 2, admitted with ankylosing spondylitis and opioid dependence, did not have a care plan addressing their substance use disorder. The facility did not identify or analyze risks associated with their condition, nor were any safety interventions implemented. During an interview, the facility's administrator acknowledged the need for care planning and monitoring for residents with substance use disorders, but this was not reflected in the care plans of the affected residents.
Neglect of Resident's Incontinence and Hygiene Needs
Penalty
Summary
The facility failed to protect a resident from neglect, specifically in addressing concerns related to incontinence and personal hygiene. The resident, who was admitted with diagnoses of Wernicke's Encephalopathy and adult failure to thrive, was found by family members to be frequently naked, wet with urine, and surrounded by urine-soaked bedding and floors. Despite these observations, the facility did not document or address these issues adequately, leading to the resident's removal from the facility against medical advice. Interviews with staff revealed that the concerns were known but not properly communicated or documented. Staff C, the Resident Care Manager, and Staff D, the Social Services Director, were aware of the family's complaints but failed to escalate the issue to the facility Administrator or discuss it in the Interdisciplinary Team meetings. Staff C admitted to witnessing the unsanitary conditions but did not create any documentation or implement effective interventions. The facility's lack of response to the family's repeated concerns and the absence of a documented care plan to address the resident's incontinence and hygiene needs contributed to the neglect. The Administrator was unaware of the situation until after the resident's removal, indicating a breakdown in communication and oversight within the facility's management structure.
Failure to Report Allegations of Neglect
Penalty
Summary
The facility failed to report allegations of potential neglect to the State Agency immediately as required, concerning a resident who left the facility Against Medical Advice (AMA). The resident's family had raised concerns during a care conference that the resident was always naked, not dressed, and had urine everywhere. Despite being aware of these concerns on several occasions, including during a care conference, the Social Services Director and the Resident Care Manager did not report the concerns to the Administrator or the State Agency. The Director of Nursing was informed, but no report was made to the State Agency. A record review confirmed that no report of possible neglect was submitted by the facility regarding the care of the resident.
Failure to Follow COVID-19 Precautions and PPE Protocols
Penalty
Summary
The facility failed to adhere to quarantine and isolation precautions during a COVID-19 outbreak, affecting four out of five residents and involving improper use of personal protective equipment (PPE) by one staff member. Observations revealed that residents with current COVID-19 infections had their room doors open, contrary to CDC guidelines that require doors to be closed if safe. Specifically, two residents with Aerosol Precaution signs had their doors wide open, with no documented safety reasons for this. Additionally, a staff member was observed in a quarantine room wearing only a surgical mask instead of the required N95 respirator, eye protection, gown, and gloves, while interacting with a resident who was not wearing any PPE. Interviews with staff members highlighted a lack of communication and documentation regarding quarantine precautions. A physical therapy assistant was unaware of the need for PPE when working with a resident in a quarantine room, and a registered nurse confirmed the absence of precaution orders in the electronic medical records for the involved residents. The facility's administrator and director of nursing acknowledged the need for closed doors for COVID-19 positive residents and confirmed that quarantine precautions should be documented in the residents' care plans and electronic health records.
Failure to Notify Medical Provider of Resident's Condition Change
Penalty
Summary
The facility failed to assess and respond to a change in condition for a resident, leading to a deficiency in quality of care. The resident, who had diagnoses of end-stage renal disease, diabetes, and seizures, was admitted to the facility and was on a medication regimen to prevent seizure activity. The resident tested positive for COVID-19 and experienced vomiting and a seizure, but the medical provider was not notified in a timely manner. Staff interviews revealed that the resident had vomited and missed doses of seizure medication, but this information was not communicated to the medical provider or documented in the provider medical book. Staff E, a Resident Care Manager, noted that they were unaware of the resident's vomiting and missed medication until after the resident had a seizure and was transported to the hospital. Staff D, another Resident Care Manager, also stated they were not informed of the resident's condition changes and missed medication doses. The Nurse Practitioner confirmed they were not notified of the resident's vomiting and missed medication, which should have prompted a notification to the medical provider. This lack of communication and documentation placed the resident at risk for medical complications and unmet care needs.
Inadequate Discharge Planning Leads to Unsafe Discharges
Penalty
Summary
The facility failed to implement an effective discharge planning process for three residents, leading to unsafe discharges and unmet care needs. Resident 4 was admitted with urinary retention and an indwelling catheter, requiring a urologist appointment for further management. Despite the resident's condition and the need for follow-up, the facility discharged Resident 4 without proper documentation of their urinary status or a provider order for discharge. Additionally, the resident's report of feeling feverish on the day of discharge was not communicated to the receiving facility. Resident 1, who had severe cognitive impairment and a history of substance abuse, left the facility against medical advice (AMA) multiple times. The facility failed to adequately monitor and manage the resident's behaviors, including drug use and elopement. The AMA discharge form was not properly completed, lacking the resident's signature and documentation of the risks associated with leaving the facility. Resident 5, who was cognitively intact and independent with activities of daily living, chose to discharge AMA due to boredom and restlessness. The facility did not document any discharge barriers or provide adequate education on the risks of leaving AMA. The AMA form was incomplete, missing information on potential complications and the facility's release from liability. The facility's failure to properly assess and document discharge needs and plans resulted in unsafe discharges for all three residents.
Failure to Address Substance Use and Elopement Risks
Penalty
Summary
The facility failed to identify, evaluate, and implement safety interventions for residents with substance use disorders, leading to potential risks of elopement and substance use within the facility. Resident 1, with severe cognitive impairment and a history of substance abuse, was admitted with a desire to leave the facility and exhibited exit-seeking behavior. Despite being identified as at risk for elopement, the baseline care plan did not address these risks adequately. Resident 1 frequently left the facility without staff knowledge, was found with drug paraphernalia, and exhibited signs of substance use, yet interventions were not effectively implemented to mitigate these risks. Resident 2, admitted with a history of psychoactive substance abuse and other medical conditions, was initially unresponsive and dependent on staff for activities of daily living. However, as Resident 2's condition improved, the care plan failed to address the risk of elopement or substance use within the facility. The assessments and care plans were incomplete, lacking critical information on substance use disorder and elopement risk, leaving Resident 2 vulnerable to potential hazards. Resident 3, with moderate cognitive impairment and a history of alcohol abuse, was identified as at risk for elopement and had a wanderguard bracelet placed. However, the care plan did not address the substance use disorder or the risk of substance use while in the facility. The facility's staff, including nursing assistants and social service directors, were unsure of the processes for dealing with substance use emergencies and were not adequately trained to recognize signs of substance use, contributing to the facility's failure to provide a safe environment for residents with substance use disorders.
Deficiency in Urinary Catheter Management
Penalty
Summary
The facility failed to accurately assess and manage the urinary status of a resident, identified as Resident 4, who was admitted with an indwelling urinary catheter due to acute urinary retention. The facility's policy required a comprehensive assessment and medical justification for the continued use of an indwelling catheter, which was not adequately followed. Resident 4's medical records showed inconsistencies in catheter care documentation, with omissions noted on specific dates, and a lack of a urinary toileting program attempt despite the resident's ability to perform most activities of daily living independently. Resident 4 was admitted to the facility with a history of urinary tract infections and acute cystitis, and had a urinary catheter placed in the hospital due to urinary retention. Despite the hospital's discharge orders for continued catheter use until a urologist could evaluate the situation, the facility did not ensure a follow-up appointment with a urologist was scheduled. Furthermore, the facility's nursing staff canceled the urologist consult without proper documentation or provider orders, and Resident 4 was discharged back to their previous living setting with the catheter still in place. Interviews with facility staff revealed a lack of clarity and communication regarding Resident 4's catheter management. Staff members were unable to locate provider orders for catheter discontinuation or urologist consultation, and there was no documentation of monitoring for urinary retention or routine catheter care. The Director of Nursing acknowledged the oversight in monitoring and follow-up, and the facility's failure to adhere to its own policies and procedures for catheter management and resident assessment.
Failure to Schedule Dental Appointment for Resident
Penalty
Summary
The facility failed to schedule a necessary dental appointment for a resident, identified as Resident 59, who was experiencing ongoing mouth pain. The resident was cognitively intact and capable of making decisions regarding their care, with a diagnosis that included cavities. A dental care plan dated January 2, 2024, indicated that Resident 59 had broken teeth and required nursing staff to coordinate dental care arrangements. A dental visit on May 15, 2024, documented that the resident requested to have all their teeth extracted due to pain, and several teeth were extracted during that visit. However, a referral for the extraction of the remaining teeth was not documented, nor was there any evidence that the remaining teeth had been extracted. Interviews with the resident and staff revealed that the resident had communicated their need for a dental appointment to have their teeth extracted, but the appointment was not scheduled. The resident reported severe pain, rating it a 10 on a scale of 1-10, and continued to experience significant discomfort. Staff J, responsible for making appointments and arranging transportation, acknowledged that the appointment request had been missed. Staff I and the Director of Nursing confirmed that an appointment should have been made for the resident, indicating a lapse in the facility's coordination of necessary dental services.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were conducted every 30 days for the first three months after admission and then every 60 days as required for eight of the fourteen sampled residents. This deficiency was identified through interviews and record reviews, revealing that several residents did not have documented physician visits within the required timeframes. For instance, Resident 12, who was admitted with depression and stroke, had no physician visits documented in their Electronic Medical Record (EMR). Similarly, Resident 21, with diagnoses including diabetes and depression, had no physician visit notes during their five months in the facility. Other residents, such as Resident 15, Resident 24, and Resident 42, also experienced significant gaps between physician visits, exceeding the mandated intervals. The facility's Executive Director and Medical Records staff acknowledged the issue, noting that the facility had recently switched to a new provider group, which may have contributed to the lack of proper tracking and documentation of physician visits. The staff were unsure of the follow-up procedures if a resident was not seen, indicating a lapse in the system to ensure compliance with the required visit schedule.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to ensure that residents received their medications as ordered, leading to significant medication errors for three residents. Resident 42, who had diagnoses including end-stage kidney disease, seizures, and diabetes, missed multiple doses of medications such as levetiracetam, Advair, erythromycin, and others due to unavailability or absence during dialysis appointments. The staff did not coordinate medication administration times with dialysis schedules, resulting in missed doses when the resident was out of the facility. Resident 36, also requiring dialysis, missed doses of several medications including acetaminophen, atorvastatin, apixaban, and others. These omissions occurred on days when the resident was at dialysis, and the facility did not send medications with the resident or adjust administration times to accommodate the dialysis schedule. This lack of coordination and planning led to repeated medication omissions. Resident 80, who had recently undergone oral surgery, experienced a delay in receiving an antibiotic prescribed to prevent infection. The facility did not obtain the medication until three days after the surgery due to communication issues with the oral surgeon's office. Staff failed to promptly secure the necessary orders and medication, which could have been addressed by contacting the facility's provider for immediate assistance.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene and use of personal protective equipment (PPE) during medication administration and wound care, as well as failed to implement Enhanced Barrier Precautions (EBP) for residents at risk of infection. During a medication pass observation, Staff F, an Infection Preventionist/Registered Nurse, did not perform hand hygiene or wear gloves while administering insulin to Resident 78, who required assistance with activities of daily living due to diabetes. This oversight was contrary to the facility's hand hygiene policy, which mandates handwashing before handling medications and after contact with a resident's skin. Resident 12, who was colonized with MRSA and had weeping leg wounds, was not placed on EBP, despite the risk of infection transmission. The resident expressed concerns about their MRSA status and the lack of precautions taken. Observations revealed that Resident 12's room lacked signage and PPE supplies necessary for EBP, and the resident's soiled stockings indicated inadequate infection control measures. Staff interviews confirmed that Resident 12 should have been on EBP due to their draining wounds, but this was not implemented. Resident 17, who had pressure sores and was on EBP, did not receive care in accordance with these precautions. Staff EE and Staff FF provided personal and wound care without wearing the required PPE, despite the presence of an EBP sign outside the resident's room. Staff interviews revealed a lack of awareness and understanding of EBP requirements, leading to non-compliance with infection control protocols. Additionally, the facility's water management plan was outdated and inadequately maintained, with missing test results and unclear procedures, further compromising resident safety.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for several residents by not providing clothing protectors according to their preferences. This deficiency was observed in four residents who were cognitively intact and had varying levels of assistance required for eating. The facility's policy on resident rights emphasized treating each resident with respect and dignity, which was not upheld in this instance. Resident 1, who required no assistance with eating, reported that the Executive Director removed all clothing protectors, leading to the use of bath towels instead. Resident 6, who needed setup/clean-up assistance, was observed with food stains on their clothing and expressed dissatisfaction with the lack of clothing protectors. Similarly, Resident 9, who also required setup/clean-up assistance, was found with food spills on their clothing and stated that they had requested a clothing protector but were denied. Resident 45, who needed similar assistance, was seen with food debris on their clothing and expressed that it was from their breakfast. Interviews with staff revealed that the removal of clothing protectors was intended to transition to a fine dining experience using cloth napkins, as directed by Staff A. However, this change was not communicated effectively to the residents, leading to misunderstandings and dissatisfaction. Staff members acknowledged that residents preferred clothing protectors and that their removal resulted in residents' clothing being soiled, which contradicted the facility's policy of promoting residents' dignity and self-worth.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consent for psychotropic medications prior to administration for three residents, which is a requirement to ensure residents and their representatives are fully informed of the risks and benefits of medications. Resident 21, who had moderate cognitive impairment and diagnoses including diabetes, brain dysfunction, and depression, was prescribed Seroquel on 06/13/2024 without prior consent, despite having been on the medication previously and it being discontinued earlier. Resident 19, who was alert and had diagnoses including diabetes, anxiety, and bipolar depression, began taking Effexor XR on 10/06/2024, but consent was only documented 19 days later. Staff interviews confirmed that consents should be obtained before the first dose and when doses change. Resident 333, who was severely cognitively impaired with diagnoses including traumatic brain injury and depression, was prescribed Effexor and Seroquel on 06/14/2024. The consent for Seroquel was signed three days after the medication was started, and there was no consent for Effexor. Staff interviews, including with the Director of Nursing, confirmed that consents for psychotropic medications should be obtained when the medication is ordered, and acknowledged the absence of the required consents.
Failure to Provide Required Beneficiary Notices
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents, which is required to inform them of the estimated costs of services that may no longer be covered by Medicare Part A. Resident 46, who was cognitively intact and required assistance with activities of daily living, did not receive the SNFABN until 19 days after their last covered day. Resident 62, who was independent with activities of daily living but had severely impaired cognition, did not receive a SNFABN at all. This oversight placed both residents at risk of being unable to make informed financial and care decisions regarding their continued stay. Interviews with facility staff revealed that the Business Office Manager, Staff N, was responsible for issuing the SNFABNs. Staff N admitted to missing Resident 62 and failing to issue the notice as required. The Executive Director, Staff A, acknowledged the failures and stated that the process of issuing SNFABNs the day after a resident's Medicare Part A coverage ended was not followed. The deficiency was identified as a failure to comply with the requirements for providing beneficiary notices, as referenced by WAC 388-97-0300(1)(e)(5)(6).
Failure to Ensure Privacy of Residents' Mail
Penalty
Summary
The facility failed to ensure the privacy of residents' mail, affecting six residents who were part of the sample reviewed for privacy. Resident 1, who was cognitively intact and able to direct their care, reported during a Resident Council interview that their mail was consistently opened before delivery. Other residents, including Residents 29, 42, 45, and 47, confirmed similar experiences of receiving opened mail. Resident 19 specifically mentioned that their mail from the Department of Social and Health Services (DSHS), behavioral health, and welfare was opened, and they had discussed this issue with Staff N, the Business Office Manager. Staff interviews revealed that the mail was initially handled by Staff P, the Receptionist, who passed it to Staff N for sorting before returning it for delivery. Staff P confirmed that mail from DSHS addressed to residents had been opened. Staff N was unavailable for interview due to being on leave. The Executive Director, Staff A, acknowledged that mail should be delivered unopened and attributed the issue to confusion over which mail was intended for residents versus the facility. Staff A affirmed that residents have a right to privacy with their mail and that the facility requires permission to open it.
Failure to Reimburse Resident for Lost Property
Penalty
Summary
The facility failed to protect a resident's property from loss and did not reimburse the resident in a timely manner for the loss of a cell phone. Resident 19, who has diagnoses including diabetes and quadriplegia and is cognitively intact, reported that their cell phone was stolen in November 2023. Despite being informed by the Executive Director, Staff A, that reimbursement was in process, the resident had not received the reimbursement check and had to purchase a new cell phone using their own funds. Interviews and record reviews revealed that there were no entries in the missing property logs or grievance logs regarding the resident's cell phone. Staff L, Director of Social Services, indicated that missing property forms were submitted to Staff A. Staff A acknowledged that they were aware of the missing cell phone several months prior but had not submitted the reimbursement request. They admitted that the reimbursement should have been processed within five business days, acknowledging the delay in resolving the issue.
Failure to Complete and Implement PASARR for Residents
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Reviews (PASARR) were completed or implemented as required for two residents. Resident 12, who was admitted with a diagnosis of depression, had a PASARR Level I screen indicating mental illness and functional limitations, necessitating a Level II review. Despite a Level II Notice of Determination recommending specialized behavioral health services, these services were not documented or provided. Interviews revealed that Resident 12 had not seen a behavioral health provider since admission, and an appointment was only scheduled after the deficiency was identified. Resident 21 was admitted without a PASARR completed prior to admission, contrary to requirements. The PASARR Level I was completed five days after admission by the facility's social services staff, as no earlier form was found. The Director of Social Services indicated that the PASARR should have been completed by the hospital, but it was not done before the resident's admission. This oversight in both cases placed the residents at risk for a decline in their mental health and a decrease in their quality of life.
Failure to Follow Care Plan Interventions for Residents
Penalty
Summary
The facility failed to ensure care plan interventions were followed for three residents, leading to unmet care needs and discomfort among other residents. Resident 54, who had a stroke and paralysis, required substantial assistance with activities of daily living and was dependent on staff for bed mobility and transfers. Despite a care plan and physical therapy recommendation to assist Resident 54 into a wheelchair daily, there was no documentation of attempts or refusals, and the resident was frequently observed lying in bed. Staff interviews revealed inconsistencies in following the care plan, with one staff member stating the resident often refused assistance, but these refusals were not documented. Additionally, the facility did not adhere to care plan interventions for Residents 39 and 67, who were romantically involved and had severe cognitive impairments. Their care plans required staff to ensure public displays of affection were appropriate and to prevent them from entering each other's rooms. However, observations and interviews indicated that these interventions were not consistently followed, as the residents were seen entering each other's rooms and engaging in public displays of affection, causing discomfort among other residents. Staff interviews highlighted a lack of consistent supervision and adherence to the care plans.
Deficiencies in ADL Assistance for Two Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, leading to deficiencies in their care. Resident 60, who had diagnoses including adult failure to thrive, osteoporosis, and hypothyroidism, was not provided with the necessary showers, assistance, cueing, supplements, and referrals to promote their nutrition. The resident was mildly cognitively impaired and required maximum assistance with showering and toileting hygiene. Despite being incontinent, Resident 60 received only one shower in a 30-day period, and there was a persistent smell of urine in their room. The resident also experienced significant weight loss, and there were multiple instances where they were not assisted or cued during meals, leading to uneaten food and inadequate nutritional intake. The facility also failed to ensure that Resident 60 received the prescribed high protein/high calorie drinks, with 11 out of 100 opportunities missed due to the drinks being out of stock. Additionally, a referral to a dental or ENT provider was recommended by the speech therapist due to the resident's jaw pain, but no such appointment was made. Interviews with staff revealed a lack of awareness and communication regarding the resident's care plan, dietary needs, and the necessity for regular toileting and hygiene assistance. Resident 75, who had necrosis/gangrene of the fingers and amputations of both legs, was also not provided with the scheduled showers. Despite being alert and able to communicate their needs, Resident 75 reported receiving only one shower since their admission 45 days prior. The facility's records showed no documentation of showers or refusals, and staff interviews confirmed that the resident's bathing schedule was not followed. The lack of showers contributed to hygiene issues, as evidenced by the presence of stains on the resident's clothing and bedding.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests of a resident with severe cognitive impairment and physical limitations. The resident, who had a history of stroke and hemiplegia, expressed interest in activities such as reading, listening to music, being around animals, being outdoors, practicing religion, and engaging in favorite activities. Despite these preferences, the care plan only documented independent leisure activities like watching TV and spending time with visitors, along with 1 to 1 visits with activity staff. However, the resident had not attended any activity programs over the prior quarter, and staff failed to ensure the resident was escorted or transported to activities as needed. Observations revealed that the resident spent most of their time lying in bed, watching TV, or napping, and they reported not receiving assistance to get into their wheelchair to attend activities. The Life Enrichment Director acknowledged that activities for the resident mainly consisted of in-room visits and admitted that pet visits were no longer offered. The director also stated that no reading materials or audiobooks had been provided, despite the resident's interest in reading. The resident had initially refused activities upon admission, leading staff to stop inviting them, although the director recognized that the resident should still be invited to activities.
Failure to Implement Bowel Management Protocol
Penalty
Summary
The facility failed to implement a bowel management protocol for two residents, leading to a deficiency in care. Resident 21, who had diagnoses including diabetes, brain dysfunction, and a history of stroke, was cognitively impaired and required assistance with daily activities, including toileting. Despite having orders for Milk of Magnesia, Bisacodyl suppository, and Fleet enema to manage constipation, the resident did not have a bowel movement for six days, from June 11 to June 16, 2024. The medication administration record showed that the prescribed laxatives were not administered as needed, and there were no entries indicating that the resident was offered or refused the medications. Similarly, Resident 75, who had necrosis/gangrene of the fingers and amputations due to frostbite, was cognitively intact and required assistance with toileting. This resident was on opioid pain medication, which could cause constipation. Despite having orders for Miralax, Senna, Milk of Magnesia, Dulcolax, and Fleet enema, the resident experienced multiple periods without bowel movements, ranging from three to five days, between May 29 and June 21, 2024. The medication administration records indicated that the as-needed medications were not given when required, and there were no corresponding entries documenting that the medications were offered or refused. Interviews with staff revealed a lack of adherence to the bowel management protocol, contributing to the deficiency.
Failure to Schedule Vision Appointment for Resident
Penalty
Summary
The facility failed to schedule a necessary vision appointment for a resident, identified as Resident 59, who was cognitively intact and able to communicate their needs. The resident had informed both the Resident Care Manager and the Transportation staff about their need for a vision appointment approximately a month prior. Despite this, the appointment was not scheduled, placing the resident at risk for worsening vision and decreased quality of life. The resident experienced intermittent eye pain and had previously undergone an eye exam, which indicated the need for retinal surgery. However, due to a communication lapse, where the eye clinic contacted an outdated phone number and subsequently closed the referral after two unsuccessful attempts, the necessary follow-up appointment was not made. Staff T, responsible for scheduling appointments, acknowledged the oversight and the Director of Nursing confirmed that the process could have been handled better.
Failure to Remove Urinary Catheter and Initiate Bladder Training
Penalty
Summary
The facility failed to remove a urinary catheter and provide bladder training as ordered for a resident, which increased the risk of catheter-associated urinary tract infections and diminished quality of life. The resident, who was cognitively intact and able to communicate their needs, was admitted with an indwelling urinary catheter due to obstructive uropathy. A hospital progress note indicated that the catheter was initially placed because the resident was unable to void and needed to be removed for bladder training. Transition of care orders from the hospital also documented the need for bladder training. Despite these orders, the urinary catheter was not removed, and bladder training was not attempted. The resident expressed frustration about the catheter not being removed prior to discharge, and a family member confirmed that the orders for removal were not followed. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing, verified that the catheter should have been removed and bladder training should have been initiated, as per the orders dated 04/22/2024.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care services for Resident 80, who had diagnoses of bipolar disorder and substance abuse in remission. The resident was cognitively intact and capable of making decisions regarding their care. On the day of a scheduled behavioral health appointment, the resident was informed only 15 minutes prior that the facility could not provide transportation, leading to the resident missing the appointment. This appointment was crucial for medication review and adjustment, and the resident expressed significant distress over missing it, as they had no alternative means of transportation and had been waiting for the appointment for a month and a half. Subsequently, the resident was unable to reschedule the appointment due to a no-show fee charged by the behavioral health clinic. Interviews with facility staff revealed that the appointment was not placed on the facility's calendar until three days before the scheduled date, which was insufficient time to arrange transportation. The Social Service Director did not recall being informed about the appointment but did not dispute the resident's claim that they had notified the staff a week in advance. This oversight resulted in the resident missing a critical appointment for their mental health and sobriety management.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 9.38 percent. This was identified through observations and interviews involving two residents. Resident 9, who was cognitively intact and had diagnoses including diabetes, chronic pain, and anxiety, did not receive their medications correctly. A Licensed Practical Nurse (LPN) failed to clean the insulin pen tip, did not perform a test dose, and removed the needle too quickly after administering insulin. Additionally, the LPN documented that Resident 9 used their Flovent inhaler, although the resident did not actually use it. Resident 78, also cognitively intact with diagnoses including a broken right upper arm, diabetes, and heart disease, received incorrect insulin administration. A Registered Nurse (RN) did not clean the insulin pen tip or prime the pen before administering the insulin dose. The Director of Nursing Services confirmed that the proper procedures for insulin pen use were not followed by the staff involved.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and handling of medications, specifically controlled substances and expired medications, in two medication storage rooms and a medication cart. In the South Medication Room, a Levemir insulin pen was found with a pharmacy label indicating an expiration date of 03/08/2025, while the manufacturer's label showed an expiration date of 11/2023. In the North Medication Room, the refrigerator lock was not engaged, and an emergency kit inside had a broken red tag lock. This kit contained Lorazepam, a schedule IV-controlled substance, which was not secured as required. Additionally, the North Medication Cart contained expired medications, including Acetaminophen and Vitamin B-12 tablets, and unlabeled tablets were found in the cart's drawers. Interviews with staff revealed that the emergency kit was usually locked, but the lock was not replaced after a check on 06/20/2024. The Director of Nursing Services confirmed that the emergency kit should have been double locked and expired medications should have been removed from the cart.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager possessed the required credentials, specifically a Food Service Manager certification. This deficiency was identified during interviews and record reviews. Staff H, the Dietary Manager, admitted to not having the necessary certification and mentioned plans to take the class. Additionally, the Registered Dietician (RD), Staff K, was only employed part-time at the facility. The Executive Director and Director of Nursing acknowledged that the absence of a full-time RD and the lack of certification for Staff H did not meet regulatory requirements, as per WAC 388-97-1160(1). This situation placed all residents at risk of receiving dietary services that might not meet necessary nutritional requirements or adhere to industry standards.
Deficiency in Meal Temperature and Quality
Penalty
Summary
The facility failed to provide palatable, attractive meals at a safe and appetizing temperature for six of eight sampled residents. The deficiency was identified through observations, interviews, and record reviews. Residents reported that meals were often served cold, and the menu did not always reflect what was actually served. The facility's plate warmer was broken, which contributed to the issue of cold food. Residents expressed dissatisfaction with the lack of fresh fruits and vegetables, and some reported being served canned fruits and vegetables instead. Additionally, there were complaints about the lack of meal substitutions and the inability to reheat food. Several residents, including those with conditions such as rheumatoid arthritis, Parkinsonism, peripheral vascular disease, end-stage renal disease, Crohn's disease, and kidney failure, were affected by the facility's failure to provide meals at the appropriate temperature. These residents were cognitively intact and had varying levels of assistance required for eating and activities of daily living. During interviews, residents expressed dissatisfaction with the dining experience, citing issues such as cold food, lack of menu variety, and unavailability of certain food items like bananas and salads. Staff interviews revealed that the dietary manager was aware of the broken plate warmer and the challenges in obtaining necessary ingredients due to budgetary constraints. The executive director was initially unaware of the extent of the residents' food concerns but acknowledged receiving some complaints about cold food. The facility's inability to reheat food was attributed to concerns about cross-contamination. The dietary manager also mentioned being locked out of ordering certain food items from the supplier's website, which further limited the facility's ability to meet residents' dietary preferences and needs.
Failure to Provide Meals for Resident Attending Dialysis
Penalty
Summary
The facility failed to provide at least three meals daily for a resident who attended outside medical appointments on specific days of the week. The resident, who had diagnoses including end-stage renal disease, diabetes, and heart disease, was cognitively intact and required no staff assistance for activities of daily living. Despite the resident's repeated requests to have their evening meal held for them on days they returned late from dialysis appointments, the facility only complied once. As a result, the resident often went without an evening meal, receiving only a sack lunch during their dialysis appointments, which they consumed before returning to the facility. Interviews with facility staff revealed a lack of communication and adherence to the process of holding meals for residents who are out of the building during regular mealtimes. The Dietary Manager admitted to not communicating with the kitchen staff to hold a meal for the resident, and the Executive Director was unsure if the kitchen staff were following the process of holding a hot meal for residents not present at scheduled mealtimes. This oversight placed the resident at risk for unplanned weight loss and nutritional deficits.
Failure to Ensure Resident Received Bathing Services
Penalty
Summary
The facility failed to communicate effectively with the hospice provider regarding bathing services for a resident, identified as Resident 15, who was under hospice care. This resident, who had severe cognitive impairment and required maximum assistance with personal hygiene, did not receive a shower or sponge bath for over seven weeks due to a scheduling error. The hospice was responsible for providing bathing assistance twice a week, but a mistake led to the cancellation of the resident's bath aide services. The facility's records, including the electronic medical record and paper shower log, showed no documentation of bathing during this period. Interviews with facility staff revealed that there was a misunderstanding about who was responsible for the resident's bathing. Staff members believed hospice was providing the baths, but hospice records confirmed that the last bath was given on a specific date over seven weeks prior. The facility's Executive Director and Director of Nursing acknowledged the oversight and confirmed that the facility did not ensure the resident received adequate bathing and grooming, which was ultimately their responsibility.
Failure in Safe and Timely Discharge Planning
Penalty
Summary
The facility failed to ensure a safe discharge for Resident 56, who was admitted with diagnoses including encephalopathy, bipolar disorder, and adult maltreatment. Despite being cognitively intact and requiring supervision for ADLs, Resident 56 expressed a desire to discharge home with their spouse, against whom there was an open APS investigation and a restraining order. The resident eventually left the facility AMA with a representative, but the facility did not notify APS as required by their policy. Interviews with staff revealed a lack of clarity and adherence to the process for AMA discharges, contributing to the unsafe discharge. For Resident 79, the facility failed to honor discharge preferences in a timely manner. Resident 79, admitted with heart failure, anxiety, and depression, expressed a desire to discharge to another state where a family member worked. Despite this request being made early in their stay, the discharge process was delayed. Staff interviews confirmed that discharge planning should have occurred sooner, indicating a failure in the facility's discharge planning process.
Failure to Protect Resident from Verbal Abuse and Neglect
Penalty
Summary
The facility failed to act promptly after altercations between two residents, leading to one resident experiencing verbal abuse and psychosocial harm. The affected resident, who was cognitively intact and had a complex medical history, reported anxiety, tearfulness, lack of sleep, and expressed fear due to their roommate's aggressive behavior. Despite being aware of the situation, the staff delayed moving the resident to a different room, which resulted in the resident feeling unsafe and ultimately deciding to discharge against medical advice. The roommate, who had a history of stroke and dementia, exhibited moderate cognitive impairment and frequent verbally aggressive behaviors. These behaviors included yelling, cursing, and making threats, which were documented in the resident's care plan. However, the facility did not implement new interventions or adequately address the escalating situation after the incidents occurred, leaving the affected resident vulnerable to further distress. Interviews with staff members revealed that the verbally aggressive behaviors of the roommate were well-known and had been ongoing for some time. Despite this knowledge, the facility's response was insufficient, as they failed to provide immediate safety measures for the affected resident or monitor for potential psychological harm. The lack of timely intervention and appropriate care plan adjustments contributed to the deficiency in protecting residents from abuse and neglect.
Failure to Implement Effective Fall Prevention Strategies
Penalty
Summary
The facility failed to consistently implement interventions to reduce fall hazards, monitor for intervention effectiveness, and modify interventions when necessary for a resident with severe cognitive impairment. This resident, identified as Resident 4, experienced multiple falls within a short period, indicating a lack of effective fall prevention strategies. The facility's policy required revising care plans and implementing new interventions following falls, but this was not consistently done for Resident 4. Resident 4 had a history of falls and was at high risk due to cognitive impairment and overestimating their abilities. Despite this, the facility did not adequately document or implement new interventions after each fall. For instance, after a fall on May 7, 2024, no new interventions were added to the care plan, and a medication review was delayed. Additionally, incident reports for some falls were incomplete or missing, and there was a lack of documentation for 1:1 monitoring, which was supposed to be in place. Interviews with staff revealed a general understanding that new interventions should be implemented promptly after a fall to prevent further incidents. However, the facility's actions did not align with this understanding, as evidenced by the repeated falls and insufficient documentation. The facility's failure to adhere to its fall prevention policy and effectively manage Resident 4's care plan contributed to the resident's repeated falls and potential risk for injury.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for Resident 3, who was a trauma survivor with a history of domestic violence. The facility's policy required universal screening for trauma and the development of care plans to mitigate potential triggers. However, upon admission, Resident 3's social service admission and discharge evaluation was incomplete, and the care plan did not specify the resident's history of domestic violence or identify potential triggers to prevent re-traumatization. Resident 3, diagnosed with anxiety, depression, and PTSD, was admitted to the facility with a history of verbal abuse from their spouse. Despite this, the care plan only included general interventions related to medication management and psychosocial well-being, without addressing specific trauma-related needs. Shortly after admission, Resident 3 was placed in a room with a roommate known for verbally aggressive behaviors, which led to an incident where the roommate aggressively grabbed Resident 3's arm, causing confusion and distress. Interviews with facility staff revealed a lack of awareness and documentation regarding Resident 3's trauma history and potential triggers. Staff acknowledged that trauma and potential triggers should be listed in the care plan, but Resident 3's care plan lacked such details. Additionally, the facility delayed implementing measures to prevent contact between Resident 3 and their spouse, who was identified as a source of trauma, until several weeks after admission.
Failure to Implement Person-Centered Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement person-centered care plans with individualized interventions for a resident diagnosed with dementia, leading to increased behaviors and diminished quality of life. The facility's policy on dementia care emphasized the need for non-pharmacological approaches and person-centered care plans to address behaviors. However, the care plan for the resident in question was not reviewed or updated, and it lacked individualized non-pharmacological interventions. The resident exhibited increased agitation and combativeness, yet the assessments failed to document effective interventions or behavioral symptoms accurately. The resident, who had a history of stroke and dementia, showed moderate cognitive impairment and fluctuating moods. Despite the resident's increased agitation and combativeness, the care plan did not include specific strategies to address these behaviors. Nursing progress notes documented frequent behaviors such as crying out, panic attacks, anxiety, hallucinations, delusions, and verbal outbursts. These behaviors were often triggered during care or when a peer was present in the resident's room. Staff interviews revealed that the resident's behaviors were known but lacked specific interventions to manage them effectively. Interviews with various staff members, including nursing assistants, registered nurses, and social services, highlighted the resident's frequent verbal outbursts and the absence of effective behavioral interventions. Staff acknowledged that the resident's behaviors could be related to pain, but pain interventions and alternative care options were not adjusted. The facility's failure to implement a person-centered care plan with individualized interventions for the resident's dementia-related behaviors resulted in unmet needs and a diminished quality of life for the resident.
Failure to Report Potential Abuse and Misappropriation
Penalty
Summary
The facility failed to identify and report several incidents of potential abuse and misappropriation of property to the State Survey Agency as required. In the case of Resident 4, who had a history of verbal aggression, there were multiple incidents where they verbally abused their roommate, Resident 3, over TV volume disputes. Despite these incidents being documented in nursing progress notes, they were not reported as potential abuse. Staff interviews revealed a lack of awareness and action regarding these incidents, and the facility's incident log did not reflect these occurrences. Similarly, Resident 6, who had severe cognitive impairment and a history of behavioral issues, was involved in an incident where they became agitated and physically aggressive towards their roommate, Resident 5. This incident was documented in the facility's incident log but was not reported to the State Survey Agency as potential abuse. Staff interviews indicated a lack of awareness of the incident, and the investigation into the incident was incomplete, lacking staff or resident interviews. Additionally, the facility failed to report the potential misappropriation of Resident 2's wallet, which contained important personal items and cash. Despite the missing wallet being reported to the facility's management, it was not documented in the facility's grievance or incident logs, nor was it reported to the State Survey Agency. Staff interviews revealed a lack of awareness of the missing wallet, and the facility's administrator acknowledged the incident but did not consider it potential misappropriation due to the absence of specific allegations of theft.
Inadequate Documentation and Improper Discharge Procedures
Penalty
Summary
The facility failed to ensure that facility-initiated discharges had a valid basis and that the discharge documentation included the required components for two of the three sampled residents. Resident 1, who was admitted for wound care and completion of a six-week course of IV and oral antibiotics for osteomyelitis, was discharged against medical advice (AMA) without proper documentation or a valid reason. The resident was informed that failure to return to the facility by a certain time would result in discharge without a safe discharge plan. The discharge occurred without completing the AMA form, documenting the resident's condition, or notifying the necessary staff. Additionally, the resident's PICC line was discontinued without a provider order, and the resident was discharged with incomplete antibiotic treatment. Resident 2, who had a history of stroke and intentional salicylate overdose, was also discharged AMA without proper documentation or a valid reason. The resident had moderate cognitive impairment and was on mood-stabilizing medications. Despite a planned discharge with home health services, the resident left the facility during a personal outing and did not return. The facility failed to document the reasons for postponing the planned discharge, details of why the discharge was considered AMA, or that the resident had been kept informed. No AMA paperwork was completed, and medications were not sent with the resident. Interviews with facility staff revealed inconsistencies in the discharge process and a lack of adherence to facility policies. Staff acknowledged that residents could leave for personal outings but were encouraged to return by a specific time. However, there was no consistent monitoring of resident sign-outs, and staff were unsure of the AMA discharge process. The facility was able to meet the needs of both residents, yet failed to follow proper procedures for AMA discharges, resulting in inadequate documentation and potential risks to the residents' health.
Failure to Monitor Dialysis Tolerance and Collaborate with Dialysis Center
Penalty
Summary
The facility failed to consistently monitor a resident's tolerance to dialysis treatments and collaborate care with the dialysis center. The resident, who had end-stage renal disease and was dependent on dialysis, had a care plan that required staff to check the dialysis access port post-dialysis and monitor for complications. However, the facility did not consistently complete the dialysis communication forms, which were essential for tracking the resident's pre-dialysis and post-dialysis vital signs and any complications during treatment. Review of the resident's medical records from February to April 2024 showed significant gaps in the documentation of dialysis communication forms, vital signs, and weights. The February Medication Administration Record (MAR) indicated that standard dialysis physician orders were in place only until February 19, 2024, and no monitoring was found from February 20th onwards. In March, there were no standard dialysis physician orders from March 1st to March 14th, and the resident refused dialysis on March 15th without any weight or blood pressure recorded. In April, no standard dialysis physician orders were present until the date of the investigation. The Director of Nursing confirmed that there is a standard physician order set for dialysis-dependent residents and that the facility's expectation was for staff to complete the dialysis communication form each time the resident went to dialysis. However, upon reviewing the MARs, it was evident that the required dialysis physician orders were only sporadically present, making it difficult to determine if the resident was being adequately monitored and tolerating dialysis treatments. This lack of consistent monitoring placed the resident at risk of unrecognized complications and unmet care needs.
Failure to Accurately Submit Direct Care Staffing Information
Penalty
Summary
The facility failed to ensure that direct care staffing information, including data for agency and contract staff, was correctly submitted to the Centers for Medicare and Medicaid Services (CMS) for Quarter 3 of 2023. This failure was identified through a review of the Certification and Survey Provider Enhanced Reports (CASPER) Payroll-Based Journal Staffing Data Report, which showed that the facility reported staffing levels lower than required. During interviews, the Administrator revealed that the Human Resources Manager, who has since been terminated, was responsible for reporting the PBJ data, and the Administrator was supposed to check the data for accuracy before submission. The error occurred because the Human Resources Director did not include agency staff in the numbers and incorrectly calculated nurse hours. The Administrator, who was in training at the time, was unsure if the Interim Administrator had reviewed the data before submission.
Failure to Timely Assess Fall Risk and Implement Safety Interventions
Penalty
Summary
The facility failed to consistently assess fall risk, timely initiate fall care plans, and implement new safety interventions for two residents reviewed for falls. Resident 1, who had a history of falls and was identified as high risk, experienced multiple falls after admission. Despite being identified as high risk, the baseline care plan did not document fall risk or interventions, and no new interventions were implemented after falls occurred on multiple occasions. The facility's incident reports and care plans did not reflect timely or adequate responses to these falls, leading to repeated incidents without appropriate preventive measures being put in place. Resident 2, also identified as high risk for falls, experienced a fall the day after admission. The baseline care plan did not document fall risk or interventions, and the comprehensive care plan addressing falls was not initiated until several days after the fall occurred. Staff interviews revealed that information on required levels of assistance and safety interventions was often missing for new admissions, and there was a lack of immediate initiation of new safety interventions following falls. The facility's policy required residents to be assessed for fall risks on admission, quarterly, after a fall, and with a change of condition. However, the facility did not adhere to this policy, as evidenced by the delayed initiation of fall care plans and the absence of new safety interventions following falls. Staff acknowledged the deficiencies in timely assessment and intervention, and the facility's documentation practices were found to be inadequate in addressing the fall risks of the residents involved.
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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