Avalon Care Center At Northpointe
Inspection history, citations, penalties and survey trends for this long-term care facility in Spokane, Washington.
- Location
- 9827 North Nevada, Spokane, Washington 99218
- CMS Provider Number
- 505496
- Inspections on file
- 46
- Latest survey
- September 17, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Avalon Care Center At Northpointe during CMS and state inspections, most recent first.
A resident with opioid use disorder and a history of hepatitis received a lower methadone dose than prescribed by the OTP provider after a facility physician assistant changed the order based on recommendations from a hepatology clinic, without documented coordination with the OTP. The facility did not have a specific policy for OTP-managed residents and only reported the dosing discrepancy after being questioned by OTP staff.
A resident with opioid use disorder and chronic liver conditions experienced a change in methadone dosage by facility staff without documented coordination with the opioid treatment program (OTP) provider. The facility administered a lower methadone dose based on recommendations from a hepatology clinic, but did not consult the OTP, resulting in a discrepancy that was only discovered when unused medication was returned. Interviews revealed a lack of clear policy and confusion among staff regarding provider responsibilities for MOUD management.
Two residents experienced significant weight loss due to the facility's failure to maintain acceptable nutrition parameters. One resident lost 7.9% of their weight over three months, while another lost 8.51% in one month. Observations showed that residents were not offered alternate meals or nutritional supplements despite poor intake. Staff interviews revealed a lack of timely interventions and communication, contributing to the residents' weight loss.
The facility failed to follow professional standards for food safety, including improper storage and temperature monitoring of food items. Expired eggs were found in the refrigerator, and food temperatures were not consistently checked or documented during meal service, increasing the risk of contamination and bacterial growth.
The facility failed to submit MDS assessments to CMS within the required timeframe for four residents, affecting data accuracy and monitoring. The MDS Director and DON acknowledged the late submissions, confirmed by a validation report showing multiple late files.
The facility failed to administer bowel care medications as ordered for several residents, leading to prolonged periods without bowel movements. Despite physician orders for laxatives to be given after specific timeframes, the medications were not administered, and no documentation explained the omissions. Staff interviews revealed a misunderstanding of the protocol, contributing to the deficiency.
The facility failed to ensure proper respiratory care for three residents, lacking provider orders and documentation for oxygen and CPAP use. One resident used oxygen without orders, another had a CPAP machine without documented use or maintenance, and a third did not consistently use their CPAP despite having an order. These deficiencies risked respiratory complications and diminished quality of life.
The facility did not complete annual performance reviews for two nursing assistants, Staff P and Staff Y, as required. This was discovered through interviews and record reviews, which showed no documentation of completed evaluations. The administrator was unaware of the lack of a process for these evaluations, which posed a risk to residents' care quality.
The facility failed to administer medications as ordered for three residents, leading to significant medication errors. A resident with diabetes and high blood pressure missed insulin doses and had blood pressure medication administered against parameters. Another resident missed insulin and sevelamer doses during dialysis sessions, with no adjustments made. A third resident received blood pressure medication despite low readings. These failures risked medical complications.
The facility failed to maintain proper temperature controls for medication storage in two medication rooms and one refrigerator. In the West medication room, no thermometer was present, and in the East medication room, the absence of a thermometer was acknowledged by the DON. The refrigerator contained various medications, and the temperature logs were incomplete. The Administrator expected staff to monitor temperatures, but no policy was provided.
The facility failed to provide appetizing and palatable food, leading to dissatisfaction among residents. Complaints included mushy vegetables, processed chicken, inedible eggs, and overly salty meals. A test tray confirmed these issues, with food being bland and unappetizing. Despite residents expressing concerns, improvements were not made, and the dietary manager delayed addressing these issues.
The facility failed to ensure arbitration agreements were properly reviewed and explained to three cognitively impaired residents or their legal representatives. The agreements were signed by the residents themselves, despite their severe cognitive impairments, rather than by their legal representatives or POA. This oversight placed the residents at risk of being uninformed of their rights and losing legal protection.
The facility failed to implement enhanced barrier precautions for two residents with draining wounds, and staff improperly used N95 masks during a COVID-19 outbreak. Infection prevention policies were outdated, and the water management plan was incomplete, increasing the risk of infection spread.
Two residents in an LTC facility were not informed of medication changes, violating facility policy. One resident with cognitive impairment had their Seroquel and Ativan dosages increased without their POA's knowledge, leading to increased sedation and falls. Another resident experienced a decrease in pain medication without being informed. Staff interviews confirmed the need for notification and documentation of such changes.
The facility failed to notify the State Long-Term Care Ombudsman of hospital transfers and discharges for several residents, as required by policy. This deficiency was identified through interviews and record reviews, revealing that residents were transferred to the hospital without the necessary notifications. Staff interviews indicated a lack of awareness regarding the notification requirement, and the Ombudsman confirmed the facility's failure to notify them, except in cases of eviction notices.
The facility failed to provide timely bed-hold notices to five residents or their representatives during hospital transfers, risking their awareness of the right to retain their rooms. This deficiency was identified through interviews and record reviews, highlighting the lack of documentation and communication regarding bed-hold options.
The facility failed to timely and accurately complete MDS assessments for several residents, affecting data gathering and monitoring of residents' progress. Some assessments were completed weeks or months late, and inconsistencies were found in cognitive assessments. Staff acknowledged being behind on MDS completion, with 76 assessments overdue.
The facility failed to investigate falls and implement safety interventions for residents, leading to repeated falls and injuries. Two residents with substance use disorders were not assessed or managed properly, resulting in one resident eloping. Additionally, the facility did not ensure safe smoking practices, lacking supervision and safety measures for residents who smoked.
The facility failed to ensure proper monitoring and documentation of psychotropic medication use for residents, leading to potential chemical restraint and unmet care needs. A resident with dementia was administered increasing doses of Seroquel without consistent behavior monitoring or implementation of non-medication interventions. Similar issues were noted for two other residents with depression and anxiety, where documentation of behavior and side effects was incomplete.
A resident with bipolar disorder, high blood pressure, and cervical cancer was not evaluated for self-administration of medications, leading to unsupervised medication intake. The resident was found with loose pills and expressed uncertainty about them. An LPN admitted to possibly leaving the medications unattended, and the Resident Care Manager confirmed no assessment for self-administration had been conducted.
The facility failed to provide weekly and alternative menus to residents, denying them the right to choose their meals. Three residents, who were cognitively intact, reported not receiving menus or being unaware of their availability. Staff confirmed that menus were only given upon request, resulting in a low number of residents submitting meal choices. This deficiency potentially impacted residents' nutritional needs and quality of life.
The facility failed to provide complete information on services and charges not covered under the per diem rate for two residents. One resident received an incomplete SNFABN, while another resident's POA was informed of Medicare ending via phone but not given written notice of costs. The Business Office Manager confirmed the lack of documentation.
The facility failed to maintain a homelike environment and sanitation for residents, with drywall damage in several rooms and an unclean wheelchair for a resident. Observations over several days showed gauges and holes in the drywall of three residents' rooms, and a wheelchair with debris and a brown substance for another resident. Staff interviews indicated a lack of timely maintenance and cleaning responsibilities.
A facility failed to document and communicate a resident's transfer information to the receiving hospital. The resident, with cognitive impairment and conditions like diabetes and anxiety, was transferred for evaluation of agitation and psychosis. The transfer form lacked documentation of communication with the hospital, and staff confirmed the expectation to notify the hospital of the resident's condition.
A facility failed to complete a timely PASARR for a resident admitted after an exempted hospital stay. The resident, with depression and anxiety, was expected to stay for 30 days or less but remained beyond this period. A Level I PASARR indicated the need for a Level II, but it was not completed until 40 days after the expected discharge. The Social Service Director acknowledged the importance of timely PASARR completion for mental health care.
A facility failed to follow a physician-ordered podiatry referral for a resident with diabetes and Multiple Sclerosis, leading to delayed foot care. Despite a September note indicating the need for podiatry evaluation, the resident's toenails were not addressed until January by a nurse practitioner. Staff interviews revealed confusion and delays in arranging podiatry care, with uncertainty about sending residents out for appointments. The resident had not been seen by a podiatrist by the time of the survey exit.
A facility failed to ensure accurate communication and care planning for a resident receiving dialysis via a CVC. Despite the resident never having a fistula, the care plan inaccurately included interventions for a fistula, and staff documentation reflected this error. The Pre-Dialysis Assessment forms were inconsistently returned, and staff were initially unaware of the correct access site, leading to a deficiency in dialysis care.
The facility failed to provide adequate staffing, impacting resident safety and care. A resident with cognitive impairment experienced multiple falls due to insufficient supervision, while another resident with substance abuse history eloped due to lack of a care plan. Additionally, a resident reported long call light wait times, highlighting staffing challenges, especially during evenings and weekends.
A facility failed to consistently monitor a resident for adverse effects of a blood thinning medication, as required by provider orders. The resident, with heart failure and high blood pressure, was taking Xarelto. Documentation was incomplete across multiple shifts, as confirmed by interviews with a Registered Nurse and the Director of Nursing, who acknowledged the deficiency in monitoring.
The facility failed to maintain resident beds in safe operating condition, with four beds having exposed wires and peeling electrical tape on bed controls. Observations revealed these issues in multiple rooms, and the Maintenance Director admitted to not conducting regular inspections, relying instead on work orders to identify disrepair.
The facility failed to maintain functional call bell systems for two residents, leading to potential safety risks. A resident's call light was non-functional for weeks, and another resident's call light failed during an urgent need. Maintenance relied on work orders to address issues, lacking regular audits.
The facility failed to ensure personal refrigerators for two residents were clean, free of expired foods, and maintained at appropriate temperatures. One resident's refrigerator had a brown liquid spill and lacked a temperature log, while another's contained expired yogurt and pudding. Staff interviews revealed confusion over responsibility for monitoring these refrigerators.
The facility failed to investigate potential abuse allegations for two residents and falls for two others. A resident alleged their call light was removed, leading to a fall, while another had a scab allegedly caused by staff. Investigations were inadequate, lacking thorough staff interviews and specific incident details. Additionally, falls involving two other residents were not investigated, as required by facility policy.
The facility failed to provide adequate discharge planning and documentation for two residents, leading to potential risks of unsafe discharges. One resident with cognitive impairment was discharged without proper documentation, while another resident with mental health issues eloped and was not properly followed up. Staff interviews revealed inconsistencies in the discharge process and a lack of clarity regarding responsibilities.
The facility failed to provide necessary assistance to a resident during an outside appointment and did not adhere to the care plan for bathing another resident. A resident who was severely cognitively impaired and dependent on staff for ADLs was left without a caregiver at an appointment, leading to unmet needs. Another resident, who required assistance for bathing, did not receive consistent care as per their care plan, with several instances of missed or refused baths not being addressed.
A resident at risk for pressure ulcers due to immobility and health conditions developed a stage four pressure ulcer on the left heel, which the facility failed to identify and treat in a timely manner. Despite revisions to the care plan and interventions like an air mattress and heel floating, the ulcer was not promptly addressed, leading to delayed wound healing. Staff interviews revealed a lack of awareness and timely response to the resident's condition.
A resident reported an allegation of rough treatment by a staff member to Social Services, but the incident was not immediately documented in the facility's Incident Log. The Social Services staff member reported the allegation to unidentified staff, but the Administrator was only informed during a clinical meeting days later, leading to a delay in reporting to the State Survey Agency.
A resident with an open surgical wound requiring wound vacuum therapy did not receive the prescribed continuous treatment due to staff misinterpretation of the treatment schedule. The wound vacuum dressing was removed prematurely and replaced with a wet-to-dry dressing without proper documentation or notification to the medical provider. Staff were unfamiliar with the therapy's requirements, leading to a risk of delayed healing and infection.
A resident reported receiving a dissolving pain pill, which was not part of their prescribed medications. An investigation revealed that a nurse had signed out controlled substances without documenting their administration and destroyed medications without a witness. The facility confirmed drug diversion and terminated the nurse.
A resident with dementia and anxiety in an LTC facility suffered a fractured humerus due to inadequate supervision. Despite requiring substantial assistance, the resident was moved away from the nurse's station, leading to wandering and falls. Staff confusion over supervision levels and insufficient staffing contributed to the incident, as the resident's impulsive behavior and low oxygen saturation were not properly managed.
The facility failed to provide adequate nursing staff, resulting in residents not receiving showers as care-planned and experiencing delays in call light responses. A resident with morbid obesity and diabetes only received weekly showers instead of twice weekly, while another resident with rheumatoid arthritis reported waiting up to 30 minutes for call light responses. Staffing shortages, including the absence of shower aides, contributed to these deficiencies.
A resident with pneumonia and heart failure experienced low oxygen saturations on two occasions, but the provider was not notified by the staff. Despite the resident's oxygen levels dropping below the specified threshold, staff applied supplemental oxygen and did not perceive the need to inform the provider, as the levels improved. The resident was cognitively impaired and had behavioral symptoms, which may have contributed to the incidents.
The facility failed to assess a resident for the removal of an indwelling urinary catheter and did not ensure proper securement of catheters for two residents. One resident experienced pain and bleeding, with no assessment for catheter removal despite lacking a diagnosis requiring it. Another resident had discomfort and bloody urine due to unsecured catheter tubing. These failures increased the risk of catheter-associated urinary tract infections, pain, and urethral trauma.
The facility failed to evaluate the competency of three LPNs responsible for urinary catheter care for two residents, leading to concerns about their skills. The LPNs provided care without documented evaluations, and residents expressed concerns about their competency. The Staff Development Coordinator confirmed the lack of documentation and noted that two LPNs no longer worked at the facility.
A resident with hypertensive kidney disease and primary pulmonary hypertension had blood pressure medications administered despite orders to hold them if the systolic blood pressure (SBP) was below 100. The MAR showed the medications were held on one day when the SBP was 99/59, but administered the next day when the SBP was 94/55. There was no documentation of provider notification or adherence to medication hold instructions, as confirmed by interviews with the Resident Care Manager and DON.
The facility failed to resolve and document grievances for three residents, leaving issues like aid concerns, pest problems, and missing glasses unresolved. Staff interviews revealed a lack of awareness about the requirement for written grievance resolutions, and the facility's grievance policy was not provided.
The facility failed to develop care plans for two residents at risk for falls and wandering. One resident with dementia and a high fall risk score did not have fall prevention interventions in their care plan. Another resident, also with dementia, was assessed as at risk for wandering but did not have a care plan addressing this until after an elopement incident. Staff confirmed these oversights during interviews.
A resident was transferred to the hospital due to a decline in condition, but their representative was not notified until over five hours later. The resident experienced stress due to the lack of immediate notification and absence of a representative at the hospital. An LPN admitted to the delay in notification due to a busy night, and a Resident Care Manager emphasized the need for immediate notification in such cases.
A resident with Crohn's disease and an ostomy was not provided with a specialized diet, leading to inappropriate food being served and contributing to malnourishment. The facility failed to assess and document the resident's dietary preferences and intolerances, despite communication from the resident's representative. The dietary manager and RD did not complete necessary assessments, resulting in the resident's hospitalization.
Failure to Administer Methadone as Prescribed by OTP Provider
Penalty
Summary
The facility failed to administer methadone in accordance with the dosage prescribed by the Opioid Treatment Program (OTP) provider for a resident being treated for opioid use disorder (OUD). The resident, who had a history of Hepatitis B and C, was managed by the OTP for methadone dosing, with care plans indicating that the dosage was to be determined at weekly outpatient appointments. Following a hospital visit for an opioid overdose, the hospital coordinated with the OTP to temporarily reduce the resident's methadone dose, with a plan to gradually return to the previous dosage as directed by the OTP. Despite clear orders from the OTP to increase the methadone dose back to 70mg daily, facility staff administered only 50mg daily for several days. This change was made based on a verbal order from a physician assistant at the facility, who cited recommendations from the resident's hepatology clinic to reduce or eliminate methadone use. There was no documentation that the OTP was consulted or that care was coordinated between the OTP provider and the hepatology team regarding this change in methadone dosing. The facility did not have a specific policy for residents utilizing an OTP and relied on the OTP provider's orders for methadone administration. However, the facility did not report the deviation from the OTP's prescribed dose until questioned by OTP staff about unused medication. Interviews with facility staff revealed confusion about which provider was responsible for managing methadone dosing for OUD, and there was no evidence of direct coordination between the involved medical providers regarding the resident's methadone regimen.
Failure to Coordinate MOUD Dosage Changes with OTP Provider
Penalty
Summary
The facility failed to coordinate with the opioid treatment program (OTP) provider regarding changes to the medication dosage for opioid use disorder (MOUD) for a resident. The resident, who had a history of opioid use disorder and was being treated with methadone, also had diagnoses of Hepatitis B and Hepatitis C. After the resident experienced an opioid overdose and was hospitalized, the hospital coordinated with the OTP to temporarily reduce the methadone dose, with plans for the resident to return to the OTP for further dosing adjustments. Upon the resident's return, the OTP ordered a gradual increase of methadone back to the original dose. However, a physician assistant at the facility verbally changed the methadone dose to a lower amount based on recommendations from the resident's hepatology clinic, without documented coordination or consultation with the OTP provider. Facility staff administered the lower dose for several days, and the discrepancy was only discovered when the OTP noticed unused methadone in returned vials and questioned the facility. There was no documentation of communication with the OTP regarding the dose change or attempts to coordinate care between the OTP and the hepatology provider. Interviews with facility staff revealed a lack of clear policy regarding residents utilizing OTPs and confusion about which provider was responsible for managing methadone dosing for opioid use disorder. The medical director clarified that only the OTP should manage methadone dosing for opioid use disorder, but this protocol was not followed in the resident's case. The facility did not have documentation of proper coordination with the OTP, leading to the identified deficiency.
Failure to Address Nutritional Needs Leads to Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutrition for two residents, leading to significant weight loss and potential harm. Resident 4 experienced a weight loss of 7.9% over approximately three months and 14.29% over six months. Despite being cognitively intact and able to eat with setup assistance, Resident 4's weight loss was not adequately addressed. Observations showed that Resident 4 was not offered alternate meals or nutritional shakes when they consumed less than 50% of their meals, contrary to the facility's policy. Staff interviews revealed that interventions for weight loss were not implemented in a timely manner, which could have mitigated some of the resident's weight loss. Resident 14, who was severely cognitively impaired, experienced an 8.51% weight loss in one month. The resident's weight loss was not reported to the dietician, and no evaluation was conducted to determine the need for further interventions. Observations indicated that Resident 14 was not offered alternate meals or nutritional supplements despite poor meal intake. Staff interviews highlighted a lack of communication and oversight, as the new Registered Dietician was not informed of the resident's weight loss, and interventions such as nutritional supplements were not put in place. The facility's failure to adhere to its nutrition and hydration policy placed both residents at risk for further decline in their weight and overall health. The lack of timely interventions and communication among staff contributed to the residents' significant weight loss and the potential for unintended consequences of poor nutrition. The report underscores the need for consistent monitoring and proactive measures to address nutritional deficiencies in residents.
Deficiency in Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by improper food storage, preparation, and temperature monitoring. During an observation, a crate of pasteurized eggs with an expired date was found in the walk-in refrigerator, which was acknowledged and disposed of by the Dietary Manager. This oversight in discarding expired food items poses a risk of bacterial growth and potential resident illness. Additionally, the facility did not consistently monitor or document food temperatures during meal service. Observations revealed that temperatures were not checked for all food items, such as a chef's salad served in the dining room, and there was no documentation of temperatures for the kitchen tray line. The Dietary Manager admitted that the facility did not check temperatures after the first tray line and only randomly checked temperatures during the second tray line without documentation. This lack of consistent temperature monitoring and documentation increases the risk of food contamination and bacterial growth, compromising food safety for residents.
Late Submission of MDS Assessments
Penalty
Summary
The facility failed to encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for four of eleven sampled residents. This deficiency involved the Minimum Data Set (MDS), an assessment tool used to gather information about residents' functional status, strengths, weaknesses, and preferences. The facility was required to submit MDS records for all residents in Medicare- or Medicaid-certified beds, and these records must be transmitted electronically within 14 days of the assessment completion date. However, the facility did not meet these requirements for Residents 7, 12, 86, and 90, as their assessments were submitted late. Resident 86 was discharged on August 25, 2024, but the assessment was completed on August 29, 2024. Resident 7 was discharged on October 25, 2024, with the assessment completed on October 29, 2024. Resident 12's quarterly assessment was completed on February 4, 2025, despite the observation end date being December 19, 2024, and the discharge assessment was also late. Resident 90's quarterly assessment was completed on February 1, 2025, with an observation end date of January 14, 2025. The facility's MDS Director and Director of Nursing acknowledged the late submissions, which were confirmed by a validation report showing 23 out of 79 files were submitted late, including those of the mentioned residents.
Failure to Administer Bowel Care as Ordered
Penalty
Summary
The facility failed to consistently monitor and provide timely bowel care for seven residents, leading to a deficiency in care. Residents 23, 36, 54, 62, 4, 39, and 46 were all affected by this oversight. Each resident had specific physician orders for laxatives to be administered if they had not had a bowel movement within a certain timeframe. However, the facility did not adhere to these orders, resulting in prolonged periods without bowel movements for the residents. Resident 23, who was cognitively intact and dependent on staff for activities of daily living, did not receive the prescribed laxatives despite not having a bowel movement for several days on multiple occasions. Similarly, Resident 36, also cognitively intact, went without bowel movements for five days without receiving the necessary medication. Staff interviews revealed a misunderstanding of the facility's protocol, with some staff believing bowel medication should be given after 72 hours, contrary to the physician's orders. Other residents, including Resident 4, 54, 39, 46, and 62, experienced similar issues, with their medication administration records showing that laxatives were not given as ordered. Interviews with staff, including the Director of Nursing, confirmed that the facility's expectation was to offer bowel care medication after 48 hours of no bowel movement unless otherwise specified by the physician. The lack of documentation for the omissions further highlighted the deficiency in care provided to these residents.
Failure to Ensure Proper Respiratory Care and Documentation
Penalty
Summary
The facility failed to ensure that respiratory treatments had provider orders, that these orders were carried out, and that care plan goals and interventions were developed for three residents. Resident 359, who had chronic obstructive pulmonary disease (COPD) and cardiomyopathy, was observed using oxygen therapy without any provider orders for its administration or maintenance. Despite having an oxygen concentrator and using oxygen via nasal cannula, there was no documentation in the care plan or medical records to support this treatment. Resident 358, diagnosed with heart failure and sleep apnea, had a CPAP machine in their room but lacked provider orders for its use, settings, or maintenance. The resident reported that their CPAP machine was not set up until three days after admission, and there was no documentation of its routine use or care in the medical records. Staff interviews confirmed the absence of necessary orders and care plans for the CPAP machine. Resident 71, with respiratory failure, COPD, and sleep apnea, had an active order to use a CPAP machine nightly. However, the resident reported not using the CPAP for several nights, contradicting the documentation in the medication administration record. Staff interviews revealed a lack of awareness about the resident's non-compliance with CPAP use, despite the presence of an order and care plan. These deficiencies placed the residents at risk for respiratory complications and diminished quality of life.
Failure to Conduct Annual Staff Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for two nursing assistants, Staff P and Staff Y, as required by regulations. This deficiency was identified through interviews and record reviews, which revealed that there was no documentation of completed yearly performance evaluations for these staff members. During an interview, the facility's administrator admitted to being unaware of the lack of a process for conducting these evaluations and mentioned that the facility was in the process of initiating them. This oversight placed residents at risk of receiving care from inadequately trained or underqualified staff, potentially affecting their quality of life.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to ensure that three residents received their medications as ordered by their physicians, leading to significant medication errors. Resident 22, who had diabetes and high blood pressure, did not receive insulin and blood sugar checks on multiple occasions, and their blood pressure medication, Metoprolol, was administered despite their heart rate being below the prescribed threshold. There was no documentation explaining these omissions or deviations from the physician's orders. Resident 71, who had end-stage renal disease and diabetes, missed several doses of insulin and sevelamer due to being out of the facility for dialysis sessions. The staff did not send medications with the resident to dialysis, and there was no communication with the physician to adjust medication timing or dosage. The resident confirmed they did not receive medications during dialysis sessions, and the staff entered a code indicating the resident was out of the facility without medications. Resident 46, who had high blood pressure, was given Metoprolol despite their systolic blood pressure being below the prescribed parameter on several occasions. There was no documentation explaining why the medication was not held, and staff interviews confirmed that the medication should have been withheld according to the physician's orders. These failures in medication administration and monitoring placed the residents at risk for medical complications.
Medication Storage Temperature Control Deficiency
Penalty
Summary
The facility failed to ensure proper temperature controls for medication storage in two of three sampled medication rooms and one of three medication storage refrigerators. In the West medication room, no thermometer was present to monitor the room temperature where various medications were stored. Similarly, in the East medication room, no thermometer was observed, and the Director of Nursing acknowledged the absence of a thermometer to monitor the room temperature. The refrigerator in the East medication room contained various insulins, intravenous medications, and concentrated oral antianxiety medications. The temperature log for the refrigerator showed only one entry for February 2025 and incomplete entries for January 2025, with the Director of Nursing acknowledging these omissions. During an interview, the Administrator stated that staff were expected to check the medication room refrigerator temperatures to ensure medication quality. However, no policy on medication storage was provided upon request. The lack of proper temperature monitoring and documentation placed residents at risk of receiving medications that may not be at their optimum efficacy, potentially leading to adverse side effects and diminished quality of life.
Facility Fails to Provide Palatable and Appetizing Food
Penalty
Summary
The facility failed to provide appetizing and palatable food for five residents, leading to dissatisfaction and potential risks for decreased nutritional intake and diminished quality of life. Residents reported issues such as mushy vegetables, processed chicken patties, inedible eggs, overly salty food, and unappetizing presentation. Despite expressing their concerns to dietary staff, residents did not see improvements. A test tray sampled by the survey team confirmed the residents' complaints, revealing unappetizing and bland food, with some items being lukewarm and lacking flavor. Resident 48, who had gastroesophageal reflux disease and an esophageal ulcer, also reported the food was sometimes too salty and lacked flavor. The dietary manager, Staff W, acknowledged the importance of tasting food to ensure palatability but had delayed attending Resident Council meetings to address these concerns. The State Ombudsman office confirmed multiple complaints from residents about the food, highlighting the facility's failure to address these issues promptly.
Failure to Ensure Proper Review of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that the arbitration agreement was reviewed and explained in a form, manner, and/or language understood by the residents or their legal representatives for three sampled residents. This deficiency was identified for residents who were severely cognitively impaired and included those with diagnoses such as non-Alzheimer's dementia and Alzheimer's dementia. The arbitration agreements were signed by the residents themselves, despite their cognitive impairments, rather than by their legal representatives or power of attorney (POA). This oversight placed the residents at risk of being uninformed of their rights and losing legal protection. Interviews and record reviews revealed that the facility's process for offering arbitration agreements did not adequately assess the residents' cognitive abilities to understand and sign the agreements. Staff Z, the Admission Director, stated that they reviewed residents' records upon admission to determine their capacity to sign the agreement. However, this process failed in the cases of Residents 14, 60, and 90, who all had severe cognitive impairments. The facility's Administrator, Staff A, confirmed that arbitration agreements should have been offered to the residents' representatives or POA, acknowledging the oversight in these cases.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement enhanced barrier precautions for two residents with draining wounds, which is crucial to prevent the spread of multidrug-resistant organisms (MDROs). Resident 54 was observed with yellow drainage from a heel wound on their pillowcase, and there was no enhanced barrier sign or personal protective equipment (PPE) nearby. Similarly, Resident 46 had bloody drainage from a sore under their armpit, but there was no enhanced barrier sign or PPE available. These observations indicate a lack of adherence to infection control protocols, which are essential to prevent the spread of infections. The facility also demonstrated improper use of N95 respirators by several staff members during an active COVID-19 outbreak. Staff members were observed wearing N95 masks with straps incorrectly positioned, which compromises the mask's ability to form a proper seal and protect against airborne particles. Despite receiving training on PPE use, staff members cited reasons such as convenience and discomfort for not wearing the masks correctly. This improper use of N95 masks during a COVID-19 outbreak poses a significant risk to both staff and residents. Additionally, the facility's infection prevention and control policies were outdated and not reviewed annually as required. The water management plan was incomplete, lacking facility-specific information necessary for effective Legionella control. These deficiencies in infection prevention protocols and policy management further contribute to the risk of spreading infections within the facility.
Failure to Inform Residents and Representatives of Medication Changes
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed and consented to new medication changes, which affected two residents. Resident 90, who had severe cognitive impairment and multiple diagnoses including dementia and traumatic brain injury, was administered Seroquel and Ativan without the knowledge or consent of their power of attorney (POA). The facility increased the dosage of Seroquel multiple times and added Ativan to the treatment plan without notifying the POA, despite the resident experiencing increased sedation and falls. Interviews with staff confirmed that the POA should have been informed of these medication changes. Resident 54, who was cognitively intact but had a representative due to occasional confusion, experienced a decrease in their pain medication, Xtampa, without being informed. The representative was unaware of the medication change, and the facility failed to document any notification to the resident or their representative. Staff interviews revealed that the resident or their representative should have been notified of the medication change and a progress note should have been made. The facility's policy required that residents and/or their representatives be informed of changes in health status, including medication changes. However, the facility did not adhere to this policy, resulting in a lack of informed consent for medication changes for both residents. This failure prevented the residents and their representatives from making informed decisions regarding treatment and potentially impacted the residents' quality of life.
Failure to Notify Ombudsman of Hospital Transfers and Discharges
Penalty
Summary
The facility failed to ensure that the Office of the State Long-Term Care Ombudsman was notified of hospital transfers and discharges for five out of six sampled residents. This deficiency was identified through interviews and record reviews, which revealed that the facility did not provide the required notifications for residents who were transferred to the hospital. The facility's policy, dated July 2018, stated that notifications to the Ombudsman should occur before or as close as possible to the time of a facility-initiated transfer or discharge, with emergency transfer notifications sent at least monthly. Resident 4, who was cognitively impaired and unable to make decisions regarding their care, was transferred to the hospital due to increased behaviors, but there was no documentation of Ombudsman notification. Resident 46, who was cognitively intact, was sent to the hospital after a fall but also lacked documentation of Ombudsman notification. Similarly, Resident 71, who was cognitively intact, was transferred to the hospital for vomiting, fever, and high blood sugar without Ombudsman notification. Resident 90, with severe cognitive impairment, was transferred to the hospital twice after falls, yet no Ombudsman notification was documented. Resident 30, who was cognitively intact, was transferred to the hospital after a fall, but again, there was no documentation of Ombudsman notification. Interviews with facility staff, including the Administrator, Licensed Practical Nurse, Resident Care Manager, and Social Service Director, revealed a lack of awareness and practice regarding the requirement to notify the Ombudsman of hospital transfers and discharges. The Ombudsman confirmed that the facility had not been notifying them of such events, except when issuing a 30-day eviction notice. This oversight placed residents at risk of not having access to additional advocacy services from the State Long-Term Care Ombudsman.
Failure to Provide Bed-Hold Notices to Residents
Penalty
Summary
The facility failed to provide a bed-hold notice to residents or their representatives at the time of discharge or within 24 hours of transfer to the hospital for five sampled residents. This deficiency was identified through interviews and record reviews. For Resident 4, who was cognitively impaired, there was no documentation of a bed-hold notice being provided after being sent to the hospital due to increased behaviors. Similarly, Resident 46, who was cognitively intact, was not informed about the bed-hold until two days after their discharge following a fall. Resident 90, with severe cognitive impairment, was transferred to the hospital twice without any documentation of a bed-hold notice being offered. Resident 30, who was cognitively intact, was sent to the hospital after a fall, yet no bed-hold notice was documented. Resident 71, also cognitively intact, was sent to the hospital for evaluation due to vomiting, fever, and high blood sugar, but there was no record of a bed-hold notice being provided. Interviews with staff confirmed the lack of documentation and emphasized the importance of offering a bed-hold to ensure residents' rights to return to their rooms. The failure to provide timely bed-hold notices placed residents at risk of not being informed about their rights during hospitalization.
Failure to Timely and Accurately Complete MDS Assessments
Penalty
Summary
The facility failed to timely and accurately complete Minimum Data Sets (MDS) for 9 out of 11 sampled residents, which affected federal health information data gathering and placed residents at risk for inaccurate monitoring of their progress over time. The MDS assessments were not completed within the required time frames, as evidenced by several residents' assessments being signed off weeks or even months after the observation end dates. For instance, Resident 3's quarterly assessment was not signed as completed until over a month after the observation end date, and Resident 12's discharge assessment was completed over a month late. Additionally, there were inconsistencies in the MDS assessments for some residents, such as Residents 14, 109, and 90, where sections of the assessments conflicted regarding the residents' cognitive abilities and communication capabilities. These discrepancies were acknowledged by the Director of Nursing, who admitted that the assessments did not accurately reflect the residents' status as of the assessment reference date (ARD). Interviews with facility staff, including the MDS Director and the Administrator, confirmed that the facility was behind on completing MDS assessments as required. The MDS Director provided a list showing 76 MDS assessments were still in progress beyond the ARD, indicating a systemic issue with timely assessment completion. This failure to adhere to required timelines and ensure accurate assessments compromised the facility's ability to monitor residents' health data effectively.
Deficiencies in Fall Prevention, SUD Management, and Smoking Safety
Penalty
Summary
The facility failed to ensure proper investigation and implementation of safety interventions for residents who experienced falls. Four residents were identified as having sustained falls without adequate investigation or monitoring. For instance, one resident had multiple falls, including a major injury, but the care plan interventions such as placing a fall mat were not consistently implemented. Another resident was left alone in their room despite being at high risk for falls, and the care plan interventions were not followed, leading to repeated falls. The facility also failed to assess and manage risks associated with substance use disorders (SUD) for two residents. One resident with a history of methamphetamine and alcohol use eloped from the facility shortly after admission, and there was no care plan addressing their SUD. Staff interviews revealed a lack of training and understanding of how to assess and manage SUD risks. Another resident who used marijuana did not have a care plan addressing their SUD, and staff were unsure if counseling was offered. Additionally, the facility did not adequately assess residents' ability to smoke safely. One resident was identified as needing supervision to smoke safely, but the facility did not provide supervision or reassess the resident's smoking ability after a hospital visit. The facility's smoking policy was unclear, and there were no designated smoking areas or safety measures such as fire blankets or extinguishers in place, despite residents smoking on the property.
Inadequate Monitoring and Documentation of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were not given psychotropic medications unless necessary to treat specific conditions documented in the clinical record. This deficiency was observed in three residents, including Resident 90, who was admitted with diagnoses such as dementia and traumatic brain injury. Despite the absence of active orders for antipsychotic medications upon admission, Resident 90 was started on Seroquel due to reported agitation and impulsiveness. The facility did not implement the provider's recommendations for environmental treatment of agitation, and there was inconsistent documentation of behavior monitoring and non-medication interventions. Resident 90 experienced frequent falls and was administered increasing doses of Seroquel, along with Ativan for anxiety and agitation. However, the facility's documentation lacked specific details of the behaviors experienced by Resident 90, and there were significant omissions in behavior monitoring records. Interviews with staff revealed that behavior documentation was critical for determining medication adjustments, yet the records were incomplete and lacked sufficient detail to justify the medication changes. Similar deficiencies were noted for Residents 22 and 23, who were prescribed psychotropic medications for conditions such as depression and anxiety. The facility failed to consistently document behavior and adverse side effect monitoring as required. Staff interviews confirmed that documentation was incomplete, which is essential for monitoring the residents' mental health and the effects of psychotropic medications. The lack of proper documentation and monitoring placed residents at risk of being chemically restrained and having unmet care needs.
Failure to Evaluate Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was evaluated for the ability to self-administer medications, which is a requirement for residents who are cognitively intact and capable of managing their own medication. Resident 74, who had diagnoses including bipolar disorder, high blood pressure, and cervical cancer, was observed with several loose pills on their overbed table, not in a medication cup, and expressed uncertainty about the identity of the pills. The resident mentioned that nurses usually watched them take their medications to prevent choking or dropping them, but acknowledged that this supervision was not consistent. Staff interviews revealed that the Licensed Practical Nurse (LPN) who administered the medications to Resident 74 did not recall leaving the medications unattended but admitted it was possible they were called away. The Resident Care Manager confirmed that nurses were expected to supervise medication administration unless the resident had been assessed and approved for self-administration, which had not been done for Resident 74. This oversight placed the resident at risk for missed doses or unintended health consequences, as the necessary assessment and approval process for self-administration had not been completed.
Failure to Provide Menus and Support Resident Meal Choices
Penalty
Summary
The facility failed to ensure that weekly menus and alternative menus were provided to residents, which denied them the right to choose their meal preferences. This deficiency was observed in three residents who were cognitively intact and capable of making decisions regarding their care. Resident 23 reported that menus were not handed out and had to be requested, often taking days to receive, which resulted in missed opportunities to choose meals. Staff interviews confirmed that menus were kept at the nurses' station and only provided upon request, with a low number of residents actually submitting their meal choices. Resident 36 expressed dissatisfaction with the food quality and was unaware of the availability of menus, indicating a lack of communication from the staff. Similarly, Resident 48, who had a medical condition requiring dietary considerations, stated that meals tasted the same and they were not offered alternative food choices or menus. Staff interviews revealed that the facility had not developed an effective solution to ensure residents could make their own food choices, with only a small fraction of residents submitting menus. This failure potentially affected the residents' nutritional needs and quality of life.
Failure to Provide Complete Advanced Beneficiary Notices
Penalty
Summary
The facility failed to provide complete information on services and charges for those services not covered under the facility's per diem rate for two residents, Resident 91 and Resident 14, who were reviewed for advanced beneficiary notices. Resident 91 received a Notice of Medicare Non-coverage (NOMNC) indicating that Medicare payment for physical therapy, occupational therapy, and skilled nursing care would end on January 2, 2025. Although Resident 91 was given a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), the notice was incomplete and did not inform the resident of the costs for continuing to reside in the facility. Similarly, Resident 14 received a NOMNC stating that Medicare payment for services would end on December 23, 2024. However, there was no documentation that a SNFABN or any other written notification was provided to Resident 14 or their power of attorney (POA) to inform them of the costs for continuing care after Medicare payment ceased. In an interview, Resident 14's POA confirmed that they were informed of the Medicare ending via a phone call but were not provided with or signed any documents regarding the daily cost for care. The Business Office Manager confirmed the lack of documentation of the facility's per diem rate on the SNF/ABN forms for both residents.
Failure to Maintain Homelike Environment and Sanitation
Penalty
Summary
The facility failed to provide a homelike environment for several residents, as evidenced by the poor condition of the drywall in the rooms of Residents 39, 46, and 83. Resident 39, who was severely cognitively impaired, had a room with gauges and a hole in the drywall behind their recliner and near the headboard. Similar damage was observed in Resident 46's room, who was cognitively intact, with gauges on multiple walls. Resident 83, also severely cognitively impaired, had drywall damage near their window and headboard. These observations were made over several days, indicating a lack of timely maintenance and repair. Additionally, Resident 14, who was severely cognitively impaired, was observed in an unclean wheelchair on multiple occasions. The wheelchair had white debris on the cushion and wheels, and a brown substance on the legs, which was not addressed over several days. Staff interviews revealed that everyone was responsible for cleaning wheelchairs, highlighting a failure in maintaining sanitation and dignity for the resident. These deficiencies were noted during observations and interviews with facility staff, including the Maintenance Director and Administrator.
Failure to Document and Communicate Resident Transfer Information
Penalty
Summary
The facility failed to ensure that a resident's medical record contained documentation of a hospital transfer and that the receiving hospital received information about the resident's condition. This deficiency involved a resident with cognitive impairment and diagnoses including diabetes, depression, and anxiety. The transfer form for the resident, who required a proxy for decision-making, indicated a transfer to the hospital for evaluation of behaviors such as agitation and psychosis. However, the section of the form that should have documented whether a report was called into the hospital was left blank, and there was no further documentation indicating that any information was relayed to the hospital at the time of transfer. Interviews with staff confirmed that it was expected for the hospital to be notified of the resident's condition, which was crucial for understanding the resident's status and history.
Delayed PASARR Completion for Resident After Exempted Hospital Stay
Penalty
Summary
The facility failed to ensure a timely completion of a Pre-Admission Screening and Resident Review (PASARR) for a resident who was admitted after an exempted hospital stay. Resident 46, who had diagnoses including depression and anxiety, was admitted to the facility directly from a hospital with an expected stay of 30 days or less. A Level I PASARR was completed prior to admission, indicating the need for a Level II PASARR due to the exempted hospital stay. However, the resident did not discharge within the expected 30 days and remained at the facility. A new PASARR was not completed until 40 days after the exempted stay period had expired. This delay in completing the PASARR was acknowledged by the Social Service Director, who stated that timely completion was important for implementing recommendations to care for the resident's mental health.
Failure to Follow Podiatry Referral for Resident
Penalty
Summary
The facility failed to ensure a physician-ordered foot care referral for a podiatrist was followed for Resident 54, who was reviewed for wound care. Resident 54 had diagnoses including diabetes, Multiple Sclerosis, and depression, and was cognitively intact. A provider progress note from September indicated the resident had long and thick toenails and required a podiatry referral for evaluation and treatment. However, the facility did not arrange for the resident to see a podiatrist, and the resident's toenails were not addressed until a nurse practitioner intervened in January. Interviews with facility staff revealed that there was confusion and delay in arranging podiatry care. Staff N, a Registered Nurse, mentioned that podiatry referrals depended on the resident's insurance, and appointments were to be arranged with an outside provider. Staff C, the Resident Care Manager, and Staff L, the Social Service Director, indicated efforts were being made to have a podiatrist visit the facility, but there was uncertainty about sending residents out for appointments. The Director of Nursing acknowledged that nail care could have been addressed sooner to prevent infections. At the time of the survey exit, Resident 54 had not yet been seen by a podiatrist.
Inaccurate Dialysis Care Plan and Communication
Penalty
Summary
The facility failed to ensure consistent communication and collaboration with the dialysis facility for a resident requiring dialysis services. The resident, who was cognitively intact and had diagnoses including diabetes and end-stage kidney disease, received dialysis via a central venous catheter (CVC). However, the facility's care plan inaccurately included interventions for monitoring a dialysis fistula, which the resident did not have. The Pre-Dialysis Assessment and Communication forms, meant to be completed and sent with the resident to dialysis appointments, were inconsistently returned, with only five out of nineteen forms being returned. These forms correctly documented the use of a CVC, yet the facility's care plan and staff documentation continued to reference a fistula. Interviews with the resident and staff revealed a lack of awareness and understanding of the resident's actual dialysis access site. The resident confirmed they had never had a fistula and showed the CVC on their chest. Staff initially stated the resident had a fistula but then corrected themselves to acknowledge the CVC. The Director of Nursing acknowledged that the dialysis orders and care plan interventions should have reflected the use of a CVC but did not. This discrepancy in documentation and communication led to the deficiency in providing appropriate dialysis care for the resident.
Inadequate Staffing Leads to Resident Safety Concerns
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its residents, as evidenced by the experiences of three residents. Resident 90, who had severe cognitive impairment and a history of falls, required constant supervision due to impulsive behavior and frequent attempts to self-transfer. Despite the need for one-on-one supervision, the facility was unable to provide it due to understaffing, leading to multiple falls and the administration of antipsychotic medication. The resident's power of attorney expressed concerns about overmedication and the resident's deteriorating condition. Resident 110, who had a history of psychoactive substance abuse and schizophrenia, was admitted to the facility without a care plan addressing their substance use disorder. The resident eloped from the facility shortly after admission, was found intoxicated, and ended up in the hospital. The facility's failure to complete necessary assessments and implement appropriate interventions contributed to the resident's elopement and subsequent hospitalization. Resident 83, who was dependent on staff for most activities of daily living, reported excessively long call light wait times, sometimes up to one hour and 40 minutes. Interviews with staff and the ombudsman revealed concerns about insufficient staffing, particularly in the evenings and on weekends. The facility's staffing coordinator and director of nursing acknowledged the staffing challenges, with some staff working multiple roles and double shifts, yet maintained that the scheduled staff was adequate to meet resident needs.
Failure to Monitor Adverse Effects of Blood Thinning Medication
Penalty
Summary
The facility failed to consistently monitor potential adverse effects from a blood thinning medication for Resident 22, who was part of a sample of five residents reviewed for unnecessary medications. Resident 22 had diagnoses of heart failure and high blood pressure and was taking Xarelto, a blood thinning medication. The provider orders required licensed staff to monitor for adverse reactions such as bleeding, severe bruising, difficulty breathing, or chest pain. However, the Medication Treatment Record for January 2025 showed multiple instances where the monitoring documentation was left blank across various shifts. Interviews with facility staff confirmed the deficiency. Staff N, a Registered Nurse, acknowledged that the documentation was incomplete and stated that the expectation was for all charting to be completed each shift as ordered. Staff B, the Director of Nursing, also confirmed that the medication monitoring had not been consistently performed, reiterating that the expectation was for documentation to be completed before the end of each shift. This lack of consistent monitoring placed Resident 22 at risk for medical complications and adverse side effects.
Exposed Wiring on Resident Beds
Penalty
Summary
The facility failed to ensure that resident beds were in safe operating condition, as observed in four out of 26 beds on the [NAME] nursing unit. Specifically, the bed controls for these beds had exposed wires and old electrical tape that had peeled off, which was noted during observations on multiple occasions. For instance, a resident in room [ROOM NUMBER]-1 was found seated on a bed with exposed wiring at the bed control, although no frayed wires were present. Similar conditions were observed in other rooms, with exposed wires and peeling electrical tape on the bed controls. During an interview, the Maintenance Director, Staff K, stated that they were unaware of beds in disrepair unless a work order was submitted. Staff K also mentioned that they did not conduct regular preventive inspections or audits of the equipment on the nursing units. This lack of proactive maintenance and reliance solely on work orders contributed to the deficiency, as the unsafe conditions of the beds were not addressed until they were specifically reported.
Deficiency in Call Bell System Functionality
Penalty
Summary
The facility failed to ensure that the call bell systems were in working condition for two residents, placing them at risk of having their urgent needs unanswered. Resident 74's call light was observed to be non-functional, with the cord pulled out of the wall and coiled up, and the button taped over. The resident reported that the call light had not worked for a couple of weeks and had informed a staff member, but the issue was not addressed until the day of the observation. The maintenance director confirmed receiving a work order but had not seen it until the morning of the observation. Similarly, Resident 4's call light was found to be non-functional when they attempted to use it to request food. The resident had experienced previous issues with the call light, which had been replaced several times. A staff member provided a manual call bell as a temporary solution and notified the maintenance director, who repaired the call light. The maintenance director admitted that they did not conduct regular audits of the equipment and relied on work orders to identify non-functioning call bells.
Failure to Maintain Clean and Safe Resident Refrigerators
Penalty
Summary
The facility failed to maintain resident personal refrigerators in a clean manner, free of expired foods, and at appropriate temperatures for two residents. Resident 74 had a small dormitory-style refrigerator with a brown liquid spilled inside, a can of soft drink resting in the liquid, and a supplement drink on the shelf. The resident was unsure who was responsible for monitoring the refrigerator's temperature, and there was no temperature log present in the room. Subsequent observations showed the refrigerator was cleaned, but there were empty coffee mugs and half-full fruit cups on top, still without a temperature log. Resident 51's personal refrigerator contained expired vanilla yogurt and butterscotch pudding, and was observed to be unclean with spilled brown liquid on the bottom shelf. Multiple observations confirmed the presence of expired food and lack of cleanliness over several days. Interviews with staff revealed confusion about who was responsible for monitoring the refrigerators. Staff X, a Nursing Assistant, was unsure of the responsibility, while Staff C, a Resident Care Manager, stated that temperature logs should be kept in resident rooms and expired food should be discarded. Staff B, the Director of Nursing, indicated that nurses were responsible for monitoring the refrigerators, including temperature checks and discarding expired food to prevent illness.
Failure to Investigate Allegations of Abuse and Falls
Penalty
Summary
The facility failed to thoroughly investigate potential allegations of abuse for two residents, Resident 30 and Resident 83. Resident 30, who had a stroke with weakness and/or paralysis affecting one side of the body, alleged that their call light was removed by staff, leading to a fall. The investigation into this incident was inadequate, as it did not include specific staff or witness statements about the removal of the call light, and the conclusion was reached without thoroughly addressing the resident's specific allegation. Resident 83, who had severe cognitive impairments and required assistance with repositioning, had a scabbed area on their arm allegedly caused by staff. The investigation into this incident was also insufficient, as it did not include staff interviews or a thorough examination of the resident's claims, and the initial conclusion ruled out abuse without adequate evidence. The facility also failed to investigate falls for two other residents, Resident 4 and Resident 14. Resident 4, who had a history of falls and was at risk for additional falls, was found lying on their floor mat and sent to the hospital, but no investigation was conducted into the fall. Similarly, Resident 14, who had a history of falls and was at risk for additional falls, was found on the floor mat next to their bed, but no investigation was conducted as the fall was not reported to the administrator. These failures to investigate potential abuse and falls placed residents at risk of further potential abuse and diminished quality of life. The facility's policy required thorough investigations of allegations, but this was not adhered to in these cases, leading to incomplete assessments and conclusions regarding the incidents involving the residents.
Inadequate Discharge Planning and Documentation for Two Residents
Penalty
Summary
The facility failed to prepare comprehensive discharge summaries and plans for two residents, leading to potential risks of unsafe discharges and unmet care needs. Resident 90, who had severe cognitive impairment and required moderate assistance with daily activities, was discharged to the community without proper documentation of their condition at discharge, who they left with, or what information was reviewed with them. The resident's power of attorney expressed concerns about overmedication and a decline in the resident's physical abilities upon discharge. Resident 110, who had a history of psychoactive substance abuse and mental health issues, was admitted to the facility but eloped shortly after. The facility did not document the resident's status or follow-up actions after they were located at a local hospital. The resident's discharge was not properly documented, and there was confusion regarding the requirements of the facility's new bridge bed program, which contributed to the lack of proper discharge documentation. Interviews with facility staff revealed a lack of clarity and consistency in the discharge process, with responsibilities for discharge planning and documentation not clearly defined. Staff acknowledged the absence of necessary documentation and the need for improvements in the discharge process, particularly in relation to the new bridge bed program.
Failure to Provide Assistance and Bathing as Care Planned
Penalty
Summary
The facility failed to ensure that a staff member was available to assist Resident 109 during an appointment with an outside provider. Resident 109, who was severely cognitively impaired and dependent on nursing staff for activities of daily living (ADLs), was left without a caregiver at the appointment. The resident, who required two nursing staff for toileting and a mechanical lift for transfers, was reported to have been dropped off at the appointment without necessary assistance. This led to a situation where the resident needed help to use the bathroom but was unattended. The Director of Nursing confirmed that a staff member or family member should have accompanied Resident 109 due to their need for assistance with ADLs. Additionally, the facility did not provide bathing as care planned for Resident 54. Despite being cognitively intact, Resident 54 required staff assistance for ADLs, including bathing. The care plan specified that the resident should be bathed one to two times per week, with a bed bath offered if the resident refused a shower. However, documentation showed inconsistent bathing, with several instances marked as non-applicable or where the resident refused, and no alternative was documented. The Director of Nursing acknowledged the resident's preference for bed baths in the evening, but this preference was not reflected in the care plan.
Failure to Timely Identify and Treat Pressure Ulcer
Penalty
Summary
The facility failed to timely identify and treat a pressure ulcer for Resident 54, who was at risk for pressure ulcers due to immobility and other health conditions such as diabetes and Multiple Sclerosis. Despite being cognitively intact and able to communicate needs, the resident developed a pressure ulcer on the left heel, which was not promptly addressed by the facility staff. The resident's representative reported the presence of a significant sore on the heel, which had been an ongoing issue for about a year, but no follow-up on a requested wound consultation was conducted. The facility's care plan for Resident 54 had been revised multiple times to address the potential for skin impairment and pressure ulcer development. However, the interventions, such as encouraging nutrition, using an air mattress, and keeping heels floated, were not effectively implemented to prevent the development of a new pressure ulcer. The facility's records showed that the left heel wound was previously healed, but a subsequent skin check documented an unstageable pressure ulcer, which later was identified as a stage four pressure ulcer. Interviews with facility staff revealed a lack of awareness and timely response to the resident's condition. Staff GG, a Nursing Assistant, was unaware of any wounds, and Staff N, a Registered Nurse, was unsure of when the wound developed. The Resident Care Manager only became aware of the pressure ulcer after the resident's representative brought it to their attention, leading to a delayed referral for wound treatment. This lack of timely identification and intervention placed the resident at risk for worsening pressure ulcers and delayed healing.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure that allegations of potential misappropriation were reported immediately to the facility administration and the State Survey Agency as required. This deficiency involved a resident who reported an allegation of rough treatment by a staff member to Staff C, Social Services, on November 14, 2024. However, the facility's Incident Log for November 2024 did not show any entries related to this resident's allegation. Staff C confirmed that the resident reported the allegation to them on the same day, and they stated that they reported it to unidentified staff who were investigating the incident while Staff C was out of the facility. Staff C typically reported abuse allegations to Staff A, the Administrator, but could not recall who they reported the initial allegation to or who directed them to report the incident. Staff A was notified of the allegation during a clinical meeting on November 18, 2024, and immediately reported it to the State Survey Agency. Staff A was unaware of the delay in reporting until reviewing the documentation in the resident's progress note. This delay in reporting placed the resident at risk for abuse.
Failure to Provide Proper Wound Care
Penalty
Summary
The facility failed to provide necessary wound care services for Resident 3, who was admitted with an open surgical wound requiring wound vacuum therapy. The treatment administration record indicated that the wound vacuum dressing was to be changed on specific days, but staff misinterpreted this as the only days the therapy should be applied. Consequently, the wound vacuum dressing was removed prematurely and replaced with a wet-to-dry dressing without proper documentation or notification to the medical provider. This misinterpretation and lack of adherence to the prescribed treatment regimen placed the resident at risk for delayed wound healing and potential infection. Interviews revealed that staff responsible for Resident 3's care were not familiar with the continuous application requirement of wound vacuum therapy. The Director of Nursing was informed of the resident's concerns and discovered the staff's misunderstanding of the treatment protocol. Although some staff received one-on-one education on wound vacuum therapy, documentation did not show that all relevant staff, including those directly involved in the incident, received the necessary training.
Misappropriation of Controlled Substances by Staff
Penalty
Summary
The facility failed to protect residents from the misappropriation of property, specifically controlled substance medications, for one of the sampled residents. The deficiency was identified when a resident reported receiving a pain pill that dissolved in their mouth, which was not consistent with their prescribed medications. The resident was alert and oriented and aware of their medication regimen. Upon investigation, it was found that controlled substances were signed out of the logbook for this resident but were not documented as administered in the Medication Administration Record (MAR). Additionally, controlled substances for other residents were found to be missing or destroyed without a second nurse present to witness the destruction. The investigation revealed that Staff B, a Registered Nurse, was responsible for these discrepancies. Staff B had documented the removal of controlled substances from the logbook but failed to sign them as administered on the MAR. Furthermore, Staff B destroyed controlled substances without a witness, which is against the facility's policy. The Director of Nursing confirmed these findings and stated that no other residents reported missing medications or uncontrolled pain. The facility substantiated a reasonable suspicion of drug diversion and terminated Staff B's employment.
Inadequate Supervision Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision for a resident with dementia and anxiety, leading to multiple incidents of wandering and falls. The resident, who was moderately cognitively impaired and required substantial assistance for mobility, was admitted for therapy and strengthening needs. Despite being placed near the nurse's station initially, the resident was later moved to a private room further down the hall, which contributed to their wandering and subsequent fall that resulted in a fractured humerus. The care plan for the resident included measures such as frequent rounding and ensuring the call light was within reach, but these were not effectively implemented. Staff interviews revealed confusion and inconsistency in providing one-on-one supervision, which was not standard practice at the facility. The resident's family expressed concerns about the level of supervision and requested a transfer to a memory care facility, but the transfer was not completed before the resident sustained an injury. Staff members reported the resident's impulsive behavior and inability to follow instructions, which were exacerbated by low oxygen saturation levels that were not communicated to the provider. The facility's administration acknowledged the responsibility to provide appropriate supervision but did not have sufficient staff to offer one-on-one care. The lack of adequate supervision and failure to address the resident's needs led to the resident's injury and highlighted deficiencies in the facility's care practices.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure that showers were completed as care-planned and call lights were answered in a timely manner for three of four sampled residents. Resident 6, who had diagnoses including morbid obesity and diabetes, was dependent on staff for personal hygiene and bathing. Despite a care plan indicating a preference for twice-weekly showers, documentation showed that Resident 6 only received showers once a week. Resident 6 reported waiting up to 30 minutes for call lights to be answered, leading to soiled linens. Resident 5, with rheumatoid arthritis and macular degeneration, was independent for most ADLs but expressed concern about delayed call light responses, sometimes waiting up to 30 minutes. Resident 7, who required substantial assistance due to paralysis from a stroke, also experienced inconsistencies in receiving showers as per their care plan. Interviews with staff revealed that the facility was experiencing staffing challenges, with both shower aides on leave and a reliance on staff working double shifts or being pulled from other duties to cover shower tasks. Staff reported that the number of nursing assistants varied, affecting their ability to complete all tasks, including timely showering and call light responses. The Director of Nursing acknowledged the staffing issues and mentioned efforts to hire additional staff and work with a staffing agency, but there was no system in place to track call light response times on the affected unit.
Failure to Notify Provider of Low Oxygen Saturations
Penalty
Summary
The facility failed to notify the provider of a change in a resident's oxygen saturations, which was a deficiency identified during the survey. The resident, who had diagnoses including pneumonia and heart failure, was cognitively impaired and exhibited wandering and behavioral symptoms. According to the care plan, staff were instructed to monitor vital signs and notify the provider of significant abnormalities. However, on two occasions, staff did not notify the provider when the resident's oxygen saturation levels dropped below the threshold specified in the hospital discharge orders and facility provider orders. On the night of the first incident, the resident's oxygen saturation was found to be low at 85%, and although oxygen was applied and the saturation improved, the provider was not notified. In a subsequent incident, the resident was found with low oxygen saturation again after knocking over their oxygen concentrator. Despite the resident's oxygen saturation dropping to 83% and fluctuating with supplemental oxygen, the provider was still not informed. Interviews with staff revealed that they did not perceive the need to notify the provider as the resident's saturation levels improved with oxygen application, and there were no other apparent changes in the resident's status.
Failure to Assess and Secure Indwelling Urinary Catheters
Penalty
Summary
The facility failed to assess a resident for the removal of an indwelling urinary catheter and did not ensure proper securement of catheters for two residents. Resident 9, who entered the facility with an indwelling urinary catheter, was not assessed for catheter removal despite not having a diagnosis requiring one. The facility's policy required such an assessment, but there was no documentation of this being done or of any discussion with the resident about the catheter's necessity. Resident 9 experienced pain and bleeding associated with the catheter, and observations showed bright red urine with sediment in the catheter bag. Staff interviews revealed uncertainty about the catheter's necessity and noted recurrent urinary tract infections. Resident 8, diagnosed with benign prostatic hyperplasia, also experienced issues with their catheter, including irritation, discomfort, and bloody urine. The progress notes did not indicate whether the catheter tubing was secured during these complaints. A urology note confirmed discomfort due to lack of securement, and an adhesive securement device was eventually applied. Interviews with a representative and staff confirmed ongoing complaints about pain and blood in the catheter. These failures increased the risk of catheter-associated urinary tract infections, pain, and urethral trauma for the residents.
Lack of Competency Evaluation for Nurses Handling Urinary Catheters
Penalty
Summary
The facility failed to ensure that three of its Licensed Nurses (Staff J, K, and L) were evaluated for competency in handling indwelling urinary catheters before they began working with residents requiring such care. This deficiency was identified through interviews and record reviews, which revealed that these nurses were responsible for the care and monitoring of residents with indwelling urinary catheters without documented competency evaluations. Specifically, the May 2024 Treatment Administration Records (TAR) indicated that Staff K and L were responsible for Resident 8's catheter care, while Staff J was tasked with monitoring and potentially placing a catheter. Similarly, the June 2024 TAR showed that Staff J, K, and L provided catheter care for Resident 10, including flushing and irrigating the catheter. Concerns about the competency of the staff were raised by both residents and their representatives. Resident 8's representative expressed concerns about the staff's competency in catheter insertion and monitoring, while Resident 10 also voiced concerns about the nurses' competency in providing catheter care. Staff M, the Registered Nurse/Staff Development Coordinator, confirmed that new staff were supposed to be paired with experienced staff for training and evaluation, with documentation of their skills. However, there was no documentation of competency evaluations for Staff J, K, and L. Staff M noted that Staff J and K no longer worked at the facility, and Staff L had not completed a skills evaluation despite being contacted two months prior. The facility's Administrator and Director of Nursing acknowledged that Staff M was new to the position and was working on addressing staff skills and competency evaluations.
Failure to Hold Blood Pressure Medications as Ordered
Penalty
Summary
The facility failed to ensure that blood pressure medications were held when indicated for a resident with hypertensive kidney disease and primary pulmonary hypertension. The resident's medication administration record (MAR) indicated orders to hold Lisinopril and Metoprolol if the systolic blood pressure (SBP) was below 100 or if the heart rate was less than 50. On one occasion, the resident's blood pressure was recorded as 99/59, and the medications were appropriately held. However, on the following day, the resident's blood pressure was 94/55, and the medications were administered despite the order to hold them for an SBP of less than 100. The nursing progress notes and the provider communication binder lacked documentation that the provider was notified of the low SBP on the first day or that the medications were administered when they should have been held on the second day. Interviews with the Resident Care Manager and the Director of Nursing confirmed the expectation that staff should hold medications and notify the provider when parameters are not met. The failure to adhere to these instructions put the resident at risk for unintended health consequences related to low blood pressure.
Failure to Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to promptly resolve resident grievances and provide written grievance decisions for three residents reviewed for grievances. The grievance report log from June 2024 to August 2024 showed unresolved grievances for several issues, including aid concerns, pest issues, missing glasses, activities, wound rounds, nurse concerns, food, and urine color. Resident 7 reported filing multiple complaints without receiving any response from the facility. The grievance forms indicated that some issues were followed up verbally, but no written resolutions were provided to the residents. Staff interviews revealed that the facility was aware of the timeliness issues in grievance follow-ups but had not yet resolved them. The Administrator and Director of Nursing were unaware that written grievance resolutions were required and this requirement was not included in the facility's policy. The facility's grievance policy was requested but not provided, indicating a lack of compliance with the necessary components for handling grievances as per regulatory standards.
Failure to Develop Care Plans for Fall and Wandering Risks
Penalty
Summary
The facility failed to develop a care plan to address assessed risks for accident hazards for two residents, leading to unmet care needs. Resident 2, who had dementia and was at risk for falls, was discharged from the hospital with orders indicating their fall risk. Despite a fall risk assessment score of 11, which confirmed the resident's risk for falls, the care plan initiated on June 13, 2024, did not include any interventions related to fall prevention. This oversight was confirmed by Staff E, the Resident Care Manager, during an interview. Similarly, Resident 8, diagnosed with dementia and assessed as at risk for wandering/elopement with a score of 9, did not have a care plan addressing these risks until after an elopement incident occurred. Although the resident expressed a desire to leave the facility and was confused, the staff member who completed the assessment initially believed the resident was not at risk due to their compliance with directions. The care plan was only updated with interventions for wandering and elopement on August 24, 2024, after the resident had already eloped. This was confirmed by Staff A, the Administrator, and Staff B, the Director of Nursing.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to ensure timely notification of a hospital transfer for one of the residents, identified as Resident 2, whose condition had declined. On 05/17/2024, a nurse's progress note indicated that Resident 2 was transferred to the hospital at 1:15 AM due to a change in condition, including decreased alertness, disorientation, pallor, and abnormal vital signs. The nurse on the oncoming shift was informed of the transfer later that morning, and a voicemail was left for the resident's representative, but there was no documentation of the exact time of notification. Interviews revealed that the resident's representative was not informed of the transfer until more than five hours later, after receiving automated messages from the hospital. Resident 2 expressed experiencing physical and mental stress due to the emergency transfer and the lack of a representative upon arrival at the hospital. Staff D, an LPN, confirmed calling emergency services for the transfer but admitted to notifying the representative later in the shift due to a busy night. Staff A, a Resident Care Manager, stated that immediate notification was necessary for hospital transfers, especially since Resident 2 had an altered mental status and could not advocate for themselves.
Failure to Accommodate Dietary Needs for Resident with Crohn's Disease
Penalty
Summary
The facility failed to assess and accommodate the dietary preferences and intolerances of a resident diagnosed with Crohn's disease, who also had an ostomy and was at risk for malnutrition. Despite the resident's need for a specialized diet to manage their condition, the facility did not order a specialty diet, and the resident was placed on a regular diet without consideration for their specific dietary needs. The resident's diet requisition form listed allergies but omitted their food preferences and intolerances, leading to the resident receiving inappropriate foods such as salads and high-fiber items, which are not recommended for individuals with Crohn's disease. Interviews revealed that the dietary manager and registered dietician did not adequately assess the resident's dietary needs. The dietary manager admitted to not completing an assessment of the resident's preferences and intolerances, while the registered dietician based their evaluations solely on chart reviews due to the resident being asleep during attempts to interview them. Despite receiving communication from the resident's representative about the resident's dietary needs, no new diet requisition form was completed. This oversight resulted in the resident being served foods they could not tolerate, contributing to their malnourishment and subsequent hospitalization.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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