Avalon Care Center Federal Way, L.l.c.
Inspection history, citations, penalties and survey trends for this long-term care facility in Federal Way, Washington.
- Location
- 135 South 336th Street, Federal Way, Washington 98003
- CMS Provider Number
- 505510
- Inspections on file
- 27
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Avalon Care Center Federal Way, L.l.c. during CMS and state inspections, most recent first.
The facility failed to assess and obtain consent for bed rail use for two residents, leading to one resident sustaining an injury. Despite expectations for assessments and consents, these were not completed, placing residents at risk.
The facility failed to implement an effective Antibiotic Stewardship Program, resulting in inappropriate antibiotic use for six residents. The facility did not maintain accurate documentation or assessments using McGeer's and Loeb's criteria, and specific deficiencies were noted for each resident. The Infection Preventionist acknowledged the lack of up-to-date documentation and assessments due to workload challenges.
The facility failed to provide required written notices to residents and their representatives at the time of transfer or discharge to an acute care hospital. This deficiency was identified for several residents who were transferred to hospitals on various dates. The facility's administrator acknowledged the absence of a process for written transfer notifications, resulting in the failure to provide these notifications.
The facility failed to update care plans for several residents, leading to discrepancies between documented care and actual resident needs. One resident's care plan inaccurately listed a pressure ulcer location, while another's included unnecessary IV monitoring instructions. A third resident's plan contained conflicting information about their transfer abilities. Additionally, a resident receiving hospice care had no related goals or interventions in their care plan, and another resident's preference for bed positioning was not reflected in their plan.
The facility failed to provide restorative nursing programs (RNP) for several residents with limited range of motion (ROM) and mobility, as required by their care plans. Residents, including those with functional limitations and medical conditions such as amputations and strokes, did not receive necessary exercises and assistance to maintain or improve their functioning. The facility lacked dedicated staff for RNPs, expecting CNAs to incorporate these duties into their ADL care, leading to inadequate documentation and implementation of RNPs.
The facility failed to ensure sanitary conditions in food handling and storage. Staff did not perform proper hand hygiene while preparing meals, and the dishwasher machine was not maintained correctly, with ineffective chlorine tests and incorrect temperature documentation. Additionally, unit refrigerators contained unlabeled and expired food items, contrary to facility policy.
The facility failed to maintain an effective infection prevention and control program, with staff not consistently performing hand hygiene or using PPE as required. There was also a lack of interventions to prevent Legionnaires' disease, and no documentation of infection surveillance using McGeer's or Loeb's criteria for residents on antibiotics. These deficiencies placed residents and staff at risk for infections and antibiotic resistance.
The facility failed to inform two residents or their representatives about the risks and benefits of psychotropic medications and did not obtain consent before administration. One resident with schizophrenia, anxiety, and depression received medications without documented consent, while another with dementia received antipsychotic medication without documented discussion of risks and benefits with their guardian.
The facility failed to ensure two residents had appropriate Advanced Directives (AD) and guardianship documentation. One resident had no AD or guardianship despite impaired memory, and another had expired guardianship paperwork with no current documentation. Staff interviews confirmed the lack of necessary records, risking residents' rights to have their medical treatment preferences honored.
The facility failed to initiate a grievance process for two residents who reported issues. One resident reported missing personal items after a hospital stay, but no grievance form was completed, and the administrator was unaware of the issue. Another resident reported long call light response times during the night shift, but no grievance form was filled out, and the administrator was not informed. This lack of action prevented prompt investigation of the complaints.
The facility failed to document the communication of necessary information to the receiving health care institution for two residents transferred to an acute care hospital. The facility's policy requires documentation of communicated information, including contact details, care instructions, and care plan goals, to ensure a safe transition. However, no such documentation was found for the transfers of these residents, as confirmed by the Unit Manager.
The facility failed to provide written bed hold notifications to two residents or their representatives during hospital transfers, as required by policy. One resident with impaired memory was hospitalized multiple times without receiving notifications, while another resident with complex medical conditions also did not receive the required notification. Admissions coordinators confirmed the oversight.
A facility failed to complete a Significant Change in Status Assessment (SCSA) within the required timeframe for a resident who was admitted to hospice care due to protein-calorie malnutrition. The SCSA was completed 76 days after the resident's hospice start date, contrary to the requirement for completion within 14 days. The MDS Coordinator acknowledged the oversight.
A facility failed to accurately complete a PASRR assessment for a resident with schizophrenia, anxiety, and major depression, omitting the major depression diagnosis and not conducting a required Level II evaluation. The resident, with moderately impaired cognition and on multiple psychiatric medications, was admitted without a complete assessment, risking inadequate mental health services. The Social Services Director admitted the oversight, acknowledging the need for a review at admission.
The facility failed to meet professional standards of practice, as evidenced by discrepancies in medication administration and documentation for several residents. A resident on a feeding tube received oral medications, another received pain medications without clear parameters, and a third had inaccurate tube feeding documentation. Additionally, a resident's frequent refusal of a laxative was not communicated to the provider.
A resident with impaired memory and unclear speech was not provided with a functional communication system. Despite a care plan indicating the need for evaluation and alternative communication methods, these were not implemented. Staff confirmed the resident was not evaluated for communication needs, and attempts to use a communication binder were unsuccessful and undocumented.
Two residents in an LTC facility did not receive necessary assistance with personal hygiene, including shaving and nail care, despite their care plans indicating dependency on staff. Observations showed one resident with long facial hair and another with long fingernails and facial hair. The DON confirmed the lack of documentation and assistance.
The facility failed to provide necessary care and services to three residents, including not treating or monitoring skin issues for two residents and improperly setting an air mattress for another. One resident had untreated wounds and fungal infection, another did not receive required weekly skin checks, and a third was uncomfortable due to incorrect air mattress settings. Staff interviews confirmed these deficiencies, which were contrary to the facility's policies.
A resident with existing stage 3 pressure ulcers did not receive consistent weekly skin assessments or necessary interventions, such as an air mattress, to prevent new ulcers. Observations showed the resident was often left lying on their back, contrary to care plan instructions. The facility failed to document a new deep tissue injury, and the lack of timely assessments and repositioning contributed to the development of new pressure ulcers.
A resident with impaired thought processes was at risk due to the improper use of a wedge cushion and pillows between the mattress and bed frame, intended to prevent falls. Staff used these devices without assessing their potential to restrain the resident, contrary to facility policy.
The facility failed to obtain informed consent for bed rails for three residents, violating policies and resident rights. Bed rails were used without attempting alternatives, conducting safety assessments, or obtaining consent. Residents were unaware of the bed rails' presence, and staff acknowledged the oversight.
The facility failed to document and implement pharmacist recommendations in a timely manner for three residents, leading to potential risks. A resident's medication regimen reviews were missing from records, another experienced delays in medication adjustments, and a third had unimplemented recommendations due to late receipt of the MRR form.
The facility failed to ensure two residents were free from unnecessary psychotropic medications. One resident received antianxiety medication without a proper stop date, while another was on long-term antianxiety medication without documented rationale or attempts at gradual dose reduction. Staff interviews revealed non-adherence to policies on psychotropic medication management.
A medication error rate of 8% was observed when an LPN failed to ensure a resident consumed all prescribed medications, resulting in two tablets being dropped and unnoticed until a surveyor intervened.
The facility failed to secure medications and biologicals for three residents, leading to potential risks of medication errors. A resident had unsecured skin treatments on a windowsill, another had OTC cough lozenges on a nightstand without a PO, and a third had wound treatment supplies on a dresser. Staff confirmed these items should be stored securely.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess and obtain consent before implementing bed rails for two residents, leading to a deficiency. Resident 1, who had severe memory impairment and vision issues, was not assessed for the safe use of bed rails, nor was consent obtained. Despite not being part of the care plan, bed rails were left on Resident 1's bed from a previous occupant, resulting in the resident sustaining a cut above the left eyebrow. Staff interviews confirmed the lack of assessment and consent, and the expectation that these should have been completed prior to bed rail use. Resident 2, who required substantial assistance with bed mobility but had no memory impairment, was also found to have bed rails installed without prior assessment or consent. The comprehensive care plan for Resident 2 did not indicate the use of bed rails, and staff confirmed that assessments and consents were expected but not obtained. These oversights placed both residents at risk for injury and highlighted a failure in the facility's procedures for implementing bed rails.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program (ASP) to ensure the appropriate use of antibiotics (ABO) for six residents. The facility's policy required validation of ABO prescriptions for correct indication, dose, route, and duration, and the use of McGeer's and Loeb's criteria to guide ABO prescribing. However, the facility did not maintain accurate and complete ABO line listing documentation, and there was no evidence of McGeer's or Loeb's criteria being met for the residents reviewed. Additionally, the facility did not maintain an ASP binder with necessary documentation, such as meeting minutes and tracking information. Specific deficiencies were noted for each resident. Resident 204 had two ABOs not documented on the ASP line listing. Residents 80 and 77 completed ABOs without documentation of symptoms meeting McGeer's or Loeb's criteria. Resident 64 was admitted on an ABO for colitis, but hospital records indicated the colitis was resolved, and there was no evidence of pneumonia. Residents 47 and 3 completed ABOs without any assessment or ABO time-out. The Infection Preventionist, who also held multiple roles, acknowledged the lack of up-to-date ASP documentation and assessments, citing workload challenges.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide required written notices to residents and their representatives at the time of transfer or discharge to an acute care hospital. This deficiency was identified for seven residents who were transferred to hospitals on various dates. The facility's policy, dated July 2018, mandates that a notice of transfer must be provided to the resident or their representative when an emergency transfer to an acute care facility is ordered. However, record reviews showed no documentation of such notifications being provided for any of the residents reviewed, including Residents 94, 31, 1, 20, 26, 23, and 59. During an interview, the facility's administrator acknowledged the absence of a process for written transfer notifications, resulting in the failure to provide these notifications to residents transferred to hospitals. The lack of written notification placed residents at risk for discharges that were not aligned with their stated goals for care and preferences. The deficiency was noted under the Washington Administrative Code (WAC) 388-97-0120 (2)(a-d).
Inaccurate and Outdated Care Plans in LTC Facility
Penalty
Summary
The facility failed to ensure that care plans (CPs) were accurately reviewed and revised to reflect the current status and needs of residents, as required. This deficiency was identified for five residents during a survey. For Resident 41, the CP inaccurately documented a pressure ulcer (PU) on the coccyx area, while the resident actually had PUs on the right and left buttocks. The resident reported not receiving assistance for repositioning, and staff interviews confirmed the CP was not updated to reflect the resident's actual condition. Resident 61's CP inaccurately included instructions for monitoring an intravenous (IV) medication site, despite the resident not receiving IV medications. Observations and staff interviews confirmed the absence of an IV site and the lack of current IV medication orders. Similarly, Resident 6's CP contained contradictory information regarding their ability to transfer independently, with observations and interviews indicating the resident was mostly independent, yet the CP and Kardex were not updated to reflect this. Resident 68's CP failed to include goals or interventions related to hospice care, lacking instructions for staff on coordinating care with hospice services. For Resident 32, the CP directed staff to keep the bed in a low position, but observations showed the resident preferred and was able to adjust the bed independently. Staff interviews confirmed the CP was not updated to reflect the resident's preferences and non-compliance with the plan of care.
Failure to Provide Restorative Nursing Programs for Residents with Limited ROM
Penalty
Summary
The facility failed to provide restorative/rehabilitative treatment and services for seven residents with limited range of motion (ROM) and mobility, which was necessary to maintain or improve their highest level of functioning. The facility's policy on Quality of Care Restorative Nursing Programs (RNP) required that these programs be developed and formalized by a supervising nurse. However, the facility did not have dedicated staff to provide RNPs, and the responsibility was expected to be incorporated into the duties of Certified Nursing Assistants (CNAs) during the provision of Activities of Daily Living (ADL) care. Resident 47, who had functional limitations in ROM to both arms and legs, was not provided with a RNP despite being assessed as needing one to prevent ADL decline. The resident was informed that they could not receive restorative nursing services until approved for Medicaid insurance. Similarly, Resident 20, who had limited ROM in the right shoulder, was not assisted with walking as required, and there was no documentation of staff assisting with daily walking. Resident 40, who required assistance with mobility and ROM exercises, did not receive the interventions as care planned, and there was no task documentation for staff to sign off on. Other residents, including Residents 41, 61, 32, and 59, also did not receive the necessary RNPs. Resident 41, who had a below-the-knee amputation, did not receive exercises after therapy services ended. Resident 61, who had limited ROM in the right arm, was not provided with a RNP despite being non-weight bearing. Resident 32, who had limited ROM in upper and lower extremities, did not receive the RNP as care planned. Resident 59, who had limited ROM due to a stroke, did not have a RNP in place, and there was no documentation of staff providing the necessary care. The facility's failure to implement RNPs as required placed these residents at risk of further decline in ROM, loss of function, and permanent immobility.
Sanitation Deficiencies in Food Handling and Storage
Penalty
Summary
The facility failed to maintain sanitary conditions in food preparation, storage, and service, as observed during a survey. Staff members did not consistently perform hand hygiene while preparing meal trays for residents. Specifically, a dietary aide was seen touching their face and hair with gloved hands and then handling food items without changing gloves or washing hands. Similarly, the dietary manager was observed touching their face and clothing and then continuing to handle food without proper hand hygiene. These actions compromised the sanitary conditions of the meal service. The facility's dishwasher machine was not maintained according to professional standards. Observations revealed a significant build-up of grime and debris on the machine. Staff failed to correctly perform chemical tests for chlorine concentration, which is crucial for ensuring proper sanitization of dishware. The test strips used were ineffective, and the dishwasher's temperature was recorded as higher than recommended for a low-temperature machine. Documentation discrepancies were noted in the Dish Machine Log, with incorrect temperature and chlorine concentration levels recorded. Unit refrigerators and freezers were not managed according to the facility's policy. Observations showed that food items were not labeled with resident names or use-by dates, and expired items were not discarded. Unlabeled and undated food items, including perishable goods, were found in the refrigerators, posing a risk of foodborne illness. The facility's administrator confirmed the expectation for staff to adhere to hand hygiene protocols and to dispose of food items after three days, which was not consistently followed.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. Staff did not consistently perform hand hygiene (HH) before and after resident care or contact, nor did they apply or remove personal protective equipment (PPE) in accordance with the transmission-based precaution (TBP) signs posted outside resident rooms. For instance, a certified nursing assistant (CNA) was observed handling meal trays and assisting residents without performing HH, and another staff member failed to change gloves and wash hands between dirty and clean care during incontinence care. Additionally, the facility did not implement necessary interventions to prevent Legionnaires' disease, a serious respiratory infection caused by bacteria in the water system. The maintenance director was unaware of the areas at higher risk for Legionella development and did not have monitoring or prevention techniques in place. Furthermore, the infection preventionist was not involved in the Legionella prevention process, indicating a lack of coordination and oversight in infection control measures. The facility also failed to document infection surveillance using McGeer's or Loeb's criteria for residents on antibiotics, which is part of their antibiotic stewardship program. A review of records showed no documentation of these assessments for a sample of residents, and the infection preventionist admitted that the software used did not support detailed documentation of symptoms or criteria met. This lack of documentation and oversight placed residents and staff at risk for contracting and spreading infections, as well as potential antibiotic resistance.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents or their representatives about the risks and benefits associated with psychotropic medication therapy and did not obtain consent before administering these medications. This deficiency was identified for two residents. Resident 61, who had moderately impaired cognition and diagnoses of schizophrenia, anxiety, and depression, was regularly administered antipsychotic, antianxiety, and antidepressant medications without documented consent. The Director of Nursing acknowledged the lack of documentation and stated that consent should have been obtained prior to medication administration. Similarly, Resident 34, diagnosed with dementia with agitation, received antipsychotic medication without documented evidence that the risks and benefits were discussed with the resident or their legal guardian. Although a family member provided consent over the phone, there was no documentation of a discussion regarding the medication's risks and benefits. Staff members confirmed that guardians should be informed and provide consent for such medications.
Failure to Ensure Advanced Directives and Guardianship Documentation
Penalty
Summary
The facility failed to ensure that two residents had appropriate Advanced Directives (AD) in place, which is a violation of the residents' rights to have their medical treatment preferences honored. For Resident 61, the facility did not have a copy of an AD in the resident's record, and there was no documentation of attempts to obtain guardianship, despite the resident having moderately impaired memory and being their own responsible party. Interviews with the Social Services Director and the Director of Nursing revealed that Resident 61 was unable to make decisions and had no appointed guardian, and the facility was working on appointing one but could not provide documentation. For Resident 6, the facility's records showed that a letter of limited guardianship had expired, and although the admission record listed a guardian as the responsible party, there was no documentation of an AD or current guardianship paperwork in the resident's record. Interviews with the Social Services Director and the Administrator confirmed that Resident 6 had a guardian, but the necessary paperwork was not uploaded in the resident's record. This lack of documentation and failure to ensure current guardianship and ADs placed the residents at risk of not having their medical treatment preferences honored.
Failure to Initiate Grievance Process for Resident Complaints
Penalty
Summary
The facility failed to initiate a grievance process for two residents who reported issues, which is a violation of their grievance policy. Resident 1, who had no memory impairment, reported missing personal items, including gowns, potted plants, and snacks, after returning from a hospital stay. The resident had informed a staff member about the missing items, but no grievance form was completed, and the administrator was unaware of the issue due to not reviewing the care partners' checklists. Resident 47 reported long call light response times during the night shift, which was documented in their electronic health record. Despite the Social Service Director notifying the administrator about this complaint, no grievance form was filled out, and the administrator was not informed. This lack of action prevented the facility from investigating the complaint promptly.
Failure to Document Transfer Information
Penalty
Summary
The facility failed to document the communication of necessary resident information to the receiving health care institution for two residents who were transferred to an acute care hospital. According to the facility's policy on Admission, Transfer, & Discharge, when a resident is transferred or discharged, the facility must document that appropriate information was communicated to the receiving provider. This information includes contact details of the resident's practitioner, resident representative information, advance directive information, special instructions for ongoing care, comprehensive care plan goals, and other necessary documentation to ensure a safe and effective transition of care. For Resident 1, there was no documentation that any information regarding the resident's health condition or contact information was provided to the acute care hospital when the resident was transferred on May 28, 2024. Similarly, for Resident 31, there was no documentation of information being provided to the hospital for transfers on May 27, 2024, and June 4, 2024. In an interview, the Unit Manager acknowledged the lack of documentation and emphasized the importance of providing a thorough report to the receiving facility to ensure appropriate care for the residents.
Failure to Provide Bed Hold Notifications
Penalty
Summary
The facility failed to provide written notifications of bed hold policies to residents or their representatives when residents were transferred to the hospital or went on therapeutic leave. This deficiency was identified during a review of records for two residents, Resident 59 and Resident 23, who were transferred to the hospital multiple times. The facility's policy, revised in November 2018, required that residents be informed of their right to hold their bed at the time of transfer or within 24 hours if the transfer was emergent. However, there was no documentation indicating that such notifications were provided for the hospitalizations of Resident 59 on four occasions and Resident 23 on one occasion. Resident 59, who had impaired memory and thinking abilities, was hospitalized several times between November 2023 and March 2024, but there was no record of bed hold notifications being provided. Similarly, Resident 23, who had complex medical conditions including diabetes and pressure ulcers, was sent to the hospital in January 2024, yet no documentation of a bed hold notification was found. During an interview, the admissions coordinators confirmed that the notifications were not completed as required, as evidenced by their review of the binder used to track hospitalizations and bed hold notifications.
Failure to Timely Complete SCSA for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) within the required 14 days for a resident who experienced a significant change in condition. The resident, identified as Resident 68, was admitted to hospice services on April 5, 2024, due to protein-calorie malnutrition and an inability to absorb nutrients, with a life expectancy of less than six months. Despite this significant change, the facility did not complete the SCSA until June 20, 2024, which was 76 days after the hospice start date. This delay in assessment was acknowledged by the MDS Coordinator, who confirmed that the SCSA should have been completed when the resident began hospice care.
Inaccurate PASRR Assessment for Resident with Mental Health Needs
Penalty
Summary
The facility failed to ensure accurate completion of Pre-Admission Screening and Resident Review (PASRR) assessments for a resident, which is crucial for determining appropriate placement and necessary mental health services. The facility's policy mandates that all residents undergo PASRR screening before admission, with the Social Services department responsible for maintaining accurate records. However, the PASRR Level 1 assessment for a resident with schizophrenia, anxiety, and major depression was incomplete, as it did not include the major depression diagnosis, and a Level II evaluation was not conducted as required. The resident, who had moderately impaired cognition and was on antipsychotic, antianxiety, and antidepressant medications, was admitted without a complete PASRR assessment. The Social Services Director acknowledged the oversight during an interview, noting that the Level 1 PASRR form was inaccurate and should have been reviewed for accuracy at the time of admission. This inaction left the resident at risk of not receiving the necessary mental health services tailored to their needs.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for several residents, as evidenced by the nursing staff's failure to follow and/or clarify Physician Orders (POs) and notify providers of resident refusals of treatment. For Resident 66, there was a discrepancy in medication administration as the resident, who was on a feeding tube and had an NPO order, received medications that were ordered to be administered by mouth. Additionally, the staff did not hold a high blood pressure medication as ordered on specific days prior to dialysis. Resident 32, who was capable of understanding and communicating, had POs for pain management that lacked specific parameters for administering opioid medication. The staff administered opioid medication for low pain levels and over-the-counter medication for higher pain levels, contrary to the expected practice. Resident 59, with severe cognitive impairment and on tube feeding, had discrepancies in the documentation of the amount of tube feeding administered, with staff failing to accurately record the amounts as observed on the pump. Resident 67, who had no memory impairment, frequently refused a prescribed laxative medication, yet there was no documentation that the provider was notified of these refusals. The staff failed to document the refusals and notify the provider, as expected by the facility's standards. These deficiencies highlight a lack of adherence to professional standards in medication administration and documentation, potentially placing residents at risk for unmet care needs.
Failure to Provide Adequate Communication Support for Resident
Penalty
Summary
The facility failed to provide a functional communication system for a resident with impaired memory and unclear speech, identified as Resident 61. Upon admission, the resident was assessed to have communication difficulties, with no behaviors or rejection of care noted. Observations revealed that the resident was unable to communicate effectively, relying on head shakes for yes or no responses. Despite the communication care plan indicating the need for evaluation by occupational therapy or physical therapy for a communication board, and alternative communication methods like a computer or sign language, these interventions were not implemented. Interviews with staff, including the Director of Nursing and the Rehab Director, confirmed that the resident was not evaluated for communication needs by a speech therapist, and the occupational therapy evaluation was not documented. The staff attempted to use a communication binder, which was unsuccessful, but this was not documented in the resident's records. The lack of appropriate communication tools and evaluations placed the resident at risk for unmet care needs and social isolation.
Failure to Assist Residents with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for two residents, specifically in the areas of personal hygiene and grooming. Resident 61, who was admitted with impaired memory and required maximal assistance with personal hygiene, was observed on multiple occasions with long facial hair. Despite the resident's care plan indicating dependency on staff for personal hygiene, there was no documentation of the resident's preferences or any refusals of care, as confirmed by the Director of Nursing. Similarly, Resident 62, who required one-person assistance with personal hygiene and had no memory impairment, was observed with long fingernails and facial hair. The resident reported not having a razor for shaving and needing help with nail care. The care plan for Resident 62 also indicated a need for maximal assistance with personal hygiene, yet the necessary care was not provided. The Director of Nursing acknowledged that staff should have assisted with shaving and nail care but failed to do so.
Deficiencies in Resident Care and Monitoring
Penalty
Summary
The facility failed to provide necessary care and services to three residents in accordance with professional standards and their comprehensive person-centered care plans. Resident 41, who was admitted with a below-the-knee amputation and other medical conditions, had unhealed pressure ulcers and other wounds. Despite observations of multiple open and scabbed areas on the resident's left shin and macerated toes with debris, the facility did not treat or monitor these skin issues. The Treatment Administration Record showed no treatment or monitoring for these conditions, and staff interviews confirmed the lack of treatment orders and awareness of the resident's fungal infection. Resident 67, admitted with cellulitis and skin tears, also did not receive the required weekly skin checks as per the facility's care plan. The last documented skin check was over a month prior to the survey, and staff interviews revealed that the expected weekly skin checks were not performed or documented. This oversight left the resident's skin conditions unmonitored and untreated, contrary to the facility's policy. Resident 59, who had severe cognitive impairment and was at risk for pressure ulcers, was found lying on an air mattress set incorrectly for their weight. The resident expressed discomfort due to the firmness of the mattress, and staff confirmed that the mattress settings were not adjusted according to the resident's weight. The care plan lacked specific instructions for the air mattress settings, leading to improper use and discomfort for the resident.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers (PUs), as per professional standards of practice. Resident 41, who was admitted with stage 3 PUs on the buttocks and was at risk for developing new PUs, did not receive consistent weekly skin assessments as required. The facility was aware of the resident's existing PUs and risk factors but did not evaluate or implement additional pressure relief measures until over a month after admission. Observations showed the resident was frequently left lying on their back, contrary to care plan instructions to avoid such positioning. The facility's inaction included not updating the care plan with necessary interventions like an air mattress and heel floater, which were not ordered despite the resident's condition. The wound care provider and nursing staff failed to acknowledge and document a new deep tissue injury on the resident's foot, which was identified later by the Director of Nursing. The lack of timely skin assessments and failure to reposition the resident as needed contributed to the development of new pressure ulcers, diminishing the resident's quality of life.
Failure to Assess Safety of Assistive Devices
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for Resident 68, who was part of a sample reviewed for such hazards. Resident 68, who had severely impaired thought processes and was receiving end-of-life services, was observed on multiple occasions with a wedge cushion and pillows placed between the mattress and bed frame. These devices were intended to prevent the resident from falling out of bed. However, there was no assessment conducted to determine if these devices restrained the resident's movement, which could pose an entrapment risk. Staff interviews revealed that the wedge and pillows were used to prevent falls, but the Director of Nursing acknowledged that these items should not be placed in such a manner as they could restrain the resident. The facility's policy on accident hazards and supervision required consideration of the risks and benefits of assistive devices before implementation, but this was not adhered to in the case of Resident 68. The lack of assessment and improper use of devices placed the resident at risk for accidents and injury.
Failure to Obtain Consent for Bed Rails
Penalty
Summary
The facility failed to obtain informed consent for the use of bed rails for three residents, which was a violation of their own policies and resident rights. The facility's policy required that alternatives be attempted before using bed rails, and if bed rails were necessary, an assessment for safety risks should be conducted, and informed consent should be obtained from the resident or their representative. However, for Residents 1, 297, and 20, the facility did not attempt alternative measures, did not assess the residents for the safe use of bed rails, and did not obtain informed consent. Resident 1 had bed rails attached to their bed without consent, despite having no memory impairment and being capable of making their own decisions. Similarly, Resident 297 had bed rails without a physician's order, screening, evaluation, or consent, and was unaware of why the bed rails were present. Resident 20 also had bed rails without consent, although an enabler bar screening evaluation and physician order were present in their records. Staff interviews confirmed the lack of consent and the importance of involving residents in their care decisions.
Failure to Document and Implement Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were properly documented in the resident records and that the recommendations were reviewed and implemented in a timely manner. This deficiency was observed in three residents. For Resident 34, the pharmacist made recommendations in May and June 2024 regarding the medication regimen, but these MRRs were not available in the resident's records. The Director of Nursing confirmed the absence of these records, indicating a lapse in documentation. For Resident 67, a pharmacy recommendation made on March 20, 2024, to adjust medication and monitoring was accepted by the physician on March 24, 2024, but was not noted by a facility nurse until April 10, 2024, resulting in a delay in implementing the changes. Similarly, for Resident 32, the pharmacist recommended a gradual dose reduction of psychotropic medications in May 2024, but this recommendation was not implemented because the MRR form was not received by the staff until July 2024. These lapses in documentation and timely action placed residents at risk for adverse side effects and negative outcomes.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 24 and 32, were free from unnecessary psychotropic medications. Resident 24, who had diagnoses of bipolar disorder, anxiety disorder, and depression, was receiving antianxiety medication as needed without a proper stop date, contrary to the facility's policy that such medications should be limited to 14 days unless otherwise documented. The staff did not clarify the order with the provider to establish a stop date, resulting in the resident receiving the medication multiple times over a short period without proper oversight. Resident 32, diagnosed with anxiety and depression, had been on antianxiety medication three times daily for nearly 18 months without a documented rationale for continuation or attempts at gradual dose reduction (GDR). The interdisciplinary team (IDT) had not reassessed the resident's medication use quarterly as recommended, and the last documented review was over six months prior. Despite recommendations from a pharmacy consult to discuss GDRs, there was no documentation indicating attempts to reduce the medication or reasons for contraindication. Interviews with facility staff revealed a lack of adherence to policies regarding the management of psychotropic medications. Staff acknowledged the importance of GDRs and monitoring resident behaviors to evaluate the necessity of continued medication use. However, the facility did not follow through with these practices, leaving residents at risk for unnecessary medication use and potential adverse effects.
Medication Administration Error
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate during a medication pass. This deficiency involved one of five nurses, specifically a Licensed Practical Nurse (Staff N), who did not properly administer medications to Resident 203. During the observation, two out of 25 medications intended for Resident 203 were not consumed as they fell into the resident's lap. Staff N did not notice the dropped tablets and began to leave the room until a surveyor intervened. Upon being alerted, Staff N returned to the resident and handed them the tablets to take. Staff N admitted in an interview that they usually ensured residents swallowed their medications but failed to do so in this instance.
Failure to Secure Medications and Biologicals
Penalty
Summary
The facility failed to ensure that drugs and biologicals were secured for three residents, leading to potential risks of medication errors and unauthorized self-administration. For Resident 52, several skin treatments and ointments were observed on the windowsill in their room, which were used by the wound care team and then returned to the same unsecured location. This practice was contrary to the facility's policy, which requires medications to be stored in a locked compartment within the resident's room unless there is a Physician's Order (PO) for bedside storage. Similarly, Resident 90 had a large bag of over-the-counter cough suppressant lozenges on their nightstand without a PO or assessment for self-administration. Staff O, a registered nurse, confirmed the presence of the lozenges and acknowledged the need for a PO and secure storage. For Resident 23, several wound treatment supplies were found on top of a dresser in their room. Staff P, the Unit Manager, indicated that once treatment supplies were brought into a resident's room, they remained there, which was not in line with the facility's policy. The Director of Nursing confirmed that medicated treatment supplies and over-the-counter medications should not be left unattended at a resident's bedside.
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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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