Avalon Health & Rehabilitation Center - Pasco
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasco, Washington.
- Location
- 2004 N 22nd Avenue, Pasco, Washington 99301
- CMS Provider Number
- 505126
- Inspections on file
- 48
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Avalon Health & Rehabilitation Center - Pasco during CMS and state inspections, most recent first.
The facility failed to follow its grievance policy and to provide feedback after multiple cognitively intact residents raised concerns during a special Resident Council meeting with corporate staff. Residents, including those independent with ADLs and those requiring assistance, reported grievances about activities, dietary issues, resident rights, staffing, showers, and call light response times, but received no subsequent response or action. The Social Services Director acknowledged that some concerns should have been treated as grievances but did not initiate grievance forms because corporate staff were leading the meeting. The Administrator described a process for logging and following up on grievances within several days but was unsure if a list of concerns from the meeting was ever received. Regional leadership and the CNO confirmed that the issues raised were grievances, that a list had been provided to the facility, and that the facility should have followed its grievance process and communicated back to residents.
A resident with intact cognition and multiple medical conditions, including urinary issues and bipolar II disorder, reported that an RN failed to listen to concerns about a leaking catheter and later entered the resident’s room demanding to know why a different nurse had been requested. The RN argued with the resident about the incident, stated the catheter issue was a CNA responsibility, and repeatedly refused to leave the room despite the resident’s multiple direct requests, telling the resident to "settle down" and remaining until another RN intervened. Leadership later acknowledged that the resident did not want this RN providing care, that the RN returned to the room despite this, and that the resident was not protected from further contact, constituting verbal abuse under the facility’s abuse policy.
A resident with intact cognition and multiple medical conditions reported that an RN failed to assist with catheter care, leading to incontinence, and then confronted and argued with the resident, refused to leave the room despite repeated requests, and continued providing care after the resident requested a different nurse. Another RN reported the incident as alleged verbal abuse to the DON and completed a witness statement, but did not notify the State Agency. The DON acknowledged the allegation, requested witness statements, and recognized that the nurse should have been removed from resident care, yet the nurse continued caring for the resident and the Administrator was not informed until several days later. The incident was not entered into the incident log and was not reported to the State Agency in accordance with the facility’s abuse prevention and reporting policy.
A resident with intact cognition and multiple medical conditions, including bipolar II disorder and hypertension, reported that a nurse made inappropriate remarks and refused to leave the room when the resident requested to speak with a different nurse. An RN documented a witness statement about the verbal abuse incident and informed the DON, but neither the RN, the DON, nor the Administrator reported the allegation to the State Agency Hotline as mandated reporters, despite facility policy requiring timely reporting of suspected abuse and alleged violations.
The facility failed to complete an investigation into an allegation that an RN verbally abused a resident with intact cognition and multiple medical conditions, including bipolar II disorder and hypertension, who required setup/cleanup assistance for ADLs. Facility policy required identifying responsible staff, interviewing involved persons and witnesses, determining whether abuse occurred, and documenting the investigation. The DON initiated the investigation and then handed it off to the administrator due to illness, but the investigation was never finished, and it was not reassigned to another appropriate staff member as the administrator later acknowledged it should have been.
A resident with dementia, disorientation, aphasia, and severely impaired cognition, who required extensive assistance with ADLs and had recently increased exit-seeking behavior after a psychotropic dose reduction, eloped through a service door without triggering the WanderGuard alarm. Staff had placed the WanderGuard device on the back, bottom right side of the resident’s metal wheelchair frame without testing it at the door or receiving training on correct placement, contrary to manufacturer instructions that warn metal can interfere with the signal. The device did not activate the door alarm when the wheelchair exited, but did alarm when removed from the wheelchair and passed through the door, and a root cause analysis found that the metal wheelchair frame blocked the system from reading the WanderGuard.
A nurse failed to follow infection control practices during med pass by not performing required hand hygiene between residents and by popping pills from medication cards into a bare hand before placing them into medication cups. A resident with respiratory failure, kidney failure, and anemia, who was independent in ADLs and cognitively intact, reported observing this improper handling of medications on multiple occasions, including lack of glove use and handwashing. Observations confirmed that the nurse accepted used cups from a resident, left the room, and immediately prepared another resident’s medication without hand hygiene, while also having visibly soiled, overgrown fingernails. The DON and Administrator stated that staff were expected to avoid touching medications with bare hands and to perform hand hygiene before entering and after exiting each resident room, which did not occur in these instances.
The facility did not complete required criminal background checks for several agency RNs and LPNs before allowing them to work unsupervised with residents. Multiple agency nurses worked shifts without valid BGCs, contrary to facility policy and state regulations, as confirmed by staff interviews and record review.
Two residents with significant medical histories experienced prolonged periods without bowel movements, and despite having standing orders for bowel care, there was no timely administration of medications or clear documentation of assessments. Staff interviews revealed inconsistent communication and confusion regarding the bowel management protocol, and a review of facility records confirmed the absence of a clearly defined protocol for monitoring and treating constipation.
Two residents with cognitive impairment and high fall risk experienced multiple falls due to the facility's failure to develop, implement, and update individualized fall prevention care plans. In both cases, required interventions such as supervision and assistive devices were not consistently provided or documented, and incident investigations were incomplete or missing.
Three residents with varying medical conditions experienced multiple room changes without receiving written notice or documented reasons for the moves. Interviews and record reviews confirmed that neither the residents nor their representatives were provided with the required written notifications, and staff acknowledged that only verbal discussions occurred regarding the room changes.
The facility did not consistently provide or review information about resident rights and facility rules with residents upon admission or during their stay. Several residents with intact cognition and significant medical needs reported not receiving this information, and staff interviews revealed confusion and inconsistent practices regarding the distribution and review of resident rights materials.
Four cognitively intact residents, each requiring assistance with ADLs due to various medical conditions, were not provided with written notices or contact information for advocacy groups or instructions on filing complaints with the State Agency. Residents were unaware of the Long-Term Care Ombudsman and reporting procedures, and staff only referenced a poster at the entrance rather than directly informing residents, contrary to facility policy.
Two residents experienced cramped, cluttered, and dimly lit living spaces that limited their ability to use personal items, receive visitors, and safely access care. Staff and resident interviews confirmed that room layouts and space allocation did not meet policy requirements for a safe, comfortable, and homelike environment.
The facility did not provide feedback or address concerns raised by the Resident Council regarding activities and scheduling, despite repeated requests from several residents with complex medical needs. Additionally, some residents reported fear of retaliation for filing grievances, and there was no evidence that these concerns were resolved or that residents were reassured of their right to report issues without reprisal.
The facility admitted multiple residents with mental health or intellectual disability diagnoses without ensuring required PASARR Level II evaluations were completed, as indicated by missing documentation and incomplete forms. Staff confirmed that referrals were sent but not returned due to a backlog, and that admissions occurred without the necessary paperwork, in violation of policy.
Multiple residents with varying medical and psychosocial needs reported a lack of meaningful, individualized activities, with limited options such as arts and crafts, no religious services, and no access to preferred hobbies like sewing, card games, or reading materials. Staff confirmed awareness of some preferences but did not offer alternatives or sufficient one-on-one engagement, resulting in dissatisfaction and unaddressed activity needs.
Several residents reported receiving cold, unappetizing, and improperly prepared meals, with some not receiving food items that matched their dietary preferences or restrictions. Facility records and food committee notes documented ongoing complaints about food quality and temperature, and a test tray confirmed meals were often lukewarm and bland. The Dietary Manager was unaware of current issues, despite continued resident dissatisfaction.
The facility did not adequately explain the binding arbitration agreement or the right to rescind it within 30 days to several residents with intact cognition who required varying levels of assistance with ADLs. During interviews, residents reported not being informed that the agreement was optional or that they could cancel it, and staff members demonstrated a lack of knowledge about the rescission process.
Staff spoke Spanish to each other while providing care to two residents who did not understand the language, causing discomfort and frustration. Both residents, who required significant assistance and had intact cognition, reported feeling uneasy and unable to understand what was being discussed. Staff interviews confirmed the practice, and the administrator acknowledged that care should be provided in a language residents understand.
A resident who transitioned from Medicare Part A to Medicaid coverage was not provided with the required Advance Beneficiary Notice (ABN) when their Medicare coverage ended. The facility did not document or issue the ABN, leaving the resident uninformed about potential financial liability for services not covered.
A resident who required extensive assistance for transfers reported being dropped from a mechanical lift during a transfer, resulting in pain. The facility's investigation did not include interviewing the resident, observing staff using the lift, or inspecting the equipment, and no staff education was provided after the incident. The Regional Nurse Consultant confirmed the investigation was incomplete and lacked preventive actions.
Two residents transferred to the hospital did not receive written bed hold notifications at the time of transfer, as required. Both residents, one with severe cognitive impairment and another with quadriplegia, were hospitalized for acute changes in condition, but facility staff did not document or provide the necessary bed hold information to the residents or their representatives.
A resident with multiple medical conditions reported ongoing pain that was not relieved by their current medication. The physician documented a plan to adjust pain and blood pressure medications, but nursing staff did not review the physician's notes or implement the new orders in a timely manner. The DON expected staff to review these notes the same day, but this did not occur, resulting in delayed medication changes and a failure to meet professional standards of practice.
Two residents did not receive care in accordance with professional standards: one was left in bed due to an ill-fitting wheelchair despite repeated complaints of discomfort, and another experienced pain and withdrawal symptoms after not receiving prescribed pain and psychiatric medications as ordered, with multiple interruptions and abrupt changes in medication management.
A resident dependent on staff for ADLs and with multiple medical conditions was injured when a mechanical lift tipped over during a transfer to a shower chair. Two staff members were involved in the transfer, and improper use of the lift—specifically, not fully extending the stabilizing legs—was identified as the likely cause. Documentation of required staff training on the mechanical lift could not be located for those involved.
A resident who was frequently incontinent of bowel and assessed as a candidate for a scheduled toileting program was not placed on such a program. The resident, who was cognitively intact and dependent on staff for toileting, was not offered or discussed a toileting schedule, and staff did not follow up on assessment findings or establish a toileting pattern, contrary to facility policy.
Expired influenza vaccines and other medications were found in a medication storage refrigerator, and temperature monitoring was inconsistent and incomplete. The refrigerator thermometer showed questionable readings, and staff were unsure of its accuracy. Temperature logs revealed multiple missed entries, and the DON was unaware of the expired vaccines, despite policies requiring daily monitoring and documentation.
A resident with broken and loosely fitting dentures did not receive timely dental services due to a breakdown in communication and referral processes among staff. Despite documented needs and care plan interventions, the resident continued to experience problems with their dentures, which were observed to cause slurred speech and drooling. Staff interviews confirmed that the process for reporting and addressing dental concerns was not followed, resulting in unmet dental needs.
A resident with emphysema and COPD receiving hospice services did not have a care plan that included hospice coordination, responsibilities, or contact information. Facility staff, including NAs and the care manager, were not properly informed or aware of required hospice care plan elements, and there was no documentation of communication with the hospice provider.
A resident reported rough handling by a nursing assistant, but the facility failed to implement its abuse prevention policies. Despite the resident's request, the staff member continued to provide care, indicating a failure to protect the resident from further potential abuse. The administrator later acknowledged the situation as an abuse allegation.
A resident with chronic conditions reported rough handling by a Nursing Assistant to a Scheduler, who failed to report it as an abuse allegation to the Administrator. The Administrator later confirmed it should have been reported, highlighting a lapse in following reporting guidelines.
The facility failed to verify the OBRA registry status of a nurse aide, Staff F, resulting in a lapse in ensuring staff competency. The personnel file lacked documentation of a current OBRA registration, and the facility's process for maintaining registry compliance was not followed. This oversight placed residents at risk for abuse, neglect, and unmet care needs.
Three staff members failed to follow proper hand hygiene protocols during resident care, including not changing gloves or performing hand hygiene after handling soiled items and during a wound dressing change. This non-compliance with the facility's infection prevention policy was confirmed through observations and staff interviews.
A resident who was independent and had no cognitive impairments signed out of the facility but did not return as expected. The facility failed to notify administrative staff and law enforcement in a timely manner, as required by their policy. An LPN was unaware of the resident's absence until later and did not ensure timely notification, resulting in a significant delay in action.
A facility failed to implement Vagus Nerve Stimulation (VNS) therapy as ordered for a resident with epilepsy, leading to unmanaged seizure episodes. Despite physician's orders to use VNS therapy magnets during seizures, staff did not utilize them, and interviews revealed a lack of awareness and communication regarding the therapy. The magnet was found hanging on the wall, not readily accessible, and the issue was a repeat deficiency.
A facility failed to prevent and manage pressure injuries for a resident with dementia and Parkinson's disease. The resident had a Stage II pressure injury upon readmission and later developed a blister on the heel. A Nursing Assistant reported the issue to a Registered Nurse, who observed the injury but did not document or communicate it further. No preventative measures were implemented, leading to a repeat deficiency.
The facility failed to provide written notices of bed hold policies to residents during hospital transfers, affecting three residents. Despite verbal communication, no written documentation was given, leading to confusion about bed hold charges. This deficiency was a repeat issue from a previous report.
The facility failed to maintain a homelike environment in six out of ten resident rooms reviewed. Observations revealed deep scrapes, missing hardware, strong urine odors, chipped paint, and missing flooring transition strips. Staff interviews confirmed the poor condition of the rooms, with the Maintenance Director noting that ceiling holes from a water leak had been present for at least two months.
The facility failed to develop baseline care plans (BCPs) within 48 hours of admission for six newly admitted residents, leading to issues such as incorrect wound care orders and uncertainty about discharge plans. Staff interviews revealed a lack of awareness about the BCP requirements.
The facility failed to conduct comprehensive IDT care conferences for five residents, resulting in their exclusion from care planning and insufficient IDT member attendance, placing them at risk for unmet care needs.
The facility failed to ensure that nurses had the necessary competencies for CVAD care, placing residents at risk. Two nurses admitted to performing CVAD-related tasks without proper training or competency validation, and the Interim DON confirmed the lack of evidence for such training.
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of 12 percent. Errors included incorrect dosage administration for a resident with congestive heart failure and improper insulin administration for a resident with diabetes. Staff admitted to transcription errors and lack of proper training.
The facility failed to ensure an effective QAPI program that identified and corrected deficiencies in nursing staff competencies, medication administration errors, infection prevention, resident immunizations, antibiotic stewardship, and residents' homelike environment. The Administrator admitted that the QAPI process did not address these high-risk, high-volume, and problem-prone areas.
The facility failed to maintain an effective infection prevention and control program, with staff not following proper hand hygiene and glove-changing procedures, inadequate implementation of enhanced barrier precautions and PPE, and the use of non-EPA registered disinfectants. Additionally, the infection surveillance system was ineffective, leading to unmonitored and untreated infections.
The facility failed to provide education on the risks and benefits of pneumococcal and influenza immunizations to five residents, leading to uninformed declinations. Staff interviews confirmed the absence of a consistent process for educating residents.
The facility failed to educate residents on the COVID-19 vaccination, leading to uninformed declinations by five residents. Staff admitted that they did not provide necessary information about the vaccine's benefits, risks, and potential side effects, as required by the facility's policy.
The facility failed to inform two residents of their physician-ordered daily fluid intake restrictions and did not provide them with the necessary risks/benefit education, resulting in significant non-compliance with the prescribed fluid restrictions.
A resident was misinformed by nursing staff that they would have to pay out of pocket to see their preferred physician, contrary to the facility's policy. This led to the resident questioning their care and limited their participation in occupational therapy. The Administrator confirmed the resident should have been given the choice without additional costs.
The facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) to two residents when their Medicare Part A coverage ended, despite remaining in the facility. The Administrator acknowledged issues with the process, stating that social services were responsible but had not been fulfilling this task.
Failure to Process and Respond to Resident Council Grievances
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to honor residents’ rights to voice grievances and receive prompt responses, particularly regarding issues raised through the Resident Council. The facility’s policy dated 07/2018 stated that it would consider the views and act promptly upon grievances and recommendations brought forth by resident or family groups, and that it would demonstrate a response and rationale for the response. Despite this, concerns presented during a special Resident Council meeting with corporate staff were not processed through the facility’s grievance system, and residents did not receive feedback on the issues raised. Resident 1, who was cognitively intact, independent with ADLs, and serving as Resident Council president, reported that during a mock survey visit by corporate staff, residents held a special Resident Council meeting and presented multiple grievances, including activities, dietary concerns, resident rights, staffing, showers, and call light response times. Resident 1 stated that neither the facility nor corporate staff provided any response to these grievances, and that even several days later there was still no feedback. Resident 2, who was cognitively intact and independent with ADLs, also attended the meeting and reported that there had been no improvement or action on the concerns raised and that there was still no response from corporate staff at the time of follow-up. Resident 3, who was cognitively intact but dependent on one to two staff for ADLs, attended the same Resident Council meeting and reported concerns about the activities program and dietary issues, stating that no feedback had been received. Resident 4, cognitively intact and requiring moderate to dependent assistance for ADLs, also attended the meeting and stated that corporate staff had said they would get back to the residents, but no further communication had occurred. The Social Services Director acknowledged that some of the concerns voiced at the meeting should have been treated as grievances and processed with grievance forms, but did not complete them because corporate staff were running the meeting and taking notes. The Administrator described the facility’s grievance process, including logging grievances and following up within three to five days, but was unsure whether corporate staff had provided a list of grievances from the Resident Council meeting. Regional and corporate nursing leadership confirmed that the concerns raised at the meeting were grievances, that the facility had received a list of them, and that the facility should have followed the grievance process and provided feedback. This deficiency was cited under WAC 388-97-0460(2) and noted as a repeat deficiency from a prior survey.
Failure to Identify and Prevent Verbal Abuse by Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to identify and respond appropriately to an incident of verbal abuse involving Resident 5. The facility’s abuse policy defined verbal abuse as conduct that causes or has the potential to cause humiliation, intimidation, fear, shame, agitation, or degradation, and required staff to remain in control of their behavior, act professionally, and avoid retaliation. Resident 5, who had diagnoses including kidney and urinary disorders, hypertension, and bipolar II disorder, and who had intact cognition and required set up/clean up assistance for ADLs, reported that shortly after admission there were events that should not have happened and that one nurse made inappropriate remarks and would not leave the room when the resident requested another nurse. On the date of the incident, Resident 5 reported that they approached a registered nurse (Staff G) about a leaking catheter and felt that Staff G was not listening and that they were uncomfortable with Staff G providing care, so they requested a different nurse. Later, while Resident 5 was in their room, Staff G entered and stated they needed to know what the resident’s problem was with them and continued to argue with the resident. Resident 5 explained they had urinated on the dining room floor, felt embarrassed, and needed help, but Staff G responded that this was a nursing assistant issue and maintained they had done nothing wrong. Resident 5 repeatedly told Staff G they were uncomfortable talking with them and asked them multiple times to leave the room, but Staff G refused, telling the resident they needed to settle down and that they would not leave until the resident did so. Resident 5 continued to insist that Staff G leave, including telling them to get out of the room. A witness statement from another RN (Staff F) corroborated that Resident 5 had requested a different nurse due to discomfort with Staff G, and that Staff G insisted on knowing why and then entered the resident’s room. Staff F overheard Resident 5 speaking in a frantic tone about the embarrassment from the catheter leaking in the dining room and heard Staff G state that the catheter issue was a nursing assistant problem. Staff F observed Resident 5 repeatedly ask Staff G to leave and Staff G refuse, stating they would not leave until the resident settled down, until Staff F intervened and told Staff G to leave. After the incident, Resident 5 reported a headache and inquired about their last blood pressure medication dose. Facility leadership later acknowledged that Resident 5 did not want Staff G in their room, that Staff G had gone back into the room despite this, that the resident was not protected from further contact with Staff G, and that the incident constituted verbal abuse due to the confrontation and failure to honor the resident’s requests.
Failure to Implement Abuse Prevention Policy for Resident Allegation
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prevention policy in the areas of identification, investigation, protection, and reporting for one resident. The facility’s policy, revised 09/13/2022, required staff training on identifying, recognizing, and reporting abuse/neglect, mandated investigation of all allegations, and required immediate reporting of alleged violations to the administrator, state agency, and other required agencies, as well as protection of residents during and after investigations. Resident 5, who had diagnoses including kidney and urinary disorders, hypertension, and bipolar II disorder and required set up/clean up assistance for ADLs, had intact cognition per a comprehensive assessment. On the date of the incident, the resident told one RN (Staff F) they no longer wanted another RN (Staff G) to care for them, citing that Staff G had not assisted with their catheter when requested, resulting in the resident urinating on themselves. Staff G, aware of the request, went to the resident’s room and questioned the resident about why they wanted a different nurse. According to Staff F’s interview, Staff G argued with the resident, demanded a reason for the requested change, refused to leave the room despite multiple requests, and remained even as the resident yelled for Staff G to get out. Staff F reported the incident to the DON (Staff B) the same day and wrote a witness statement regarding an allegation of verbal abuse, but did not report the incident to the State Agency. Staff B acknowledged that an allegation of abuse had been reported on that date, that witness statements were requested, and that the process should have included suspending Staff G to protect the resident; however, Staff G continued to provide care to the resident. The Administrator (Staff A) stated they were not informed of the staff-to-resident incident until six days later, and the incident was not entered into the facility’s incident reporting log covering the relevant period. The incident was not reported to the State Agency until several days after it occurred, contrary to the facility’s policy requiring immediate reporting of alleged violations.
Failure to Report Allegation of Verbal Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the State Agency as required by its policy and applicable regulations. The facility’s policy, revised 09/13/2022, required reporting to the State Agency of any reasonable suspicion of a crime against an individual residing in or receiving care from the facility, as well as alleged violations involving abuse, neglect, exploitation, or mistreatment within required timeframes. Resident 5, who had diagnoses including kidney and urinary disorders, hypertension, and bipolar II disorder, required set up/clean up assistance for ADLs and had intact cognition per a comprehensive assessment. During an interview, the resident reported attempting to advocate for themself but encountering resistance from a staff member, and described a nurse who made inappropriate remarks and refused to leave the room when the resident wanted to speak with a different nurse. Staff interviews and record review showed that this allegation of verbal abuse was not reported to the State Agency. A RN (Staff F) stated they wrote a witness statement about the verbal abuse incident between Resident 5 and another RN (Staff G) and immediately informed the DON (Staff B), but did not report the incident to the State Agency despite being a mandated reporter. The DON (Staff B) confirmed being notified of the incident on the day it occurred and acknowledged it should have been reported within two hours, and that Staff F also should have reported it. The Administrator (Staff A) identified the incident as verbal abuse and stated that Staff F, Staff B, and Staff A all should have reported the incident to the State Agency Hotline. The failure of these staff members to report the allegation as required constituted the deficiency.
Failure to Complete Investigation of Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving one resident. The facility’s policy, revised 09/13/2022, required that all allegations of abuse, neglect, exploitation, and misappropriation of resident property be investigated, including identifying staff responsible for the investigation, interviewing involved persons and witnesses, determining whether abuse or mistreatment occurred, and documenting the investigation. Resident 5, who had diagnoses including kidney and urinary disorders, hypertension, and bipolar II disorder, and who required setup/cleanup assistance for ADLs, had intact cognition per a comprehensive assessment. An allegation was made that a registered nurse (Staff G) verbally abused this resident. The DON (Staff B) stated that their process for addressing abuse allegations included notifying the administrator, launching an investigation with witness statements, and reporting to required agencies. Staff B reported that an investigation into the alleged verbal abuse toward Resident 5 was initiated on the day of the incident and then given to the Administrator (Staff A) to complete because Staff B was out sick the following week. Staff B acknowledged that the investigation was not finished. The Administrator stated that the incident should have been investigated by the DON or turned over to the Resident Care Manager if the DON was unable to complete it, confirming that the required investigation was not completed.
Improper WanderGuard Placement Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and ensure proper use of an electronic wander management system, resulting in an elopement. The facility’s policy required an environment free of accident hazards and the use of supervision and assistive devices to avoid preventable accidents. Manufacturer instructions for the WanderGuard Departure Alert System specified that if wrist placement was not successful, the bracelet should be mounted away from metal surfaces such as a wheelchair frame, as metal could interfere with the signal to the door modules, and that technical service should be contacted before placing the bracelet on a wheelchair. Resident 6 had dementia, disorientation, aphasia, severely impaired cognition, and required extensive assistance with ADLs. The resident had a recent reduction in psychotropic medication that led to increased exit-seeking behavior, and a WanderGuard device was placed on the resident’s wheelchair in response. On the date of the incident, Resident 6 exited the building through a service door without the WanderGuard system triggering an alarm. The resident was later found outside on the ground by bystanders, who assisted the resident back into the wheelchair and into the building, at which time the WanderGuard alarm sounded. Subsequent investigation, including door testing and review of security footage, showed that the resident left through the service door and that the alarm did not sound when the resident exited. The Maintenance Director determined that the WanderGuard, which had been placed on the back, bottom right side of the metal wheelchair frame, did not trigger the alarm when the wheelchair passed through the door, but did trigger when the device was removed from the wheelchair and passed through the door alone. The RN who placed the WanderGuard reported not testing it at the door and not having received training on correct placement, and the DON confirmed that no staff were trained on proper WanderGuard placement. The root cause analysis concluded that the placement of the WanderGuard on the metal wheelchair frame blocked the system from reading the device.
Failure to Follow Hand Hygiene and Medication Handling Practices During Med Pass
Penalty
Summary
The facility failed to implement its infection prevention and control program during a medication pass by a registered nurse, identified as Staff G. The facility’s policy required an infection prevention and control program with standard precautions, including hand hygiene before and after resident contact, before unsterile tasks, and after contact with objects in resident rooms. During observation, Staff G was noted at the medication cart with fingernails extending beyond the fingertips and dark brown matter under the nails. Staff G obtained a card of narcotic medication, popped a pill out of the card into their bare hand, and then placed the pill into a medication cup, contrary to facility expectations that staff not touch medications with bare hands. Resident 1, who had diagnoses including respiratory failure, kidney failure, and anemia and was independent in ADLs with intact cognition, reported that Staff G did not handle medications properly. The resident stated that Staff G did not wear gloves, did not wash hands before or after passing medications, and repeatedly popped medications into a bare hand before placing them into a medication cup, and that these poor infection control practices had been observed on more than one occasion. In a separate observation, Staff G handed a medication cup and water to a resident, received the used cups back, exited the room, and immediately prepared another resident’s medication by popping it from a card into a medication cup without performing hand hygiene after leaving the room or before preparing the next dose. In interviews, the DON and the Administrator confirmed that staff were expected to perform hand hygiene between residents and to avoid touching medications with bare hands, and acknowledged that the infection control process during medication pass was not followed.
Failure to Complete Required Background Checks for Agency Nursing Staff
Penalty
Summary
The facility failed to implement its policies and procedures regarding the screening of potential staff, specifically related to conducting criminal background checks (BGCs) for agency-contracted nursing staff. Review of personnel files for five agency nurses revealed that none had documentation of a valid Washington State BGC prior to working unsupervised with residents. These staff members worked multiple unsupervised shifts without the required background clearance, despite facility policy and state guidelines mandating that all staff, including agency-contracted personnel, must have a completed and approved BGC before having unsupervised access to residents. Interviews with facility staff confirmed that the required process for background checks was not followed. The Scheduling Coordinator presented BGC authorization forms, which were not actual completed background checks, and acknowledged the oversight. The Administrator also confirmed that the established process required BGC clearance prior to unsupervised work, but this was not adhered to for the agency staff in question. This lapse resulted in agency nurses providing care and services to residents without the mandated background screening.
Failure to Monitor and Treat Constipation Due to Lack of Bowel Management Protocol
Penalty
Summary
The facility failed to monitor bowel movements and assess for and provide treatment for constipation in accordance with professional standards of practice for two residents. One resident, admitted with a healing thigh fracture, repeated falls, and heart failure, had not had a bowel movement for more than ten days. Despite notifying staff, the resident did not receive any medications for constipation until several days after the issue began. Documentation showed incomplete or missing records of bowel movements, and there was no evidence of bowel assessments being completed during the period of constipation. Medication orders for bowel care were present but lacked clear instructions on when to initiate treatment or the sequence of medications to be used. Another resident, admitted with a fractured vertebra, enlarged heart, and fecal abnormalities, also experienced a lack of bowel movements for five consecutive days. Despite having standing orders for bowel medications, there was no documentation that any medication was administered during this period. Staff interviews revealed inconsistencies in the process for monitoring and responding to residents' bowel patterns. Nursing assistants documented bowel movements but did not communicate directly with nurses when residents had not had a bowel movement. Registered nurses relied on electronic alerts and a clinical dashboard to monitor bowel patterns, but there was confusion regarding the protocol and documentation of assessments. A review of the facility's standing orders and protocols revealed that there was no clearly defined or accessible bowel management protocol indicating which medications to use or when to initiate them. The administrator confirmed that the facility lacked a defined process or protocol for bowel management. This lack of clear guidance and consistent monitoring led to delays in assessment and treatment for constipation for the affected residents.
Failure to Implement and Update Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision, monitoring, and individualized care planning to prevent avoidable falls for two residents identified as high risk. One resident, with diagnoses including throat cancer and dementia and moderate cognitive impairment, was admitted without a fall prevention care plan in place despite being assessed as high risk. This resident experienced multiple falls over several days, yet no care plan or interventions were implemented until after the third fall. Additionally, there was no investigation completed for one of the falls, and the facility's records did not reflect any updates or interventions following the initial incidents. Another resident, with a history of stroke and severe cognitive impairment, also experienced multiple falls. Investigations revealed that the resident's ordered wheelchair cushion, intended as a preventive measure, was not in place at the time of each fall. Although the care plan was reportedly updated to address this, the records showed no actual updates or interventions implemented after the falls. The facility's Director of Nursing Services acknowledged that the required fall prevention processes, including care plan development and revision, were not followed for these residents.
Failure to Provide Written Notice and Reasons for Resident Room Changes
Penalty
Summary
The facility failed to provide written notice, including the reasons for room changes, to three residents who experienced multiple room relocations. For each resident, record reviews showed no documentation of written notification or explanation for the room changes. Interviews with the residents and their representatives confirmed that they were either verbally informed or not informed at all about the moves, and none received written notice or reasons for the changes. The Social Services Director and Administrator both acknowledged that the process involved verbal discussions with residents or their representatives, but did not include providing written notice or documented reasons for the room changes. The residents involved had varying medical conditions, including broken heart syndrome, spina bifida, metabolic encephalopathy, malnutrition, respiratory failure, and muscle weakness. Assessments indicated that at least two of the residents were cognitively intact, while one had moderately impaired cognition. Despite their conditions and the frequency of room changes, there was no evidence that the facility provided the required written notifications, as confirmed by both documentation review and staff interviews.
Failure to Inform Residents of Rights and Facility Rules
Penalty
Summary
The facility failed to inform residents of their rights, responsibilities, and facility rules and regulations both orally and in writing upon admission and during their stay, as required by policy. Four residents with intact cognition and various medical conditions, including heart failure, depression, chronic pain, and spina bifida, reported not receiving information about their rights or facility rules at admission or during Resident Council meetings. Review of Resident Council meeting minutes showed that required reviews of resident rights were not consistently documented or conducted. Interviews with staff revealed inconsistencies and confusion regarding the process for distributing and reviewing resident rights information. The Admissions Director was unaware that resident guidebooks were not being handed out, and a Nursing Assistant involved in admissions did not review resident rights or know about the guidebook. The Activity Coordinator noted that reviews of resident rights at Resident Council meetings were not always completed, and the process for ensuring residents were informed was not reliably followed.
Failure to Provide Required Notices and Advocacy Contact Information
Penalty
Summary
The facility failed to provide required written notices and contact information for advocacy groups and instructions on how to file a complaint with the State Agency to four residents who were reviewed for these requirements. All four residents had intact cognition and required varying levels of assistance with activities of daily living due to diagnoses such as heart failure, depression, chronic pain, anxiety, spina bifida, and muscle weakness. Despite the facility's policy stating that residents would be given a list of names, addresses, and telephone numbers for pertinent regulatory agencies and advocacy groups, these residents were not aware of the Long-Term Care Ombudsman or how to contact the State Agency. During interviews, two residents stated they did not know what a Long-Term Care Ombudsman was or how to contact one, and all four residents indicated they did not know how or why to contact the State Agency. Staff interviews revealed that residents were only reminded of a poster with the required information at the main entrance, and staff were not actively informing residents about the Ombudsman or reporting procedures. The administrator acknowledged that the facility had not fully met regulatory requirements regarding resident notices and contact information.
Failure to Provide Safe, Comfortable, and Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents, as required by policy and regulation. For one resident with heart disease, depression, and weakness, observations revealed a cluttered and cramped room with personal items, a recliner, wheelchair, and boxes stacked in the corner, leaving no space for visitors or a bedside commode. The resident expressed a desire to use their recliner and a commode but stated there was insufficient space. Staff confirmed that the room was too small for the resident's personal chair and that the privacy curtain did not divide the space equally between roommates. Another resident, with heart failure, muscle weakness, depression, and unsteadiness, was observed in a three-bed room with limited space and dim lighting. The resident's bed was positioned against a privacy curtain, and the available space was further restricted by furniture placement, making it difficult for the resident to access their nightstand or move about the room. The resident reported that the room was too small, dark, and lacked space for personal belongings or visitors. Staff interviews acknowledged that the walk-through area at the end of the bed was not usable living space and that the room did not provide adequate space for three residents, especially when mechanical lifts were needed for transfers. The facility's policy required providing adequate lighting and allowing residents to use personal belongings in a safe and comfortable environment. However, both residents experienced limitations in their living spaces, including inadequate lighting, lack of space for personal items, and insufficient room for safe care and services. These conditions were directly observed and confirmed by staff and residents, demonstrating a failure to meet the required standards for resident environment.
Failure to Address Resident Council Grievances and Protect Residents from Retaliation
Penalty
Summary
The facility failed to address and provide feedback on concerns raised by the Resident Council (RC) for several residents, as well as failed to ensure residents were free from fear of retaliation when reporting grievances. Multiple RC meeting minutes over several months documented repeated requests from residents for additional activities and changes to the activities schedule, such as more arts and crafts supplies, Spanish language classes, and activities at preferred times. Despite these requests, there was no documented response or feedback from the facility in subsequent RC meetings, and residents reported not receiving any follow-up or information about the status of their concerns. Residents with various medical conditions, including urinary tract infection, muscle weakness, chronic pain, heart failure, diabetes, kidney disease, and spina bifida, were involved in the RC and expressed that their requests and recommendations were not acknowledged or acted upon. Interviews with residents confirmed that they did not receive feedback or see any changes based on their input, and staff interviews revealed that while concerns were reportedly passed on to appropriate departments, there was no consistent process for providing feedback to the RC group. Additionally, the facility did not ensure that residents felt safe from retaliation when reporting grievances. One resident reported discomfort and fear of reprisal after being confronted by social services staff for previous grievances, and others stated they would not report concerns due to fear of what might happen. The facility's grievance policy stated that grievances could be filed without fear of discrimination or retaliation, but there was no evidence that concerns about retaliation were resolved or that residents were reassured and protected as required.
Failure to Complete Required PASARR Level II Evaluations Prior to Admission
Penalty
Summary
The facility failed to ensure that Level II Preadmission Screening and Resident Review (PASARR) evaluations were completed prior to admission for three out of five residents reviewed. According to facility policy, individuals identified with a mental disorder or intellectual disability must have a Level II PASARR evaluation completed before admission, and the facility should not admit such individuals unless the State mental health authority has determined the need for specialized services. However, record reviews showed that residents with diagnoses including major depressive disorder, adjustment disorder, dementia with behaviors, depression, stroke, panic disorder, bipolar disorder, and PTSD were admitted without completed Level II PASARR evaluations, despite documentation indicating that such evaluations were required. For one resident, the Level I PASARR form indicated mood and psychotic disorders and a need for Level II evaluation, but no documentation of completion was found. Another resident had two Level I PASARR forms, with one not completed or signed and no evidence of a Level II evaluation, despite relevant diagnoses. A third resident's Level I PASARR form also showed a need for Level II evaluation, but again, no documentation was present. Staff interviews confirmed that referrals for Level II evaluations had been sent but not returned due to a backlog with the evaluator, and that the facility was admitting residents without the required paperwork, contrary to policy.
Failure to Provide Meaningful and Resident-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing program of meaningful activities for all residents reviewed, as evidenced by observations, interviews, and record reviews for six residents. The facility's policy required a resident-centered activities program based on comprehensive assessments and care plans, but multiple residents reported a lack of activities that matched their interests and preferences. The activities calendar showed limited options, with only two days of arts and crafts, and no religious services, card games, news groups, or sewing/needle craft groups offered. Several residents expressed dissatisfaction with the available activities. One resident, who enjoyed sewing and needlework, was told there was no sewing machine and was not offered alternatives. Another resident, who preferred knitting, crocheting, and woodworking, was unable to bring their personal sewing machine due to space limitations. Residents also reported a lack of stimulating activities, limited pet therapy visits, and no access to books or newspapers. Some residents who preferred self-directed or small group activities stated that options were not available for them, and one resident noted that the only activity performed daily was watching television. Staff interviews confirmed that the activities coordinator was aware of some resident preferences, such as sewing and needle crafts, but was not aware of others, like card games. The coordinator stated that residents were provided with a monthly activities calendar and encouraged to attend group activities, but there was no puzzle/game room and limited one-on-one in-room visits. The administrator acknowledged that the facility had room to improve in providing activities for all residents, regardless of cognitive impairment.
Failure to Provide Palatable and Appropriately Tempered Meals
Penalty
Summary
The facility failed to provide meals that were palatable, attractive, and at an appetizing temperature for 7 of 11 residents reviewed for food service. Multiple residents reported dissatisfaction with the quality and temperature of the food, with specific complaints including cold meals, unappetizing appearance, and food items that were not properly cooked or were unidentifiable. Residents also reported that their dietary preferences and restrictions were not consistently honored, with some receiving foods they could not eat due to medical or personal reasons, despite having communicated these needs to the facility. Review of facility records and food committee meeting notes revealed ongoing concerns about food quality and temperature, including reports of hard squash, cold soups and beverages, undercooked hashbrowns, soggy toast, and tough meat. Resident interviews corroborated these findings, with several stating that meals were often cold, repetitive, and unappealing. One resident described receiving a meal that did not match their selected preferences, including being served pork despite a known intolerance, and another noted that their requests to avoid certain foods were not respected. A test tray evaluation conducted by the surveyor further confirmed the issues, with food items found to be lukewarm, bland, and visually unappealing. The chicken was described as extremely dry and tasteless, and the vegetables were dark and unappetizing. The Dietary Manager acknowledged past complaints about food temperature but was unaware of ongoing issues, and the Administrator stated that resident preferences and food temperatures were expected to be honored, with follow-up required when concerns were raised.
Failure to Properly Explain Arbitration Agreement and Right to Rescind
Penalty
Summary
The facility failed to fully explain the binding arbitration agreement to residents or their representatives, including the right to rescind the agreement within 30 calendar days, and did not ensure the explanation was provided in a manner and language the residents understood. Four residents, all with intact cognition and varying levels of dependence for activities of daily living, signed the arbitration agreement without being informed that it was optional or that they had the right to cancel it within the specified period. During a Resident Council meeting, three residents stated they were not told the agreement was optional, and one did not recall signing the document. None of the four residents were informed of their right to rescind the agreement. Interviews with facility staff revealed gaps in knowledge and training regarding the arbitration agreement. The nursing assistant responsible for admission paperwork stated they did not inform residents about the right to rescind and were unaware of this option. The Health Information Director also did not know if residents could cancel the agreement after signing. The administrator confirmed that the admissions coordinator was trained by the regional director, but the deficiency persisted, as evidenced by the lack of proper explanation and documentation for the residents involved.
Failure to Maintain Resident Dignity During Care Due to Staff Speaking Spanish
Penalty
Summary
Staff members failed to provide care in a manner that maintained and promoted dignity and respect for two residents when they spoke Spanish to each other while providing personal care. Both residents, who had intact cognition and required substantial assistance with activities of daily living, reported feeling uncomfortable, frustrated, or upset because they could not understand what was being said. One resident expressed concern that the nursing assistants might be discussing them, while the other stated that the experience made them angry and upset. In one instance, a resident asked the staff to stop speaking Spanish, which led to a noticeable change in the staff member's demeanor and departure from the room. Interviews with staff confirmed that it was common for nursing assistants to speak Spanish with each other during care, as it felt natural and facilitated faster communication. However, staff also acknowledged that some residents had requested they not speak Spanish during care. The facility's administrator stated that staff should not speak Spanish around residents who do not understand the language during care, as residents might not know what is being said. The facility's policy requires treating each resident with respect and dignity in a manner that promotes or enhances their quality of life.
Failure to Provide ABN Upon Change in Medicare Coverage
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (ABN) to a resident when there was a change in Medicare Part A coverage. According to the facility's policy, residents must be informed before or at admission and periodically during their stay about available services and any charges for services not covered by Medicare or Medicaid. In this case, a resident was admitted with diagnoses including rib fractures, weakness, and arthritis, and required setup assistance for activities of daily living. The resident had intact cognition and remained in the facility after Medicare Part A coverage ended, transitioning to Medicaid coverage. Documentation review showed that the resident received Medicare Part A skilled services until the last covered day, then continued to stay in the facility for several days under Medicaid coverage before discharge. There was no documentation that the required ABN was issued to the resident upon the change in coverage. Staff interviews confirmed that the ABN should have been provided when Medicare Part A coverage ended, but it was not given, resulting in a failure to notify the resident of potential financial liability for services not covered.
Failure to Investigate and Prevent Recurrence After Mechanical Lift Fall
Penalty
Summary
The facility failed to thoroughly investigate and take preventative action following an avoidable accident involving a resident who was dependent on staff for activities of daily living, including transfers. The resident, who was cognitively intact and required assistance from one to two staff members, reported being dropped from a mechanical lift during a transfer, resulting in a fall onto a shower chair and subsequent pain to the right shoulder and neck. The facility's investigation into the incident did not include an interview with the resident, observations of staff performing mechanical lift transfers, or interviews with other residents and staff who used the mechanical lifts. Additionally, there was no documentation that the mechanical lift was inspected by the Maintenance Director for defects, nor was there any evidence of education provided to the staff involved in the incident to prevent future occurrences. The facility's policy required determination of the cause of falls, proper use and maintenance of assistive devices, and staff training, but these steps were not followed in this case. The Regional Nurse Consultant acknowledged that the investigation was incomplete and lacked necessary preventive measures.
Failure to Provide Bed Hold Notification at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of bed hold at the time of transfer to the hospital for two residents who were reviewed for hospitalization. For one resident with Parkinsonism, diabetes, heart failure, and severely impaired cognition, the medical record indicated a decline in responsiveness and refusal of medication, leading to a provider-ordered hospital transfer. There was no documentation that a bed hold notification was given at the time of this transfer. For another resident with quadriplegia, depression, and chronic pain, who required total assistance for all activities of daily living and was cognitively intact, the record showed the resident was transferred to the hospital due to swelling and pain in both lower legs. Again, there was no documentation of a bed hold notification at the time of transfer. Interviews with facility staff confirmed that the required bed hold notifications were not completed or documented at the time of transfer for both residents. Staff acknowledged that the process involves speaking with the resident or their representative and obtaining a signature, but in these cases, the notifications were missed. The facility's standard requires a 24-hour follow-up with documentation in the nursing progress note, which was not observed in the records reviewed.
Failure to Review and Implement Physician Orders
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for one resident reviewed for physician orders. A resident with diagnoses including respiratory failure, depression, and weakness, who was dependent on staff for activities of daily living and cognitively intact, reported persistent pain that was not controlled by their current dose of hydrocodone. The physician documented in the progress notes a plan to increase the hydrocodone dosage and to order a renal function panel, with a possible increase in lisinopril if the panel was stable. However, the nursing staff did not review the physician progress notes after the physician's rounds, and the Resident Care Manager was unaware of the new medication orders. The Director of Nursing stated that the expectation was for Resident Care Managers to review the physician notes the same day as rounds, but this was not done. As a result, the physician's orders for medication changes were not implemented in a timely manner. The Medical Director was not aware that the lisinopril dose had been increased and stated that they would have expected communication from the nursing staff regarding this change. The lack of review and communication regarding the physician's documented plan led to a delay in addressing the resident's pain management and medication adjustments, which did not meet the facility's policy or professional standards of practice.
Failure to Provide Appropriate Care and Medication Management
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for two residents. One resident, admitted with heart disease, muscle weakness, and lack of coordination, was dependent on staff for activities of daily living and was cognitively intact. Despite expressing a desire to participate in activities such as going outside, to the dining room, and shopping, the resident remained in bed most of the time due to discomfort and pain caused by an ill-fitting and uncomfortable wheelchair. Multiple staff interviews confirmed that the resident's complaints about the wheelchair were reported to nursing staff, but no timely referral or assessment for a more suitable wheelchair was initiated. The resident continued to experience discomfort, and only after several days was a cushion replaced, which did not resolve the underlying issue with the wheelchair's fit and support. Another resident, admitted with a history of chronic pain, depression, and insomnia, did not receive their long-term use medications as ordered upon admission. The resident's pain medication (oxycodone) was not available for nearly 36 hours after admission, and their prescribed antipsychotic medication (Seroquel) was discontinued and replaced with an over-the-counter supplement without their knowledge. The resident experienced significant distress, including pain, withdrawal symptoms, and worsening depressive symptoms. The medication administration records showed repeated interruptions in the provision of both oxycodone and Seroquel, with periods where the medications were not reordered or were abruptly discontinued and restarted multiple times. Provider notes documented the resident's ongoing complaints and distress related to these medication issues. The failures in both cases were confirmed through observation, interviews with residents and staff, and review of medical records and medication administration records. The lack of timely assessment and intervention for the wheelchair issue, as well as the failure to provide and manage essential medications according to orders and standards of practice, resulted in residents experiencing pain, discomfort, and emotional distress.
Failure to Implement Safety Interventions and Staff Training During Mechanical Lift Transfer
Penalty
Summary
The facility failed to implement appropriate safety interventions and staff training to prevent an avoidable fall for a resident who was dependent on staff for activities of daily living and had multiple medical diagnoses, including respiratory failure and diabetes. The resident, who had intact cognition, was being transferred from bed to a shower chair using a mechanical lift by two nursing assistants. During the transfer, the mechanical lift tipped over, causing the resident to fall onto the shower chair, resulting in pain to the right shoulder and neck. The incident investigation revealed that the mechanical lift tipped due to improper use, specifically the likely failure to properly extend the stabilizing legs, which, combined with the resident's weight, caused the center of gravity to shift. Staff interviews indicated that although one staff member reported having received training on the mechanical lift, the facility was unable to locate documentation of this training for the staff involved. The maintenance director confirmed that monthly preventative maintenance was performed on all mechanical lifts and found no defects with the equipment after the incident. The facility's policy required staff to be trained on the use of assistive devices and transfer equipment, but this was not verified for all staff involved in the incident.
Failure to Implement Scheduled Toileting Program for Incontinent Resident
Penalty
Summary
The facility failed to develop and implement a scheduled toileting program for a resident who was frequently incontinent of bowel, despite being assessed as a candidate for such a program. The resident was cognitively intact, able to express needs, and dependent on staff for transfers and toileting hygiene. Documentation showed that the resident was not on a toileting program, and interviews revealed that the resident had not been offered or discussed a scheduled toileting program, even though they expressed interest in trying one and dissatisfaction with using briefs. The resident also reported not having access to a bedside commode and being unable to get to the bathroom independently. Staff interviews indicated that the facility's process for establishing toileting schedules included assessments and tracking bowel patterns to identify candidates for scheduled toileting. However, staff acknowledged that the resident's assessment had not been followed up appropriately, and the resident had not been identified or placed on a toileting program, despite having a documented pattern of large bowel movements during shower transfers. The facility's policy required care and services to restore as much normal bowel function as possible for residents admitted with incontinence, but this was not implemented for the resident in question.
Expired Vaccines and Inadequate Temperature Monitoring in Medication Storage
Penalty
Summary
The facility failed to ensure that expired vaccines were discarded and did not follow CDC guidance for monitoring the temperature of vaccines stored in the medication storage refrigerator in the East/West Medication Storage room. During an observation, it was found that the refrigerator contained 24 influenza vaccines that had expired, along with other medications such as Apisol, Alteplase, and insulin pens. The refrigerator thermometer showed a questionable reading of 66 degrees Fahrenheit, and staff were unsure if this was accurate. The Infection Prevention Nurse indicated that night shift nurses were responsible for reading and recording refrigerator temperatures, but the logs revealed multiple missed temperature documentation entries over several months. The Director of Nursing was unaware of the expired vaccines and stated that the unit manager was supposed to monitor for outdates and ensure accurate temperature documentation. The Regional Nurse Consultant confirmed that temperature checks for refrigerators containing vaccines were to be completed twice daily. Despite these expectations, the temperature logs showed numerous days with missing documentation, indicating a lack of consistent monitoring. The failures to discard expired vaccines and to properly monitor and record refrigerator temperatures were in direct violation of facility policy and CDC guidance.
Failure to Provide Timely Dental Services for Resident with Denture Issues
Penalty
Summary
The facility failed to provide timely dental services to a resident who required assistance with oral care. The resident was admitted with diagnoses including heart failure, weakness, and depression, and required partial to maximal assistance for activities of daily living. Assessments documented that the resident had broken or loosely fitting dentures, and the care plan included interventions to coordinate dental care and transportation as needed. Despite these documented needs, the resident continued to experience issues with loose dentures, as observed during an interview where the resident's dentures were visibly slipping, causing slurred speech and drooling. Interviews with facility staff revealed a breakdown in the process for identifying and addressing dental needs. The Social Services Director, responsible for arranging dental appointments, was not informed of the resident's denture concerns due to a lapse in communication from nursing staff and the assessment process. The DON stated that the expectation was for a referral to be made within the first few weeks of admission, but this did not occur. The Administrator confirmed that the facility should have been actively working to schedule a dental appointment and following up to ensure the resident was seen by a dental provider.
Failure to Coordinate and Document Hospice Services for Resident
Penalty
Summary
The facility failed to establish and maintain effective communication, collaboration, and coordination of care between the facility and the hospice provider for a resident receiving hospice services. Review of the facility's policy indicated that a designated staff member should coordinate care with hospice and that a care plan should be established to identify specific responsibilities. However, the resident's care plan did not include any focus, goals, interventions, or coordination related to hospice care. Interviews with staff revealed that nursing assistants were not informed the resident was on hospice, and the care manager was unaware of the required care plan elements for hospice residents. The care manager also failed to document conversations with hospice or include hospice contact information in the resident's profile. Further interviews with the Director of Nursing and Regional Nurse Consultant confirmed that the care plan lacked required hospice information, such as the hospice provider's name, contact details, and delineation of responsibilities between hospice and facility staff. The resident in question had diagnoses of emphysema and COPD with exacerbation, required partial assistance with activities of daily living, and had intact cognition. The lack of a coordinated care plan and communication system placed the resident at risk for not receiving necessary care and services as required by facility policy and regulatory standards.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written abuse policies and procedures for the identification and protection of further abuse for a resident who reported rough handling by a staff member. The resident, who had diagnoses including traumatic ischemia of muscle, diabetes, and chronic pain, reported to a scheduler that a nursing assistant was too rough while providing personal care. Despite the resident's request not to have the nursing assistant provide further care, the staff member continued to do so, indicating a failure to protect the resident from further potential abuse. The facility's policy required immediate steps to protect residents from additional abuse once identified, but this was not followed. The scheduler, after being informed by the resident, only advised the nursing assistant via text not to perform certain tasks, rather than removing them from providing care to the resident entirely. The administrator later acknowledged that the resident's concerns constituted an allegation of abuse and that it was inappropriate for the nursing assistant to continue providing care after the concerns were reported.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving Resident 1 to the State Agency as required. Resident 1, who was admitted with chronic pulmonary respiratory disease, chronic pain, and depression, reported to Staff G, a Scheduler, that Staff F, a Nursing Assistant, had been rough during personal care and expressed a preference not to have Staff F work with them anymore. Despite Resident 1's intact cognition and clear communication of discomfort, Staff G did not report the incident to the Administrator, Staff A, as they did not perceive it as an allegation of abuse. During interviews, Staff G acknowledged that they did not report the incident because they did not believe Resident 1 was afraid or scared, although they later reflected that they might have been mistaken in not reporting it. Staff A, the Administrator, confirmed that the reported concern should have been treated as an allegation of abuse and expected it to be reported accordingly. This oversight placed residents at risk for additional abuse, as the facility did not adhere to the guidelines requiring immediate reporting of such allegations to the appropriate authorities.
Failure to Verify OBRA Registry for Nurse Aide
Penalty
Summary
The facility failed to verify the OBRA registry status of a nurse aide, Staff F, which is a requirement to ensure that staff meet competency evaluation requirements. The review of Staff F's personnel file revealed that there was no documentation of a current OBRA registration. This oversight was confirmed during an interview with Staff G, the Scheduler, who stated that their process involved keeping a copy of all OBRA registrations in a binder and noting renewal dates on a whiteboard. However, they were unable to locate the current registration for Staff F. Further investigation revealed that the facility's process for ensuring OBRA registry compliance involved obtaining the registry at the time of hire and upon renewal. Staff A, the Administrator, acknowledged the missing registry for Staff F and later confirmed via email that the OBRA registry had been located but had expired. This lapse in maintaining up-to-date registry verification placed residents at risk for abuse, neglect, and unmet care needs, as the OBRA registry also identifies individuals ineligible to work in skilled nursing facilities due to findings of abuse, neglect, or misappropriation of property.
Inadequate Hand Hygiene Practices by Staff
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by three staff members, Staff C, D, and E, during their interactions with residents. Observations revealed that Staff C and D, both Nursing Assistants, did not change their gloves or perform hand hygiene after handling a visibly soiled pad while assisting a resident with a mechanical lift. They continued to wear the soiled gloves while adjusting the resident's clothing, operating the lift, and making the resident's bed, which is against the facility's infection prevention and control policy. Staff E, a Registered Nurse, was observed performing a wound dressing change on a resident's heel without following proper hand hygiene protocols. Staff E double-gloved during the procedure, removing only the outer gloves after cleaning the wound, and continued the dressing change with the inner gloves, which were considered clean. This practice was not in line with the training received for hand hygiene, as confirmed by Staff E, who mentioned learning this technique from a physician assistant. Interviews with the facility's Infection Preventionist and Administrator confirmed that the staff did not adhere to the established hand hygiene protocols, which require handwashing or using hand sanitizer before and after resident contact, and changing gloves between soiled and clean tasks. The facility acknowledged the need for more education on hand hygiene to prevent such deficiencies in the future.
Failure to Timely Notify Administration and Law Enforcement of Missing Resident
Penalty
Summary
The facility failed to notify administrative staff and law enforcement in a timely manner when a resident did not return to the facility, placing the resident at risk for serious injury and/or exposure to the elements. According to the facility's policy titled 'Actions for a Suspected Resident Elopement,' the charge nurse is required to initiate a search and notify administrative staff, the resident's representative, and physician if the resident is not found. Administrative staff are then responsible for notifying local law enforcement. However, this protocol was not followed in the case of the resident who signed out of the facility with an expected return time but did not return as scheduled. The resident, who had no cognitive impairments and was independent in various activities, was missing from the facility for approximately 16 hours before law enforcement and the resident's physician were notified. Staff B, an LPN, was unaware of the resident's absence until they attempted to administer medications and subsequently failed to notify the administration or law enforcement in a timely manner. The resident's spouse was contacted the following morning, but the delay in notification and action by the staff resulted in a significant lapse in the facility's protocol for handling such situations.
Failure to Implement VNS Therapy for Seizure Management
Penalty
Summary
The facility failed to provide necessary care and services to maintain a resident's highest practicable level of well-being by not initiating Vagus Nerve Stimulation (VNS) therapy as ordered by the physician. The resident, who was admitted with a diagnosis of epilepsy, required total assistance for all activities of daily living and was rarely/never understood. Despite having physician's orders to use VNS therapy magnets during seizures, the facility staff did not utilize the magnets as prescribed, which was evident from the lack of documentation of their use during seizure episodes. Interviews revealed that the nurse practitioner had prescribed the VNS therapy to be applied with each seizure, but staff did not call to clarify the order. A registered nurse admitted to using the magnet only once before the order was given and was unaware of the magnets' purpose until informed by the resident's representative. The resident's representative confirmed that the magnet was not being used during seizures. An observation showed the magnet hanging on the wall behind the bedside table, indicating it was not readily accessible for use during seizures. This deficiency was a repeat issue from a previous statement of deficiencies.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to properly identify, assess, report, and implement interventions to prevent the development of pressure injuries for Resident 2, who was readmitted with dementia and Parkinson's disease. Upon readmission, Resident 2 had a Stage II pressure injury on the right upper buttocks and was dependent on staff for mobility and personal care. During an interview, a Nursing Assistant, Staff B, reported observing a dark purple blister on Resident 2's right heel, which was indicative of a Stage II pressure injury. Staff B informed a Registered Nurse, Staff C, about the observation, but neither could recall the exact date of the report or the specific details of the injury. Staff C observed the heel and noted signs of worsening skin condition but failed to document the assessment or report it to other licensed nurses. There was no documented plan to monitor the heel for changes or to prevent further skin injury. This lack of documentation and communication resulted in a failure to implement necessary preventative measures, placing Resident 2 at risk for further pressure injuries. This deficiency was noted as a repeat issue from a previous Statement of Deficiencies.
Failure to Provide Written Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written notice of bed hold policies to residents or their representatives during hospital transfers, as required by their policy. This deficiency was identified for three residents who were transferred to the hospital. Resident 1, who had no cognitive deficits, was transferred for chest pain and later received a bill for bed hold charges without prior written notice. The resident was verbally informed by a staff member but did not receive any written documentation, leading to confusion about the charges. Similarly, Resident 2, who also had no cognitive impairments, was transferred due to respiratory distress and did not receive written information about the bed hold policy, despite a verbal consent being documented. Resident 3, with intact cognition, was transferred for a scheduled surgical procedure and verbally declined the bed hold, but again, no written notice was provided. Staff members involved in these cases admitted to not providing written documentation, which was not in line with the facility's policy. This lack of written communication placed residents at risk of being unaware of their rights and potential costs associated with bed holds during hospital stays. The deficiency was noted as a repeat issue from a previous statement of deficiencies.
Facility Fails to Maintain Homelike Environment in Resident Rooms
Penalty
Summary
The facility failed to ensure that resident rooms were repaired and maintained, compromising the homelike environment for six out of ten resident rooms reviewed. Observations revealed various deficiencies, including deep scrapes and missing hardware on clothing closets, strong urine odors in bathrooms, chipped and missing paint on windowsills and door frames, and protective panels with black scratches. Additionally, some rooms had areas used for storage with miscellaneous items piled up, missing flooring transition strips covered with peeling tape, and broken door trims. One room had multiple holes in the ceiling exposing pipes and wood beams, and another had a hole in the wall with cables coming out. Interviews with staff confirmed the poor condition of the resident rooms. The Interim Director of Nursing Services and the Regional Nurse Consultant acknowledged that the rooms did not represent a homelike environment. The Administrator admitted that work needed to be done, and the Maintenance Director stated that the holes in the ceiling were due to a water leak and had been present for at least two months, with repairs scheduled for a later date.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan (BCP) within 48 hours of admission for six newly admitted residents. This deficiency was identified through interviews and record reviews, which revealed that the BCPs lacked required components such as initial goals based on admission orders, dietary orders, therapy services, social services, and PASARR. Residents 59, 165, 167, 47, 2, and 56 did not receive a BCP within the required timeframe, leading to issues such as incorrect wound care orders and uncertainty about discharge plans. Interviews with the residents confirmed that they had not received a BCP, and staff members were unaware of the requirement to provide a BCP within 48 hours of admission. Resident 59, admitted with a right lower leg skin infection and diabetes, did not receive a BCP, resulting in incorrect wound care orders. Resident 165, admitted with a sacral fracture and hyponatremia, was unsure of their discharge plan due to the lack of a BCP. Resident 167, with end-stage renal failure requiring dialysis, also did not receive a BCP. Resident 47, readmitted with a cervical spine infection and diabetes, did not remember receiving a BCP. Resident 2, admitted with a pressure injury wound and other complications, and Resident 56, admitted with a right shoulder dislocation, both did not receive a BCP within 48 hours. Staff interviews revealed a lack of awareness about the BCP requirements, contributing to the deficiency.
Failure to Conduct Comprehensive IDT Care Conferences
Penalty
Summary
The facility failed to ensure interdisciplinary team (IDT) care conferences were completed for five residents reviewed for comprehensive care planning. The residents involved were not informed or included in meetings about their care, and the required IDT members were often not in attendance. This resulted in the residents and/or their representatives not being involved in planning their care, which placed them at risk for unmet care needs. Resident 4, who had diagnoses including respiratory failure and depression, was not informed about care meetings and only attended an initial care conference with limited IDT members. Resident 6, who had a stroke and epilepsy, did not recall any care meetings, and their records showed only one meeting with insufficient IDT attendance. Resident 8, with vascular dementia and difficulty swallowing, had their last care conference canceled and not rescheduled, with the previous meeting also lacking full IDT participation. Resident 15, with hyponatremia and anxiety, had only one care conference with minimal IDT involvement. Resident 22, with myasthenia gravis and heart failure, had no documented care conferences since admission. Staff interviews revealed that the facility was behind on care conferences, and the process was not functioning correctly, with IDT members typically not attending the meetings.
Failure to Ensure Nurse Competency in CVAD Care
Penalty
Summary
The facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to safely and efficiently perform care for residents' needs in the area of Central Vascular Access Devices (CVAD). This deficiency was identified through observation, interview, and record review, revealing that two nursing staff members, Staff Y and Staff W, had not received training or had their competencies reviewed related to the care and maintenance of CVADs. Both staff members were responsible for CVAD care, including giving medications, flushes, and performing sterile dressing changes, but were unaware of critical procedures such as measuring the catheter tubing length and arm circumference to ensure the CVAD had not been displaced or to detect the presence of a thrombus. The facility's policy required these competencies to be validated and documented, but this was not done for the staff in question. During interviews, Staff Y and Staff W admitted to performing CVAD-related tasks without proper training or competency validation. Staff Y was not aware of the requirement to measure the catheter tubing length during sterile dressing changes, while Staff W did not know where to find relevant information in the medical record. The Interim Director of Nursing Services, Staff B, confirmed that there was no evidence of training or competency checks for these nurses and acknowledged that such training should be conducted at least annually. This lack of proper training and competency validation placed residents at risk for adverse outcomes related to CVADs and unmet care needs.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, resulting in an error rate of 12 percent. This was identified through three medication errors involving two residents during 25 medication administration opportunities. For Resident 22, a transcription error led to the administration of Vitamin B-12 at 500 mg instead of the prescribed 500 mcg. Staff F, an RN, did not notice the discrepancy between mg and mcg when administering the medication. Staff E, an LPN/UM, admitted to making the transcription error when entering the Vitamin B-12 order. Resident 22 had diagnoses including congestive heart failure and muscle weakness and was dependent on staff for activities of daily living (ADLs) with moderately impaired cognition. For Resident 319, who had a diagnosis of diabetes mellitus, the facility staff failed to follow proper insulin administration procedures. Staff M, an RN, and Staff N, an LPN, did not prime the insulin pen before administration, and Staff N did not wait the required five seconds before removing the needle from the resident's abdomen. Both staff members stated they were not trained to prime the pen, and Staff N admitted to not following the training to wait five seconds. The Interim Director of Nursing Services confirmed that the correct process was not followed, and the Administrator acknowledged the need for double-checking physician orders for accuracy.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program that identified high-risk, high-volume, and problem-prone areas. Specifically, the facility did not implement corrective actions for deficiencies related to nursing staff competencies, medication administration errors, infection prevention and control measures, resident immunizations, antibiotic stewardship program, and residents' homelike environment. The facility also did not make a good faith attempt at correcting identified quality deficiencies with residents' baseline care plans. These failures placed all residents at risk for unidentified complications and prompt corrective action in resident care/services areas. During an interview, the Administrator acknowledged that their QAPI process had not identified or corrected the quality deficiencies regarding nursing staff competencies, infection surveillance, immunizations (influenza, pneumococcal, and COVID-19), antibiotic stewardship, residents' homelike environment, and medication administration errors. The Administrator admitted that the QAPI process should have been aware of these high-risk, high-volume, and problem-prone areas and did not make a good faith attempt to correct the process identified with resident care plans.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, leading to multiple deficiencies. Staff members did not follow proper hand hygiene and glove-changing procedures during resident care activities. For instance, two nursing assistants, while assisting a resident with a shower and transfer, did not change their gloves or perform hand hygiene between tasks, leading to potential cross-contamination. Similar lapses were observed with other staff members during wound care and personal care activities, where gloves were not changed, and hand hygiene was not performed between soiled and clean tasks. The facility also failed to implement enhanced barrier precautions (EBP) and proper use of personal protective equipment (PPE) for a resident with an open wound. Despite the resident's condition requiring EBP, there was no signage or PPE supplies outside the resident's room. Staff entered the room and performed personal care without wearing the necessary protective equipment, increasing the risk of infection transmission. Additionally, the facility did not use Environmental Protection Agency (EPA) registered disinfectants for cleaning and disinfecting the environment. Housekeeping staff used a neutral floor cleaner without an EPA registration number for cleaning floors, including those in rooms requiring transmission-based precautions. Furthermore, the facility's infection surveillance system was ineffective, as evidenced by the failure to monitor, track, and follow up on a resident's wound infection and the lack of communication regarding antibiotic recommendations and culture results.
Failure to Provide Immunization Education
Penalty
Summary
The facility failed to ensure residents received education regarding the potential risks and benefits of pneumococcal and influenza immunizations. This deficiency was identified for five residents who either declined or received the immunizations without documented education. The facility's policy required that residents or their representatives receive information related to the risks and benefits of the immunizations, and that this education be documented in the resident's record. However, the review showed that this education was not provided or documented for any of the five residents reviewed. Resident 56, who was admitted with a right shoulder dislocation, declined both the pneumococcal and influenza immunizations without receiving the required education. Similarly, Resident 118, with diagnoses including respiratory complications and diabetes, also declined both immunizations without documented education. Resident 41, who had severe cognitive impairment and multiple health issues, declined the immunizations without receiving the necessary information. Resident 2, with a pressure injury wound and altered mental status, and Resident 31, with high cholesterol and Parkinson's disease, also declined the immunizations without documented education. Interviews with staff confirmed that there was no consistent process for educating residents about the benefits, risks, and potential side effects of the immunizations. Staff BB admitted to not providing this education during the admission process, and Staff D acknowledged the lack of a good process for informing residents. The facility's administration also confirmed the absence of a complete process for educating residents about the immunizations, leading to the deficiency identified in the report.
Failure to Educate Residents on COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that residents were offered and educated on the COVID-19 vaccination, as required by their policy. This deficiency was identified for five sampled residents who were reviewed for immunization status. The facility's policy mandated that residents and/or their representatives receive information and education related to the risks, benefits, and potential side effects of the COVID-19 vaccine before requesting consent for administration. However, the review of medical records and interviews with residents and staff revealed that this education was not provided prior to the residents' declination of the vaccine. Resident 56, who was admitted with a right shoulder dislocation, declined the COVID-19 vaccine without receiving the necessary education. Similarly, Resident 118, with diagnoses including respiratory complications and diabetes, also declined the vaccine without being informed of its benefits and risks. Resident 41, who had severe cognitive impairment and other health issues, declined the vaccine without receiving the required education. Resident 2, with a pressure injury wound and other complications, and Resident 31, with high cholesterol and Parkinson's disease, both declined the vaccine without being educated on its potential side effects and benefits. Interviews with staff members, including the Infection Preventionist/Unit Manager and the Admissions Registered Nurse, confirmed that the process for educating residents about the COVID-19 vaccine was incomplete. Staff members admitted that they did not provide handouts or verbal education about the vaccine's benefits, risks, and potential side effects. The facility's Administrator, Interim Director of Nursing Services, and Regional Nurse Consultant acknowledged the lack of a complete process for informing residents about the COVID-19 vaccination, leading to uninformed decisions by the residents.
Failure to Inform Residents of Fluid Restrictions
Penalty
Summary
The facility failed to inform two residents, Resident 22 and Resident 4, of their physician-ordered daily fluid intake restrictions and did not provide them with the necessary risks/benefit education. Resident 22, who had diagnoses including congestive heart failure and muscle weakness, was observed with multiple glasses of orange juice and large amounts of water, far exceeding the prescribed fluid restriction. Interviews with Resident 22 and staff revealed that the resident was unaware of the fluid restriction, and there was no documentation of risks/benefits education until after the surveyor's observation. The fluid intake records showed significant non-compliance with the fluid restriction, and the dietician recommended discontinuing the restriction without prior resident education or consent. Similarly, Resident 4, with diagnoses including respiratory failure, diabetes mellitus, and venous insufficiency, was also not informed about their fluid restriction. Despite being on a fluid restriction, Resident 4 reported having their water jug refilled multiple times a day and consuming fluids freely. Staff interviews confirmed that Resident 4 was on a fluid restriction, but there was no evidence of risks/benefits education provided to the resident. The fluid intake records for Resident 4 also showed significant non-compliance with the prescribed fluid restriction. The facility's policy required that residents be informed in advance of treatment risks and benefits, options, and alternatives. However, the facility did not adhere to this policy for Residents 22 and 4, resulting in their inability to make informed decisions regarding their health care. The failure to provide proper education and documentation placed the residents at risk and demonstrated a lack of compliance with regulatory requirements.
Failure to Honor Resident's Right to Choose Attending Physician
Penalty
Summary
The facility failed to honor a resident's right to choose their attending physician, as evidenced by the case of a resident who was readmitted after hospitalization for an infection. The resident, who was alert and oriented, expressed a desire to continue seeing their primary physician from the community. However, the nursing staff informed the resident that they would have to pay out of pocket to see their preferred physician, as the facility had its own physician to see residents. This information contradicted the facility's policy, which allows residents to choose their attending physician without incurring additional out-of-pocket expenses. Interviews with various staff members, including a Licensed Practical Nurse/Unit Manager, the Interim Director of Nursing Services, and the Administrator, revealed inconsistencies in the information provided to the resident. The resident's participation in occupational therapy was also limited due to their concerns about having to pay extra for their preferred physician. The Administrator confirmed that the resident should have been given the choice of an attending physician and acknowledged that the information provided to the resident was incorrect and not in line with the facility's policy. There was no coordination of services by the facility or the facility medical director for the resident's choice of attending physician.
Failure to Provide SNF Advance Beneficiary Notice
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) to two residents, which is required when Medicare Part A coverage ends and the resident remains in the facility. Resident 316, who was readmitted with heart and respiratory failure and required assistance with activities of daily living (ADLs), was not issued an SNF ABN when their Medicare Part A coverage ended. Similarly, Resident 317, admitted with a heart attack and severe cognitive impairment, was not provided an SNF ABN when their Medicare Part A coverage ended, despite remaining in the facility. The facility's policy mandates that residents be informed of services and charges, including those not covered by Medicare, and that an SNF ABN be issued before providing non-covered services. However, the facility did not follow this policy for Residents 316 and 317. The Administrator acknowledged issues with the process of issuing SNF ABNs, stating that social services were responsible for this task but had not been fulfilling it.
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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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