Avamere At Pacific Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Tacoma, Washington.
- Location
- 3625 East B Street, Tacoma, Washington 98404
- CMS Provider Number
- 505264
- Inspections on file
- 31
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Avamere At Pacific Ridge during CMS and state inspections, most recent first.
A resident admitted with a lower leg wound did not receive a full wound assessment on admission, and weekly wound monitoring and documentation were inconsistent. Nursing staff failed to record wound measurements and changes as required, and concerns about wound progression, including exposed tendon and odor, were not promptly escalated. The resident's condition worsened, resulting in hospital transfer for surgical debridement due to necrotizing fasciitis.
A resident with sleep apnea who required a CPAP device and a shower chair was discharged without these essential items due to failures in discharge planning and coordination among staff. The discharge plan did not address the resident's equipment needs, and staff interviews confirmed that necessary orders and arrangements were not made prior to discharge.
The facility failed to accurately complete PASARR assessments for four residents, risking unidentified mental health needs. A resident with Alzheimer's and depression was not referred for a Level II evaluation despite SMI/ID conditions. Another resident with anxiety and depression also lacked a Level II referral. Two residents with dementia and depression had incomplete or missing PASARR forms, which did not meet facility expectations.
A resident with a therapeutic diet requiring easy to chew foods was served meals that did not meet these dietary needs, including fried chicken and country fried steak. The facility staff, including a Registered Dietician and the Administrator, confirmed that the meals provided did not align with the prescribed diet, placing the resident at risk of choking and diminishing their quality of life.
The facility failed to maintain sanitary conditions in the kitchen, with staff items improperly stored in the walk-in refrigerator and near the tray line. Observations also revealed inadequate hand hygiene practices, as staff turned off water with bare hands and failed to wash hands after retrieving items from the floor. These actions did not meet the facility's expectations, as confirmed by the Dietary Services Manager and the Administrator.
The facility failed to ensure proper PPE use for three staff members across three halls, with observations showing entry into rooms with posted precautions without necessary PPE. Additionally, there was a lack of documentation for N95 fit testing for several staff members. The facility also did not maintain ongoing infection control data collection and analysis for three months, with missing documentation for December 2024 and incomplete tracking for January and February 2025.
The facility failed to administer influenza and pneumococcal vaccines to three residents, despite their consent and the facility's policy. A resident with asthma was not documented as having received the influenza vaccine, another with hemiplegia was not offered the pneumococcal vaccine, and a third with respiratory failure consented to the pneumococcal vaccine but did not receive it. Staff interviews confirmed the lapse in following vaccination protocols.
The facility failed to offer and provide COVID-19 vaccines to two residents. One resident, admitted with diabetes, consented to the vaccine, but there was no record of administration. Another resident, with hemiplegia and a brain bleed, had no documentation of being offered the vaccine. Staff interviews confirmed the facility's protocol to offer vaccines on admission and annually was not followed.
The facility failed to ensure CNAs received the required 12 hours of in-service training, including dementia management, and did not maintain oversight of their performance evaluations. Interviews revealed a lack of access to training records, and staff reported not receiving recent evaluations. This deficiency placed residents at risk for unmet care needs.
A facility failed to assist three residents with ADLs, including nail care and grooming. One resident with diabetes had long, yellowed nails despite a care plan for weekly nail care. Another resident with adult failure to thrive was observed with disheveled hair and dark sediment under fingernails, while a third resident dependent on staff for care was repeatedly seen with disheveled hair and a call light out of reach. Staff interviews confirmed the lack of adequate care.
The facility failed to maintain a homelike environment by not addressing maintenance issues such as gouges and peeling paint in shared bathrooms and rooms, and by using plastic utensils due to a shortage of metal silverware. Staff acknowledged these issues were not reported or addressed in a timely manner, affecting the residents' quality of life.
The facility failed to implement pharmacist recommendations for two residents, leading to a deficiency in medication management. A resident's recommendations for diclofenac gel and rivaroxaban were not addressed, and another resident's medication decrease was delayed. Staff interviews confirmed delays in reviewing MRRs, placing residents at risk for adverse effects.
The facility failed to properly store and label medications, with missing temperature logs for a medication refrigerator and undated or expired medications found in two medication carts. Staff interviews revealed a lack of awareness regarding medication expiration and documentation requirements.
The facility failed to provide timely dental services for two residents. One resident, with malnutrition and diabetes, could not wear dentures due to discomfort and was not seen by the dentist as needed. Another resident, with hemiplegia and diabetes, had dental issues identified but lacked follow-up on recommended care. Staff acknowledged the mishandling of dental care for both residents.
A facility failed to assess and obtain consent for the use of physical restraints for a resident with dementia and high fall risk. The resident was observed in a tilt-in-space wheelchair and a low bed positioned against a wall, without documented assessment or consent. Staff confirmed these items could be used as restraints and should have been assessed and consented to prior to use.
A facility failed to transmit the MDS for a resident to CMS within the required timeframe. The resident was admitted and later discharged, with both the Medicare-5 Day MDS and discharge MDS completed but not submitted. Staff interviews revealed that MDS transmissions were conducted weekly, but the resident's assessments were missed due to an oversight. An audit was being conducted to address the issue.
A facility failed to accurately code the MDS for a resident who experienced an 11.72% weight loss over six months. Despite the resident's report of poor food taste and suspected weight loss, the MDS inaccurately documented no significant weight loss. Staff interviews confirmed the coding error.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific needs. One resident experienced multiple falls without updated interventions in their care plan, while another resident with cerebral palsy and contractures lacked a plan for managing their condition. Staff interviews confirmed these omissions did not meet expectations.
A resident's care plan was not revised to reflect changes in diagnoses and medication orders. The care plan inaccurately included a dementia diagnosis and an intervention for a discontinued nutritional supplement. Additionally, it failed to document the use of an anticoagulant medication and monitoring for side effects, leading to unmet care needs and inaccurate documentation.
The facility failed to meet professional standards of care for several residents, including not notifying providers when medications were held, not following pain medication parameters, and not documenting necessary interventions. These actions placed residents at risk for unmet care needs and diminished quality of life.
A facility failed to provide an adequate activity program for two residents, one with schizophrenia and another with a history of stroke and dementia. Both residents were observed without engagement in their preferred activities, such as TV or music, despite care plans indicating these needs. Staff interviews revealed a lack of consistent implementation and documentation of activities, leading to a deficiency in meeting the residents' needs for engagement and stimulation.
The facility failed to provide care according to professional standards and care plans for several residents. A resident wore a brace without a provider order, another was not repositioned regularly to prevent skin issues, a third did not have a required knee immobilizer applied, and a fourth did not receive necessary bowel management interventions. Staff interviews confirmed these lapses in care.
A facility failed to provide necessary services to maintain or improve the range of motion for a resident with contractures. The resident, diagnosed with cerebral palsy and other conditions, was observed with rigid fingers and reported no care was provided for their hands. The care plan lacked instructions for range of motion exercises, and staff confirmed the management of the resident's contractures was inadequate.
The facility failed to maintain the required length for a bathroom emergency call light cord, which was positioned too high in a shared bathroom, potentially delaying emergency response. Observations and interviews revealed that the cord was not reported for correction in the TELS system, and both the Maintenance Director and Administrator were unaware of the issue. This placed residents, including one with multiple health conditions, at risk of being unable to reach the call light in an emergency.
A facility failed to monitor and document a resident's bi-weekly weights as ordered, despite the resident's diagnoses of malnutrition, anxiety disorder, and depression. The resident expressed concerns about food quality and potential weight loss. Staff interviews confirmed the failure to adhere to provider orders, placing the resident at risk for medical complications.
A facility failed to obtain signed consent before administering Divalproex, a mood stabilizer, to a resident with major depression, altered mental status, and dementia. The resident, unable to communicate needs, received the medication for violent behavior without documented consent. Staff confirmed the lack of consent did not meet expectations.
A facility failed to obtain and periodically review an advanced directive (AD) for a resident with depression and anxiety disorder. Despite the resident's ability to communicate needs, there was no AD in place, and incorrect documentation indicated otherwise. Interviews with staff revealed a lack of awareness and documentation regarding the resident's AD status, which did not meet facility expectations.
A long-term care facility failed to properly manage enteral nutrition for four residents, leading to significant health risks. One resident suffered aspiration pneumonia due to improper bed positioning and overfeeding, while another received thin liquids against physician orders. Additionally, there were issues with syringe labeling and head elevation during feeding for other residents, increasing the risk of adverse outcomes.
The facility failed to provide the required two-person assistance for transfers and ADLs for three residents, leading to a fall and traumatic brain injury for one resident. Despite care plans indicating the need for two-person assistance, documentation and interviews revealed inconsistencies, with only one staff member often providing assistance. This lack of adherence to care plans placed residents at risk for falls and injuries.
The facility failed to provide the required two-person assistance for three residents, leading to a fall and injury for one resident. Despite care plans indicating the need for two-person assistance, documentation and observations showed that only one staff member often provided care. This resulted in a resident rolling out of bed and sustaining a shoulder fracture, while other residents were also at risk due to inadequate assistance.
The facility failed to administer enteral nutrition according to provider orders for two residents, resulting in incomplete documentation and inconsistent monitoring of nutritional intake. Staff interviews confirmed the deficiencies in documentation and communication with providers.
The facility failed to provide pharmaceutical services for a resident, resulting in missed doses of a critical medication for pulmonary hypertension. Additionally, the facility did not consistently reconcile controlled medications in three medication carts, with multiple missing signatures in the controlled substance books, indicating improper documentation at shift changes.
The facility failed to consistently monitor behaviors and medication side effects for three residents, leading to potential risks of inadequate mental health support and increased psychotropic use. Staff acknowledged gaps in behavior monitoring records and inaccurate documentation.
The facility failed to maintain consistent medication refrigerator temperature logs in two medication rooms, with incomplete entries on multiple dates, risking the efficacy of stored medications, including vaccines.
The facility failed to maintain a call light system that allowed residents to call for help from the floor of the bathroom in two hallways. Observations showed that the call light strings in several rooms were too short to be reached if a resident was laying on the floor. The Maintenance Director and Administrator confirmed the issue, acknowledging that call lights should be accessible.
The facility failed to maintain a homelike environment in three of four halls, with observations showing exposed light bulbs, damaged drywall, and missing vent covers in several rooms. Interviews with staff confirmed that these issues should have been addressed but were not.
The facility failed to address a resident's grievance timely. A resident with anxiety, depression, PTSD, and renal insufficiency reported that their roommate's loud iPad was disturbing them and suggested providing headphones. Despite reporting this concern multiple times, no grievance was generated, and the issue remained unresolved. The Grievance Official was unaware of the concern, and the DON confirmed that a grievance form should have been filled out.
The facility failed to accurately assess two residents, leading to inaccuracies in their care planning. One resident's MDS incorrectly indicated insulin injections, while another resident's MDS failed to document a chronic stage IV decubitus ulcer. These errors were confirmed by staff and placed the residents at risk of not receiving necessary care.
The facility failed to follow medication orders for a resident with multiple diagnoses, administering hydralazine despite low systolic blood pressure. Additionally, the facility did not provide a psychiatry referral for another resident with significant behavioral issues, despite a provider's recommendation.
The facility failed to monitor and document bowel movements and implement the bowel program for two residents, leading to extended periods without documented BMs and lack of necessary bowel medications, contrary to the facility's bowel care protocol.
The facility failed to monitor and accurately document fluid intake for a resident on fluid restrictions due to dialysis. Despite clear orders, there was inconsistent documentation, and the resident had easy access to a water pitcher, leading to potential overconsumption. Staff interviews revealed confusion and lack of adherence to the prescribed fluid restrictions.
The facility failed to provide non-pharmacological interventions before administering pain medications to a resident with chronic pain syndrome and anxiety disorder. Medication administration records showed multiple instances where pain medications were given without the required documentation of non-pharmacological interventions, contrary to the resident's care plan.
The facility failed to provide written notification of the reason for transfer or discharge to three residents reviewed for hospitalization. Notifications were made verbally without any written documentation, placing the residents at risk for diminished protection from inappropriate discharges.
The facility failed to provide bed hold notices in writing at the time of hospital transfer or within 24 hours for two residents. One resident was transported due to chest pain, and another was discharged with a return anticipated, but neither received the required bed hold notice. Staff confirmed the oversight, which placed residents at risk for lack of knowledge regarding their bed hold rights.
Failure to Assess and Monitor Wound Leading to Deterioration
Penalty
Summary
The facility failed to ensure that a wound was fully assessed on admission and monitored weekly as ordered for a resident admitted with a lower leg wound. Upon admission, the nursing documentation noted the presence of a skin tear and an open wound, but did not include specific details such as the location, measurements, appearance, drainage, odor, dressing type, or pain assessment. The facility's policy required a comprehensive skin evaluation and weekly wound documentation, including measurements and progress, but these were not completed as required. There was a gap of ten days after admission before the first wound measurement was documented, and subsequent weekly wound evaluations were inconsistent, with missing daily skilled notes and measurements. The resident, who was cognitively impaired and required assistance with activities of daily living, was admitted for skilled nursing care and wound healing. Over the course of their stay, wound documentation indicated the presence of necrosis, slough, and eventually exposed tendon, with purulent drainage and odor developing over time. Despite these changes, documentation of wound progression and communication with providers was inconsistent. Staff interviews revealed that wound care training was informal, and the wound nurse learned procedures from the previous nurse and external wound clinic staff. The DON acknowledged that wound measurements and daily skilled notes were not consistently completed, and that wound assessments were not always accurate or thorough. Concerns about the resident's wound were raised by the care team, the resident's representative, and staff, particularly when the wound developed an odor and exposed tendon. Despite these concerns, there was a delay in escalating care and obtaining appropriate provider evaluation. Eventually, the resident was sent to the hospital, where they were diagnosed with necrotizing fasciitis and required emergent surgical debridement. The lack of timely and thorough wound assessment, documentation, and monitoring contributed to the deterioration of the resident's condition.
Failure to Provide Required Medical Equipment at Discharge
Penalty
Summary
The facility failed to develop and implement a comprehensive discharge plan that addressed all of a resident's needs prior to discharge. Specifically, a resident with a diagnosis of sleep apnea, who required nightly use of a CPAP device and a shower chair, was discharged to an Adult Family Home without these essential items. The resident's records documented consistent use of the CPAP device during their stay, and orders were in place for both the CPAP and a shower chair. However, the discharge summary and plan did not include arrangements for these items, and no orders were made to ensure their availability upon discharge. Interviews with facility staff revealed a lack of coordination and communication regarding the ordering of necessary durable medical equipment. The social services director acknowledged that the order for the shower chair was missed and believed nursing was responsible for ordering the CPAP, but neither item was provided at discharge. The resident care manager was aware that the equipment did not accompany the resident but was unclear about the reasons. The facility's policy required interdisciplinary collaboration to identify and arrange for discharge needs, but this process was not followed, resulting in the resident being discharged without critical equipment.
Inaccurate PASARR Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate completion of Pre-Admission Screening and Resident Review (PASARR) assessments for four out of five sampled residents, which placed them at risk for unidentified mental health care needs. Resident 5, who was readmitted with Alzheimer's, depression, and a psychotic disorder, had a Level I PASARR completed that did not indicate the need for a Level II evaluation, despite having serious mental illness/intellectual disability (SMI/ID) conditions. Staff G, the Social Service Director, was unaware of the need to forward the Level I PASARR to the Level II evaluator. Similarly, Resident 28, with anxiety disorder, depression, and a psychotic disorder, had a Level I PASARR that showed serious mental illness indicators but was not referred for a Level II evaluation. Resident 38, admitted with dementia, major depression, and bipolar disorder, was using antipsychotics and antidepressants but was not identified as needing a Level II PASARR referral. Resident 66, with major depression, altered mental status, and dementia, had no Level I PASARR form in the record. Staff G stated that PASARRs were to be completed prior to admission and reviewed for accuracy, but this was not done for Residents 38 and 66. Staff A, the Administrator, acknowledged that the lack of accurate PASARR forms did not meet expectations.
Failure to Provide Individualized Therapeutic Diet
Penalty
Summary
The facility failed to provide food in an individualized manner for Resident 23, who was on a therapeutic diet requiring easy to chew foods. Resident 23, diagnosed with schizophrenia, epilepsy, and psychosis, was at risk of aspiration and had a provider's order for a regular easy to chew texture diet. However, during observations, Resident 23 was served meals that did not meet these dietary requirements. On one occasion, Resident 23 received a large piece of unaltered fried chicken, and on another, a country fried steak, both of which were not easy to chew as required by the resident's diet order. Interviews with facility staff, including a Registered Dietician and the Administrator, confirmed that the meals provided to Resident 23 did not align with the prescribed diet. The Registered Dietician acknowledged that the fried chicken and country fried steak were regular textures and not suitable for an easy to chew diet. The Administrator stated that diet orders were supposed to be followed as per the provider's instructions, and the failure to do so did not meet the facility's expectations. This deficiency placed Resident 23 at risk of choking and diminished their quality of life.
Sanitation and Hand Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which placed residents at risk of foodborne illness. Observations revealed that the kitchen walk-in refrigerator contained personal staff items, such as energy water drinks and a coffee canned drink, which were not supposed to be stored with facility food items. Additionally, an extra-large fountain drink with a straw was found in a different area of the refrigerator. Staff Y, a Registered Dietician, confirmed that these items were likely staff belongings and should not have been stored in the facility's refrigerator. Furthermore, a preparation table behind the tray line contained a disposable coffee cup, and a shelf underneath the tray line had a disposable cup with a lid and a fork, which were identified as staff items by Staff X, the Dietary Services Manager. The report also highlighted improper hand hygiene practices among the dietary staff. Staff X and Staff V were observed turning off the water with bare hands after performing hand hygiene, which is against the expected protocol. Additionally, Staff W, a Dietary Aide, did not perform hand hygiene after retrieving a milk glass that had dropped on the ground. Staff X acknowledged that staff should use a paper towel to turn off the water and perform hand hygiene after picking up items from the floor. The facility's Administrator, Staff A, confirmed that the storage of staff items with facility food and the observed hand hygiene practices did not meet the facility's expectations.
Inadequate PPE Use and Infection Control Data Tracking
Penalty
Summary
The facility failed to ensure proper fit and use of personal protective equipment (PPE) as required for transmission-based precautions (TBP) for three nursing staff members across three different halls. Observations revealed that Staff N, O, and P entered rooms with posted contact or droplet/contact precautions without donning the necessary PPE, such as gloves, gowns, masks, and eye protection. Additionally, an aerosol precautions sign indicated that the door should remain closed and that a fit-tested N95 respirator should be worn, but there was no documentation of fit testing for several staff members, including Staff R, S, T, and U. Interviews with staff confirmed the expectation that PPE should be used according to posted signs, but documentation of fit testing was missing. The facility also failed to complete the ongoing collection and analysis of infection control data, including the identification of organisms present in the facility for three consecutive months. The infection preventionist, Staff Q, had only recently started in the position and had to create line listings and maps for January and February 2025, but none were created for December 2024. The facility's policy required daily updates to the infection control line listing, including the type and site of infection and identified organisms, but this was not adhered to. Interviews with staff confirmed the expectation for daily tracking of infections, but the necessary documentation was not maintained.
Failure to Administer Vaccines to Residents
Penalty
Summary
The facility failed to offer and provide influenza and/or pneumococcal vaccines to three residents, which was identified during a review of their electronic health records (EHR). Resident 56, who had a history of skin infection and asthma, was offered the influenza vaccine and accepted it, but there was no documentation that the vaccine was administered. Resident 37, diagnosed with hemiplegia and a brain bleed, had no documentation in their EHR indicating that they were offered, educated about, or provided the pneumococcal vaccine. Resident 48, with respiratory failure and diabetes, consented to receive the pneumococcal vaccine, but there was no record of the vaccine being administered. Interviews with facility staff revealed that the expected protocol was to offer and administer these vaccines upon admission and annually. However, this protocol was not followed for the three residents in question. Staff Q, a Registered Nurse/Infection Preventionist, acknowledged that the vaccines should have been offered and administered, but this did not occur. Staff C, a Corporate Registered Nurse, confirmed the expectation that staff should educate, offer, and administer the vaccines as part of the facility's procedures.
Failure to Administer COVID-19 Vaccines to Residents
Penalty
Summary
The facility failed to offer and provide COVID-19 vaccines to two residents, identified as Residents 28 and 37, which was identified during a review of their electronic health records (EHR). Resident 28, who was admitted with a diagnosis of diabetes, had consented to receive the COVID-19 vaccine on 10/31/2024, but there was no documentation in the EHR indicating that the vaccine was administered. Resident 37, admitted with diagnoses including hemiplegia and a brain bleed, had no documentation in the EHR showing that the COVID-19 vaccine was offered, provided, or declined. Interviews with staff revealed that the facility's protocol required offering the COVID-19 vaccine upon admission and annually, obtaining an order, and administering it if consented. However, this protocol was not followed for Residents 28 and 37, as confirmed by Staff Q, a Registered Nurse/Infection Preventionist, and Staff C, a Corporate Registered Nurse.
Deficiency in CNA Training and Performance Evaluation
Penalty
Summary
The facility failed to ensure that certified nurse assistants (CNAs) received the required 12 hours of in-service training per year, including mandatory dementia management training. This deficiency was identified through interviews and record reviews, which revealed that the facility did not maintain oversight of the CNAs' training and performance evaluations. Staff CC, a CNA, reported not remembering any recent performance evaluations or specific training requirements. Additionally, Staff Q, a Registered Nurse and Staff Development Coordinator, confirmed the lack of access to computer training records, making it impossible to verify if the required training hours were met. Further interviews highlighted the facility's inability to provide documentation of the CNAs' training and performance reviews. Staff C, a Corporate Registered Nurse, expressed the expectation that staff competencies and performance reviews should be readily available. Staff DD, a Pay Benefit Coordinator, also noted their lack of access to the training records. The facility's Administrator, Staff A, acknowledged that the records should be accessible and that necessary training should be completed to ensure staff competency in resident care. The absence of documentation and oversight placed residents at risk for potential negative outcomes and unmet care needs.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to assist three residents with activities of daily living (ADL), specifically in the areas of nail care and grooming. Resident 10, who has hemiplegia, diabetes, and deafness, was observed with long, yellowed nails despite having a care plan and provider's order for weekly diabetic nail care. Interviews with staff confirmed that Resident 10's ADL services did not meet expectations, as the resident's nails remained untrimmed. Resident 421, diagnosed with adult failure to thrive and requiring assistance with personal care, was observed in a state of neglect. The resident was seen with disheveled hair, improperly worn sneakers, and dark sediment under their fingernails. Despite being able to make needs known, staff did not offer assistance, and the resident's care plan indicated a need for partial physical assistance with various ADLs. Resident 425, who is dependent on staff for all care due to cerebral infarction, hemiplegia, and vascular dementia, was repeatedly observed with disheveled hair, dark sediment under fingernails, and a call light out of reach. The resident's care plan required one- or two-person assistance for all ADLs, yet observations showed a lack of timely and adequate care. Staff interviews confirmed the resident's dependency and the failure to provide necessary assistance as per the care plan.
Facility Fails to Maintain Homelike Environment and Dining Experience
Penalty
Summary
The facility failed to maintain a homelike environment in several areas, as observed on multiple occasions. In the shared bathroom for certain rooms, the doorway frame and walls had gouges and peeling paint, which were not reported in the TELS system for maintenance. Staff J, the Maintenance Director, acknowledged the oversight and stated that the issues should have been reported. Additionally, room observations revealed wall gouges, peeling paint, and makeshift solutions like a plastic bag used as a light cord, indicating a lack of timely maintenance. Staff A, the Administrator, was unaware of these unreported issues, which did not meet the facility's expectations. Furthermore, the facility failed to provide a homelike dining experience by using plastic utensils instead of metal silverware on one of the halls. Resident 46 noted the occasional use of plastic silverware, and Staff W, a Dietary Aide, confirmed the use of plastic utensils due to a shortage of metal ones. Staff X, the Dietary Services Manager, admitted that the facility did not maintain enough metal silverware for all residents, which could affect the homelike environment. Staff A, the Administrator, acknowledged that using plastic silverware did not meet the facility's expectations for a homelike dining experience.
Failure to Implement Pharmacist Recommendations for Medication Management
Penalty
Summary
The facility failed to act on the consultant pharmacist's medication regimen review (MRR) recommendations for two residents, leading to a deficiency in medication management. For Resident 24, the pharmacist recommended clarifying the administration parameters for diclofenac gel and discontinuing rivaroxaban in favor of apixaban due to a higher risk of side effects. These recommendations were not implemented, and the physician/prescriber response section on the MRR form was left blank. Staff interviews revealed that the pharmacy recommendations for March 2025 were received late and had not been addressed in a timely manner. For Resident 4, the facility did not review the pharmacist's recommendation to decrease certain medications until over a month later, which did not meet the expected timeline for review. The January 2025 recommendation was also not addressed. Staff interviews confirmed that the facility struggled to review MRRs within the expected 72-hour timeframe, leading to delays in addressing the pharmacist's recommendations. These inactions placed the residents at risk for adverse side effects and medical complications.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, which was observed in two of four medication carts and one of two medication rooms. Specifically, the temperature log for the medication refrigerator in the 100/200 medication room was missing documentation for 22 out of 26 opportunities in March 2025. This refrigerator stored vaccinations, medications, and emergency medication supplies. Staff E, an LPN, confirmed that licensed nurses were responsible for checking and documenting the refrigerator temperature twice daily. Additionally, the 100 hall medication cart contained several medications that were not dated when opened, including eye drops, artificial tears, and nasal spray. There were also expired containers of Fluconazole. The 300 hall medication cart had an insulin pen that was past its expiration date. Staff interviews revealed a lack of awareness regarding the expiration of medications and the requirement to date multi-use medications when opened. The Corporate Registered Nurse acknowledged that the expired and undated medications, as well as the lack of temperature documentation, did not meet the facility's expectations.
Failure to Provide Prompt Dental Services for Residents
Penalty
Summary
The facility failed to provide prompt dental services for two residents, leading to a deficiency in care. Resident 28, who was readmitted with diagnoses including malnutrition and diabetes, was unable to wear dentures due to poor fit and discomfort. Despite a referral for denture adjustment on 01/23/2025, Resident 28 was not seen by the dentist during their visit on 03/25/2025. Staff interviews revealed that the resident's need for dental care was known, but they were not included on the list for the dentist's visit, and the administrator acknowledged the mishandling of the resident's dental care. Resident 10, admitted with hemiplegia, diabetes, and deafness, also experienced a lapse in dental care. A dental examination on 05/22/2024 recommended x-rays, evaluation, and tooth extraction, but there was no follow-up documented. The care plan noted missing and decayed teeth, but the recommendations from the examination were not addressed. Staff interviews confirmed that the family should have been contacted for follow-up, but this did not occur, and the corporate RN acknowledged the failure to meet expectations in following up on dental recommendations.
Failure to Assess and Obtain Consent for Use of Physical Restraints
Penalty
Summary
The facility failed to conduct an assessment and obtain signed consent for the use of physical restraints for a resident, identified as Resident 38. This resident was admitted with diagnoses including dementia, dislocation of an internal left hip prosthesis, and depression. The resident was assessed as a high fall risk and required staff assistance for mobility, with an inability to communicate needs. Observations revealed that the resident was placed in a tilt-in-space wheelchair with the upper body reclined and in a low bed positioned next to a wall, which restricted access and movement. The care plan for Resident 38 included interventions for fall risk, such as placing the bed against the wall and keeping it in the lowest position. However, there was no documented assessment or consent for the use of the low bed, bed by the wall, and tilt-in-space wheelchair. Interviews with facility staff, including a Licensed Practical Nurse and a Corporate Registered Nurse, confirmed that these items could be used as restraints and should have been assessed and consented to prior to use. The lack of assessment and consent did not meet the facility's expectations, as per the staff interviews.
Failure to Transmit MDS Timely for a Resident
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) for one resident, identified as Resident 53, to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe. Resident 53 was admitted to the facility and later discharged, with both the Medicare-5 Day MDS and the discharge MDS completed but not submitted to CMS. Interviews with facility staff revealed that MDS transmissions were conducted weekly, but Resident 53's assessments were not submitted due to an oversight. Staff members, including a Registered Nurse/MDS Nurse, a Regional Reimbursement Analyst, and a Corporate Registered Nurse, acknowledged the lapse and indicated that an audit was being conducted to address the issue. This failure to ensure timely submission of MDS assessments placed the resident at risk for unmet care needs and diminished quality of life.
Inaccurate MDS Coding for Resident's Weight Loss
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected a significant weight loss for Resident 24, who experienced a weight loss of 11.72% over six months. Resident 24, who was readmitted to the facility with diagnoses including malnutrition, anxiety disorder, and depression, reported that the food did not taste good and suspected weight loss due to insufficient eating. The electronic health record (EHR) documented the resident's weight as 124.6 pounds on August 7, 2024, and 110.0 pounds on February 11, 2025. However, the quarterly MDS inaccurately documented no or unknown weight loss of 10% or more in the last six months. Staff interviews confirmed the MDS was inaccurately coded, failing to capture the significant weight loss.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific needs. Resident 10, who was admitted with hemiplegia, diabetes, and deafness, experienced multiple falls between October and December 2024. Although new fall interventions were developed after each incident, these were not incorporated into the resident's care plan. Interviews with facility staff confirmed that the absence of a fall prevention care plan did not meet expectations, as staff relied on care plans to guide interventions. Resident 7, admitted with cerebral palsy, anxiety, depression, and muscle contractures, did not have a care plan that included interventions for managing contractures or a range of motion plan. Observations revealed that the resident's fingers were rigid and curled, and the resident reported that staff did not address their hand condition. Despite having worked with occupational therapy and having hand splints, the resident's refusal to use them was not documented in the care plan. Staff interviews confirmed that the lack of a comprehensive care plan for maintaining the resident's functions did not meet expectations.
Care Plan Revision Deficiency for a Resident
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised and accurately reflected the resident's care needs. Resident 24, who was readmitted with diagnoses including anxiety disorder, depression, psychotic disorder, and malnutrition, had care plans that inaccurately included a diagnosis of dementia. Despite the removal of the dementia diagnosis by a mental health professional, the care plans for antipsychotic medication and nutritional problems continued to reference dementia. Additionally, the care plan included an intervention for an oral nutritional supplement that was discontinued, yet the care plan was not updated to reflect this change. Furthermore, the care plan did not document the use of an anticoagulant medication prescribed for atrial fibrillation, nor did it include interventions to monitor for side effects. Interviews with staff revealed that the care plans were not revised as needed with changes in the resident's condition or medication orders, which did not meet the facility's expectations. This oversight placed the resident at risk for unmet care needs and inaccurate care documentation.
Deficiencies in Professional Standards of Care
Penalty
Summary
The facility failed to meet professional standards of care for several residents, leading to deficiencies in care and services. For Resident 5, the facility did not notify the provider when Lantus insulin was held due to low blood glucose levels on multiple occasions. Despite the expectation that the provider should be contacted and documentation should be made in the electronic health record (EHR), this was not done, placing the resident at risk for unmanaged diabetes. Resident 10 was prescribed two PRN pain medications but did not have parameters for acetaminophen administration or orders for nonpharmacological interventions (NPI) before administering pain medications. The resident received oxycodone outside the prescribed pain parameters and without being offered NPI, which did not meet the facility's expectations. Similarly, Resident 24 received oxycodone without documented respiratory rate checks or NPI, and there was no monitoring for side effects of anticoagulant medication, which was also not documented as expected. Resident 59 was placed on one-on-one monitoring due to new behaviors and suicidal statements, but alert charting was not completed every shift, and the care plan was not updated. Resident 19's medications were not held as directed when the pulse was below 60, and the provider was not notified, contrary to the provider's orders. These failures in following provider parameters and documenting care placed residents at risk for unmet care needs and diminished quality of life.
Failure to Provide Adequate Activity Program for Residents
Penalty
Summary
The facility failed to provide an adequate activity program for two residents, leading to a deficiency in meeting their needs for engagement and stimulation. Resident 3, who has schizophrenia, diabetes, and epilepsy, was observed multiple times without any activities such as TV or music, despite their care plan indicating a preference for these activities. The resident's care plan also included one-on-one activities like listening to music and manicures, but records showed only one group and one one-on-one activity in a 30-day period. Interviews with staff revealed that both activity and nursing staff were responsible for ensuring the resident's TV was on, but this was not consistently done. Similarly, Resident 425, who has a history of stroke, hemiplegia, and vascular dementia, was observed repeatedly in bed without any TV or music playing, and no activity staff present. The resident's care plan required staff to provide social and one-on-one visits, but there were no progress notes documenting any activities for February and March 2025. The Activity Director confirmed that activities should be documented if there was any participation or attempts, indicating a lack of adherence to the care plan and documentation requirements.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and person-centered care plans. For Resident 37, there was no provider order or care plan documentation for the application of a brace/splint on the right lower leg/foot, despite observations of the resident wearing the device. Staff interviews revealed that the brace was applied without a current order, indicating a lapse in documentation and adherence to care protocols. Resident 425, who was dependent on staff for all care, was not repositioned every two hours as required to prevent skin integrity issues. Observations showed the resident remained in the same position for extended periods, contrary to the care plan and staff expectations. Interviews with staff confirmed the expectation for regular repositioning, highlighting a failure to implement necessary care interventions. Resident 38 did not have a knee immobilizer applied as per the provider's order, despite being at high fall risk and requiring the device to minimize knee movement. Observations confirmed the absence of the immobilizer, and staff interviews acknowledged the oversight. Additionally, Resident 66 did not receive necessary bowel management interventions despite a lack of documented bowel movements for six days. The facility failed to administer prescribed medications for constipation, as confirmed by staff interviews, indicating a neglect in following bowel protocols.
Failure to Provide Range of Motion Services for Resident with Contractures
Penalty
Summary
The facility failed to provide appropriate services to maintain or improve the range of motion for a resident with contractures. Resident 7, who was admitted with cerebral palsy, anxiety, depression, and muscle contractures, was observed with rigid fingers curled inward, indicating a lack of intervention for their condition. The resident communicated that staff did not provide any care for their hands. A review of the care plan revealed no instructions for performing range of motion exercises for the resident's hands. Interviews with the Director of Rehabilitation and a Corporate Registered Nurse confirmed that the resident's contracture management did not meet expectations, as services to maintain their functions were not adequately set up.
Emergency Call Light Cord Length Deficiency
Penalty
Summary
The facility failed to ensure that the bathroom emergency call light cord in one of the hallways was within the required length of no higher than six inches from the floor. Observations on multiple occasions revealed that the emergency call cord in the shared bathroom for certain rooms was positioned at the handlebar attached to the wall, which was greater than six inches from the floor. This deficiency was identified during interviews and observations with residents and staff. Resident 28, who had multiple diagnoses including high blood pressure, chronic kidney disease, dementia, and osteoarthritis, did not use the bathroom at the time of the interview. Resident 17, who was independent with transfers, walking, and toileting, used the bathroom but did not notice the short emergency call cord. Staff interviews revealed that the Maintenance Director, Staff J, acknowledged the emergency call light cords should hang approximately two inches from the floor to ensure accessibility in case of a fall. However, the short cord in the shared bathroom was not reported in the TELS system, which is used for work orders. The Administrator, Staff A, was also unaware of the issue and confirmed that the situation did not meet the facility's expectations. The failure to report and address the short emergency call cord placed residents at risk of being unable to reach the call light in an emergency, potentially delaying response and affecting their quality of life.
Failure to Monitor and Document Resident Weights
Penalty
Summary
The facility failed to monitor and consistently document the weights of a resident, identified as Resident 24, as per the provider's orders. Resident 24, who was readmitted to the facility with diagnoses including malnutrition, anxiety disorder, and depression, was ordered to have bi-weekly weights taken due to concerns about weight loss. However, a review of the electronic health record (EHR) revealed inconsistencies and omissions in the documentation of these weights. Specifically, the treatment administration records (TAR) for January, February, and March 2025 showed either missing initials or weights not documented in the weights tab, despite being marked as completed. Interviews with facility staff confirmed these documentation failures. Resident 24 expressed concerns about the taste of the food and suspected weight loss due to inadequate food intake. Staff H, a Licensed Practical Nurse/Resident Care Manager, acknowledged that the bi-weekly weights were not documented as required, and Staff C, a Corporate Registered Nurse, confirmed that the nurses did not follow the provider's orders. This lack of adherence to the prescribed monitoring placed the resident at risk for medical complications and unmet needs.
Failure to Obtain Consent for Mood-Altering Medication
Penalty
Summary
The facility failed to obtain signed consent prior to administering mood-altering medication to a resident, identified as Resident 66, who was part of a sample of five residents reviewed for unnecessary medication use. This deficiency was identified through interviews and record reviews. Resident 66, who was admitted with diagnoses including major depression, altered mental status, and dementia, was unable to communicate needs. The electronic health record (EHR) showed an order for Divalproex, a mood stabilizer, to be administered twice daily starting from February 28, 2025, and the medication was given from March 1 to March 26, 2025, for violent behavior. However, there was no consent documented in the EHR for the use of Divalproex. During interviews, both a Registered Nurse/Resident Care Manager and a Corporate Registered Nurse confirmed the absence of consent and acknowledged that this did not meet expectations.
Failure to Obtain and Review Advanced Directive for a Resident
Penalty
Summary
The facility failed to obtain and periodically review an advanced directive (AD) for Resident 24, who was admitted with diagnoses including depression and anxiety disorder. Despite being able to make their needs known, Resident 24 did not have an AD in place and declined assistance in formulating one. The Comprehensive Plan of Care Review form indicated that Resident 24 did not wish to establish an AD, and the care plan intervention required quarterly reviews of the AD status. However, documentation from care conferences on two occasions incorrectly marked that an AD was in place, and there was no documented discussion or review of the AD. Interviews with facility staff revealed that the Social Services Director acknowledged the lack of documentation regarding AD discussions during care conferences, which did not meet the facility's expectations. The Administrator confirmed that new residents or their responsible parties were asked to provide or establish an AD upon admission and that ADs were to be reviewed quarterly and as needed. However, the Administrator was unaware that Resident 24 did not have an AD or that there was no documented quarterly review, which also did not meet the facility's expectations.
Improper Enteral Nutrition Management in LTC Facility
Penalty
Summary
The facility failed to ensure proper administration of enteral nutrition for four residents, leading to significant health risks and harm. Resident 1, who was dependent on staff for bed mobility and received more than 51% of their nutrition via a feeding tube, was found in respiratory distress due to improper positioning and overfeeding. The resident was positioned at a 10-degree angle while receiving tube feeding, contrary to the facility's policy of maintaining a 30-45 degree angle. This resulted in aspiration pneumonia, requiring hospitalization and subsequent discharge to hospice care. Resident 2, who was alert and oriented, also experienced issues with tube feeding management. The resident was observed sliding down in bed, which compromised the intended head elevation during feeding. Additionally, there were discrepancies in the labeling and dating of feeding syringes, and the resident was given thin liquids despite being on a thickened liquid diet, contrary to physician orders. Staff failed to follow proper procedures for syringe replacement and fluid administration, increasing the risk of aspiration. Residents 3 and 4 also faced deficiencies in tube feeding management. Resident 3's care plan required head elevation during feeding, but there was no signage to remind staff of this requirement. Similarly, Resident 4's care plan included head elevation during feeding, but no signs were posted to ensure compliance. These oversights in care planning and execution put residents at risk for inadequate nutrition, dehydration, and other adverse outcomes.
Failure to Provide Adequate Supervision and Assistance in Transfers
Penalty
Summary
The facility failed to provide the required care planned supervision to prevent accidents and falls for three residents who required two-person assistance with transfers. Resident 1, who required substantial to maximal assistance, experienced a fall resulting in a traumatic brain injury after being transferred by a single staff member. The care plan for Resident 1 clearly indicated the need for two-person assistance, but documentation showed that only one person assisted with transfers and toileting on multiple occasions. Staff C, who was involved in the incident, was unaware of the two-person requirement, and the room lacked the peace sign indicator for such assistance. Resident 2 was assessed as dependent on staff for toileting hygiene and required substantial assistance for transfers. Despite having a peace sign posted in their room, indicating the need for two-person assistance, documentation and interviews revealed inconsistencies in the assistance provided. On several occasions, only one staff member assisted with transfers, contrary to the care plan and Kardex instructions. Staff members provided conflicting accounts of the assistance provided, with some indicating attempts to follow the two-person protocol for safety. Resident 3 also required two-person assistance for bed mobility and transfers, as per their care plan. However, nursing care notes and documentation indicated that only one staff member assisted with full ADLs, transfers, and toileting. Despite the presence of a peace sign in the room, Resident 3 reported that assistance varied depending on the shift, with only one assistant available at times. These failures in adhering to care plans and ensuring adequate supervision placed residents at risk for falls and injuries.
Failure to Provide Required Two-Person Assistance Leads to Resident Injuries
Penalty
Summary
The facility failed to provide the required care-planned supervision to prevent accidents and falls for three residents who required two-person assistance with transfers. Resident 1, who was alert and oriented but dependent on staff for repositioning and transfers, experienced a fall resulting in a shoulder fracture when a single staff member attempted to provide incontinence care without the required assistance. Despite the care plan indicating a need for two-person assistance, documentation showed that only one person assisted Resident 1 on multiple occasions, leading to the incident where the resident rolled out of bed and sustained an injury. Resident 2, assessed with moderate cognitive impairment and requiring substantial assistance for transfers, was also found to have been assisted by only one staff member on several occasions. The care plan specified a two-person moderate assist for transfers, but documentation revealed that this was not consistently followed. During an observation, Resident 2 was unable to recall how many staff assisted them, and a nursing assistant admitted to providing assistance alone, unaware of the two-person requirement. Similarly, Resident 3, who was dependent on staff for rolling and required a mechanical lift for transfers, was documented as receiving only one-person assistance for care in bed. Observations confirmed that only one staff member was present during care, despite the care plan's requirement for two-person assistance to prevent falls. These failures in adhering to care plans placed residents at risk for falls, injury, and diminished quality of life.
Failure to Administer Enteral Nutrition According to Provider Orders
Penalty
Summary
The facility failed to ensure enteral nutrition was administered according to provider orders and professional standards of practice for two residents. Resident 11 had orders for enteral feeding four times a day, totaling 1800 ml daily. However, the treatment administration record (TAR) showed multiple instances of incomplete or incorrect documentation, with the resident receiving the full prescribed amount only once in 23 days. Staff interviews confirmed the lack of consistent documentation and communication with the provider regarding the resident's nutrition intake. Resident 24 had orders for continuous enteral feeding and water flushes, but the April 2024 TAR showed incomplete documentation of the amounts provided. There were instances where the enteral feed totals and water flushes were not recorded as required. Staff interviews revealed that the documentation did not meet expectations, and the necessary monitoring and recording of nutritional intake were not consistently performed. Both residents were at risk for inadequate nutrition and hydration due to these deficiencies.
Failure to Provide Pharmaceutical Services and Reconcile Controlled Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident 55, who had diagnoses including heart failure and high blood pressure. The resident's medication, Macitentan, used to treat pulmonary hypertension, was not consistently available or administered. Documentation showed that the medication was not provided on numerous occasions from January 2024 through April 2024, and there was inconsistent documentation regarding the reasons for this and whether the provider was notified. Staff interviews revealed that the pharmacy did not carry the medication, and there was a lack of documentation showing attempts to obtain it or to seek an alternative from the provider. Additionally, the facility failed to consistently reconcile controlled medications in three medication carts. Observations and interviews showed that the controlled substance books for the 200, 400, and 300 medication carts had multiple missing signatures, indicating that the required counts were not properly documented at shift changes. Staff admitted to forgetting to sign the books, and the Director of Nursing Services confirmed that this did not meet the facility's expectations. These deficiencies placed Resident 55 at risk for medical complications due to the lack of timely medication administration and placed other residents at risk for misappropriation of their medications due to the failure to properly reconcile controlled substances. The facility's actions and inactions in these areas did not meet regulatory requirements and standards for pharmaceutical services and medication management.
Failure to Monitor Behaviors and Medication Side Effects
Penalty
Summary
The facility failed to consistently monitor residents' behaviors and medication side effects for three residents, leading to potential risks of inadequate mental health support and increased psychotropic use. Resident 5, diagnosed with Alzheimer's disease and psychotic disorder, had missing entries in their behavior monitoring record for four out of 24 days in April 2024. Staff acknowledged that this did not meet the facility's expectations for monitoring behaviors and medication side effects. Resident 33, with diagnoses including anxiety disorder, depression, bipolar disorder, and psychotic disorder, had gaps in their behavior monitoring record for several days in April 2024. Despite receiving antipsychotic and antidepressant medications, the behavior monitoring records showed blanks on specific dates, which staff confirmed should not have occurred. The Director of Nursing Services stated that the documentation did not meet the facility's expectations. Resident 184, admitted with multiple diagnoses including muscle weakness, malnutrition, depression, and anxiety, exhibited significant behavioral issues such as yelling, refusing care, and paranoia. Despite these behaviors being documented in clinical progress notes, the behavior monitoring records contained inaccurate entries that did not align with the resident's observed behaviors. Staff indicated that the behavior monitoring was supposed to be tracked accurately and that the initial preadmission screening and resident review should have been updated to address the resident's increasing behavioral issues.
Inconsistent Medication Refrigerator Temperature Logs
Penalty
Summary
The facility failed to consistently maintain the medication refrigerator temperature logs in two medication rooms, specifically the 100/200 hall and the 300/400 hall. Observations revealed that the temperature logs for April 2024 had inconsistent documentation, with either blanks or only one temperature logged on multiple dates. In the 100/200 hall medication room, the logs had incomplete entries on 11 out of 22 dates, while in the 300/400 hall medication room, the logs were incomplete on 18 out of 22 dates. Both rooms contained various liquid medications, including vaccines, which require consistent temperature monitoring to ensure their efficacy. Interviews with staff members confirmed the inconsistencies in the temperature logs. Staff H and Staff C, both Resident Care Managers/Licensed Practical Nurses, acknowledged the missing documentation and stated that the logs needed to be filled out twice a day. The Director of Nursing Services, Staff B, also confirmed that the expectation was for the temperature logs to be documented by both night and day shifts and kept in binders. Staff B noted that the logs for both medication rooms did not meet these expectations, with some temperatures logged too close together and missing entries, indicating a failure to adhere to proper medication storage protocols.
Inaccessible Bathroom Call Lights
Penalty
Summary
The facility failed to maintain a call light system that allowed residents to call for help from the floor of the bathroom in two of four hallways (Halls 200 and 400). Observations on 04/22/2024 and 04/26/2024 showed that the call light strings in the bathrooms of several rooms were too short and could not be reached if a resident was laying on the floor. During interviews, the Maintenance Director confirmed that the call light strings in specific rooms were too short, and the Administrator acknowledged that call lights should be accessible but was unsure if bathroom call lights were included in the audits. This deficiency placed residents at risk of not being able to call for assistance in case of a fall or injury.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment in resident areas for three of four halls (Halls 100, 200, and 400). Observations on multiple dates showed that light fixtures above the bathroom sinks in several rooms did not have covers, leaving light bulbs exposed. Additionally, there were deep gouges with flaking drywall in some rooms, and damaged drywall in another room was covered with yellow and blue tape. A bathroom ceiling vent cover was also missing in one room, exposing the inside of the vent. These deficiencies were observed over several days, indicating a lack of timely maintenance and repair in the facility. During interviews, the Maintenance Director and the Administrator acknowledged that staff were expected to report damage to the maintenance department for repair and that the maintenance department conducted audits to identify needed repairs. Both staff members confirmed that light fixtures should have covers, wall damage should be repaired, and all vents should be covered. However, the observed deficiencies indicated that these expectations were not being met, leading to an environment that was not safe, clean, comfortable, or homelike for the residents.
Failure to Address Resident Grievance Timely
Penalty
Summary
The facility failed to have a system and timely resolution of a grievance for Resident 31, who was admitted with diagnoses of anxiety, depression, post-traumatic stress disorder, and renal insufficiency, and had intact cognitive functions. Resident 31 reported that their roommate's loud iPad was disturbing them and suggested providing headphones to the roommate. Despite reporting this concern to staff on multiple occasions, no grievance was generated, and the issue remained unresolved. Staff R, the Administer-in-Training/Grievance Official, was unaware of the concern, and Staff B, the Director of Nursing Services, confirmed that a grievance form should have been filled out when the resident voiced the concern.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to accurately assess two residents, leading to inaccuracies in their care planning. Resident 72's admission MDS indicated that the resident received insulin injections, despite the resident not having a provider's order for insulin and not receiving any insulin during their stay. This discrepancy was confirmed by both the resident and the staff, who acknowledged the error in the MDS entry. The Director of Nursing Services also confirmed that the MDS assessment was incorrect and needed modification. Resident 5's annual comprehensive MDS failed to accurately document a pressure ulcer, despite multiple records and observations indicating the presence of a chronic stage IV decubitus ulcer on the resident's lower back. The MDS was incorrectly coded as having no pressure ulcer, which was confirmed by the staff responsible for the MDS assessments. The Adult Registered Nurse Practitioner also confirmed the presence of a chronic ulcer. These inaccuracies in the MDS assessments placed the residents at risk of not receiving the necessary care and services to meet their needs.
Failure to Follow Medication Orders and Provide Psychiatry Referral
Penalty
Summary
The facility failed to ensure nursing staff followed provider's orders for medication administration for Resident 18, who was admitted with diagnoses including diabetes, stroke, chronic kidney disease, anxiety, and depression. Despite an order to hold hydralazine if the systolic blood pressure was less than 120, the medication was administered when the systolic blood pressure was below this threshold on multiple occasions in March and April 2024. The Director of Nursing Services confirmed that the medication should have been held under these circumstances. Additionally, the facility did not provide a psychiatry referral for Resident 184, who was admitted with multiple diagnoses including muscle weakness, malnutrition, depression, and anxiety. Despite a provider's recommendation for a psychiatry referral due to the resident's increased behavioral issues, no such referral was made. The resident exhibited significant behavioral symptoms, including yelling, refusal of care, and general anxiety, which were documented by nursing staff. The Social Services Director and Adult Registered Nurse Practitioner acknowledged the oversight in not placing the psychiatry referral order.
Failure to Monitor and Document Bowel Movements
Penalty
Summary
The facility failed to consistently monitor and document bowel movements (BM) and implement the bowel program for two residents, leading to potential risks for their health and quality of life. Resident 61, who had a history of lung disease, spine fracture, opioid abuse, and constipation, experienced multiple instances where BMs were not documented for extended periods. Despite having a care plan that required monitoring and administering bowel medications as needed, the facility did not follow through, resulting in gaps of up to nine days without a documented BM. The medication administration record showed that only one as-needed constipation medication was administered during these periods, contrary to the facility's bowel care protocol. Similarly, Resident 40, who was on hospice care with diagnoses including dysthymic disorder and a right leg fracture, also experienced significant lapses in BM documentation. The resident had no documented BM for six days and four days in separate instances, and no as-needed bowel medications were administered during these times. Interviews with staff revealed that there was an expectation to monitor the EHR dashboard for alerts and administer bowel medications as needed, but this protocol was not followed. The Director of Nursing Services confirmed that the resident should have had alerts and received bowel medications during the documented periods without BMs.
Failure to Monitor and Document Fluid Restrictions
Penalty
Summary
The facility failed to have a clear system in place to monitor and accurately document fluids consumed by Resident 24, who was on fluid restrictions due to dialysis. Despite the care plan and Kardex indicating a fluid restriction of 1200 ml per day, with 600 ml provided by dietary and 600 ml by nursing, there was no consistent documentation of fluid intake. The electronic health records showed instances of overconsumption and multiple dates with no recorded fluid intake, indicating a lack of adherence to the prescribed fluid restrictions. Observations revealed that Resident 24 had easy access to a water pitcher filled with water, and the resident was unaware of their fluid restrictions. Interviews with staff members, including a CNA and the Resident Care Manager, confirmed that there was confusion and inconsistency in documenting and monitoring fluid intake. The CNA was unaware of the fluid restrictions, and the Resident Care Manager acknowledged that there was no place to record fluids consumed or flushed with medication administration in the MAR and TAR. The Director of Nursing Services confirmed that the documentation of fluid intake did not meet expectations and that the resident should not have had a water pitcher in their room. The Director also noted that the facility's policy did not clearly include enteral feedings in the fluid restriction parameters, contributing to the lack of clarity and proper documentation. The deficiency placed Resident 24 at risk for medical complications and unmet needs due to the failure to implement and monitor fluid restrictions accurately.
Failure to Provide Non-Pharmacological Interventions Before Administering Pain Medication
Penalty
Summary
The facility failed to ensure freedom from unnecessary pain medication for one resident reviewed for unnecessary medication use. Specifically, the facility did not provide non-pharmacological interventions before administering as-needed pain medications, such as acetaminophen and oxycodone HCI, to Resident 33. The resident, who had chronic pain syndrome and anxiety disorder, was alert and able to communicate needs. Despite this, the medication administration records (MAR) from April 2024 showed multiple instances where pain medications were given without documenting any non-pharmacological interventions, contrary to the care plan initiated in April 2021. Interviews with staff revealed that non-pharmacological interventions should have been offered and documented before administering pain medications. Staff C, a Resident Care Manager/Licensed Practical Nurse, and Staff B, the Director of Nursing Services, both acknowledged that the documentation did not meet expectations. The MAR entries for acetaminophen and oxycodone HCI showed 'NA' instead of the required documentation of non-pharmacological interventions, indicating a failure to follow the prescribed care plan and facility protocols.
Failure to Provide Written Notification of Transfer/Discharge
Penalty
Summary
The facility failed to provide written notification of the reason for transfer or discharge to the resident or responsible party for three sampled residents reviewed for hospitalization. Resident 81 was discharged to the hospital on 01/21/2024 and readmitted to the facility on a later date, but there was no documentation of a written notice of transfer/discharge provided to the resident or responsible party. Staff E, the Social Service Director, admitted to being unaware of the requirement for written notices. Similarly, Resident 24 was discharged to the hospital on 06/10/2023 and 06/30/2023, with no written notices documented for either transfer. Staff B, the Director of Nursing Services, confirmed that notifications were made verbally without any written documentation. Resident 33 was discharged to the hospital on 10/29/2023 and readmitted to the facility on a later date, but again, there was no documentation of a written notice of transfer/discharge provided to the resident or responsible party. Staff B confirmed that the notifications for Resident 33 were also made verbally without any written documentation. The facility's failure to provide written notifications of transfer or discharge placed the residents at risk for diminished protection from inappropriate discharges.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide a bed hold notice in writing at the time of transfer to the hospital or within 24 hours of transfer for two residents. Resident 81 was transported to the hospital due to sharp chest pain, and there was no documentation in the electronic health record (EHR) that a bed hold was offered or that a bed hold notice was provided to the resident or their representative. Staff E, the Social Service Director, confirmed that a bed hold should have been offered and a written notice provided but was not. The Administrator also stated that the expectation was for all residents to be offered a bed hold upon transfer to the hospital, with follow-up the next day, which did not occur in this case. Similarly, Resident 33 was discharged to the hospital with a return anticipated, but there was no documentation in the EHR that a bed hold was offered for the transfer. Staff E was unable to locate any documentation of a bed hold being provided, and the Director of Nursing Services confirmed that there was no bed hold documentation for Resident 33, although there should have been. This failure to provide the required bed hold notices placed the residents at risk for lack of knowledge regarding their right to hold their bed while hospitalized, potentially diminishing their quality of life.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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