Avamere Olympic Rehabilitation Of Sequim
Inspection history, citations, penalties and survey trends for this long-term care facility in Sequim, Washington.
- Location
- 1000 5th Avenue South, Sequim, Washington 98382
- CMS Provider Number
- 505327
- Inspections on file
- 36
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Avamere Olympic Rehabilitation Of Sequim during CMS and state inspections, most recent first.
The facility failed to maintain two shower rooms in a clean, sanitary, and homelike condition, despite a policy requiring such an environment. Surveyors observed scratched toilet seats with encrusted material, black matter on tiles and under sinks, soft and damaged walls with black substances believed by staff to be mildew or mold, used wet washcloths left in the rooms, a full trash can with the lid open, a shower head resting on the floor, and black and pink matter on the shower floors. A cognitively intact, medically complex resident reported concerns about odor, lack of cleanliness, and dirty linen left from prior use, leading them to avoid further showers, while another cognitively intact resident avoided the hall shower due to its condition, a broken handle, and unstable water temperature. The housekeeping supervisor, Infection Control Nurse, DON, maintenance director, and administrator acknowledged ongoing issues with cleanliness, possible mold, poor ventilation, and the age and disrepair of the shower rooms, and no mold testing had been performed.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility failed to provide adequate bathing assistance to several residents dependent on staff for this care. Despite policy requirements, residents did not receive showers as needed, with some going days without proper hygiene. Staff cited time management and care complexity as reasons for the deficiency.
Two residents in an LTC facility were not monitored for psychosocial harm following allegations of mistreatment by staff. Despite facility protocols requiring monitoring and documentation every shift, there were gaps in the progress notes for several days. The residents reported feeling mistreated and retaliated against, but the expected monitoring was not documented.
The facility failed to maintain effective infection control by not ensuring staff had appropriate PPE and did not properly don PPE for residents on droplet precautions. Staff were observed without necessary eye protection and did not change PPE between rooms. Additionally, the facility did not include the IP on the water management team and failed to implement all control measures of the Legionella Water Management Program, including routine chlorine testing and faucet inspections.
The facility failed to provide restorative nursing services for 16 residents due to staffing shortages, as the Restorative Nurse and Aide positions were vacant. This led to unmet restorative needs and long call light response times, as reported by the Resident Council. Call light audits confirmed significant delays, with some responses taking over 60 minutes.
The facility failed to provide restorative nursing programs for 16 residents due to staffing issues, leading to a lack of necessary care to maintain or improve range of motion, strength, and mobility. A resident with dementia and osteoarthritis did not receive recommended restorative therapy for contracture management, as the facility lacked a Restorative Aide until recently. This deficiency placed residents at risk for decline in physical abilities and increased dependence on staff.
The facility failed to label and store medications properly, affecting two medication carts and one medication room. Medications like Tuberculin Purified Protein and Insulin Lispro were found opened without dates, and a Fluticasone-Salmeterol Advair Diskus was expired. In the Dungeness cart, medications were undated or past discard dates. A resident had unauthorized medication in their room, contrary to facility policy.
The facility failed to maintain complete and accurate medical records for residents requiring restorative and hospice services. A resident receiving hospice care lacked current documentation, and the facility did not have records of hospice staff visits or care provided. Additionally, restorative services were discontinued due to staffing issues, and documentation for 16 residents was missing, leading to incomplete health records.
The facility failed to ensure accurate PASRR assessments for three residents, leading to potential risks in addressing their mental health needs. A resident's PASRR inaccurately documented a mood disorder and included a non-existent dementia diagnosis, while another resident's PASRR failed to indicate a serious mental illness, despite documented psychotic disorder and severe cognitive impairment. Staff acknowledged these errors and the responsibility of Social Services in managing PASRRs.
The facility failed to document and monitor behaviors and side effects related to psychotropic medications for several residents. Specific behaviors were not recorded, and necessary tests and consents were missing. Staff acknowledged the need for improved documentation and monitoring systems.
The facility failed to inform two residents of the risks and benefits of psychotropic medications and did not obtain their consent before administration. One resident was prescribed mirtazapine and Seroquel, while another was prescribed sertraline, without documented consent or information provided to them or their representatives.
A resident with arthritis and other conditions was not provided with adaptive equipment to cut food, despite a successful trial with a pizza cutter. The facility removed the tool without documented assessment or justification, leaving the resident to eat with their hands. Staff interviews revealed a lack of communication and documentation regarding the decision, and no alternative solutions were provided.
The facility failed to document advance directives for two severely cognitively impaired residents. Despite care conference notes indicating that advance directives were established, no copies were found in the residents' electronic health records. The Social Services Director admitted to not obtaining the necessary documentation, and the DON expected staff to document the ADs.
The facility failed to properly handle resident grievances, as grievances raised during Resident Council meetings and by individual residents were not logged or investigated according to policy. Issues included dissatisfaction with CNAs, meal setup concerns, and staff behavior. The use of incorrect forms led to grievances not being reviewed by the administrator, compromising the grievance process and affecting residents' quality of life.
A resident reported that a night nurse delayed pain medication due to personal grievances. The DNS investigated the issue as a grievance but failed to report it as an abuse allegation to the state. This oversight placed residents at risk for potential abuse and neglect.
A facility failed to notify the State LTC Ombudsman of a resident's transfer, as required. The resident, who was severely cognitively impaired, was transferred without documentation of notification. The Social Services Director confirmed the lack of documentation, and the DON stated that notification should have been documented.
The facility failed to accurately document the health status and care needs of three residents in their MDS assessments. One resident receiving hospice care was not coded with a terminal diagnosis, another was incorrectly noted as participating in a restorative program, and a third was inaccurately documented as being on a weight loss regimen. Staff confirmed these discrepancies, acknowledging errors in the MDS coding.
A resident with limited upper extremity function and arthritis was not consistently assisted with oral care, leading to poor hygiene. Despite being dependent on staff for personal hygiene, the resident reported infrequent assistance with brushing teeth, resulting in the use of a fingernail to remove plaque. The issue was reported to the Resident Care Manager but was not confirmed as oral care had been provided by then.
A facility failed to provide adequate pressure ulcer care for a resident at risk, resulting in a new unstageable ulcer. Despite having a skin care plan, the facility lacked consistent preventive measures and documentation, as revealed by staff interviews and missing skin audits.
A facility failed to ensure effective communication and coordination with a hospice provider for a resident receiving hospice services. The facility did not maintain a current hospice plan of care and lacked documentation of hospice staff visits in the resident's electronic health record. Despite requests, the facility did not receive necessary hospice visit notes, and staff were unable to provide details about recent visits or care provided.
The facility failed to maintain essential equipment, with kitchen and nourishment refrigerators showing unsafe temperatures, risking foodborne illness. Additionally, water temperatures in resident rooms and dining areas exceeded safe levels, risking burns. Inadequate monitoring and documentation contributed to these deficiencies.
The facility failed to follow professional standards, risking medication errors and health complications. Antihypertensives were given to a resident despite low blood pressure, compression stockings and toe separators were not applied as ordered, a Wanderguard was used without an order, and a dressing was applied without a physician's order.
A facility failed to provide necessary care to four residents as per their care plans. A resident with edema did not receive prescribed compression stockings, while another with Hallux valgus did not have toe spacers applied despite records indicating otherwise. A third resident's bruise was not monitored according to guidelines, and a fourth resident was not properly positioned for meals, impacting their ability to eat independently.
The facility failed to monitor and document the nutritional and fluid intake of two residents, leading to significant health risks. One resident experienced a significant weight loss due to inadequate weight monitoring and lack of follow-up on nutritional interventions. Another resident exceeded their fluid restriction due to improper reconciliation of fluid intake records, with no documentation of staff identifying the issue or educating the resident on adherence. These deficiencies compromised the residents' health and quality of life.
A facility failed to ensure a cognitively impaired resident had social services to assist in obtaining a legal representative. The resident, diagnosed with dementia and anxiety disorder, had an expired Health Care Decision Declaration and no legal decision-maker. Despite the resident's complex condition, no efforts were made to establish guardianship. Interviews with staff revealed a lack of action, with the Social Services Director acknowledging no steps had been taken, and the DON confirming the responsibility lay with Social Services.
A resident in an LTC facility was prescribed cyclobenzaprine 5 mg to be taken every eight hours as needed, but the medication was incorrectly entered into the MAR as being administered routinely three times daily. Despite multiple reviews by staff, the error persisted until the resident's hospital admission. The discrepancy was acknowledged by the DON, but no clarification was made.
Failure to Maintain Clean, Homelike Shower Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain two shower rooms (East and West) in a clean, sanitary, and homelike condition as required by its “Homelike Environment” policy. Surveyors observed multiple instances of unclean and deteriorated conditions, including deep scratches on toilet seats with brown and beige encrusted particles, black matter in shower tile grout and under sinks, soft and spongy wall areas with peeling and bubbling surfaces, and black substances believed by staff to be mildew or mold. In Shower Room East, surveyors also found used, wet washcloths left in the shower and under the sink, a full trash can with the lid open, the shower head touching the floor, and black and pink matter on the floor and tile lines. These conditions were observed on multiple dates in both shower rooms. A cognitively intact, medically complex resident reported that during their stay they were concerned about the shower room’s cleanliness, odor, and dirty linen left from previous use, which made them not want to shower again until discharge. Another cognitively intact resident residing on Dungeness Hall stated they did not use the hall’s shower room because it was a mess, the handle had broken off, and the water temperature fluctuated from hot to cold, so they preferred another unit’s shower room. The housekeeping supervisor reported that shower rooms were mopped daily and deep cleaned weekly but stated it was difficult to keep up due to the age and disrepair of the bathrooms and believed the black substance was mildew or mold, possibly colonized behind the walls. The Infection Control Nurse had not inspected the Grey Wolf and Dungeness Hall shower rooms for some time and was unaware of the current black substance, while the DON and Maintenance Director acknowledged staff-reported mold problems, lack of ventilation, and uncertainty about whether the black substance was mold, with no testing having been done. The administrator and maintenance director both conceded the rooms were old and could be better, and that they did not fully represent a clean, homelike environment.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Adequate Bathing Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically bathing, for five residents who were dependent on staff for this care. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain good hygiene, including bathing. However, records and interviews revealed that several residents did not receive showers as needed. Resident 4, for example, reported receiving only one shower in 15 days, while Resident 5's family member noted the resident had not had a shower in nine days. Similar issues were noted for Residents 6, 7, and 8, who also did not receive showers or bed baths as frequently as required. Staff interviews indicated that the failure to provide showers was attributed to time management issues and the complexity of care required by residents. Nursing assistants and registered nurses acknowledged the difficulty in completing all assigned tasks, including showers, during their shifts. The Director of Nursing Services and other staff members were aware of the grievances related to missed showers and attributed the issue to staff organization and time management. Despite reviewing and adjusting the shower schedule, the facility continued to face challenges in ensuring residents received the necessary bathing assistance.
Failure to Monitor Residents for Psychosocial Harm After Allegations
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for two residents, leading to a deficiency in monitoring for psychosocial harm following allegations against staff members. Resident 1, who had mild cognitive impairment and was medically complex, alleged mistreatment by staff, including being left in bed and not being assisted with toileting. Despite these allegations, there were gaps in the documentation of monitoring for psychosocial harm, as no nursing notes were recorded for several days following the incidents. Similarly, Resident 2, who was cognitively intact and medically complex, reported feeling disrespected and retaliated against by staff, which included being made to receive care in pairs and experiencing delayed call light response times. The facility's investigation revealed that there was no documentation of monitoring for psychosocial harm in the progress notes for several days after the allegations. Staff interviews confirmed that residents should have been placed on alert and monitored with documentation every shift, which did not occur for these residents.
Inadequate Infection Control and Water Management Practices
Penalty
Summary
The facility failed to maintain an effective infection control program by not ensuring that staff had appropriate personal protective equipment (PPE) available and did not properly don PPE for residents on droplet precautions. Observations revealed that staff members were not wearing the required eye protection and did not change masks and gloves between rooms for residents on droplet precautions. Staff members were also observed entering and exiting rooms without the necessary PPE, and PPE carts were found to be inadequately stocked with essential items such as eye protection, gloves, and gowns. Additionally, the facility did not include the Infection Preventionist (IP) on the water management team and failed to implement all control measures of the Legionella Water Management Program. This included not performing routine chlorine testing and not conducting regular inspections and cleaning of resident room faucets. The water management team lacked a clinician with expertise in infection prevention, and the facility did not have the necessary equipment for chlorine testing until after the deficiency was identified. The report highlights specific instances where staff did not adhere to infection control protocols, such as not wearing eye protection or changing PPE between resident rooms. It also notes the absence of the IP from the water management team and the lack of routine testing and inspections as required by the facility's water management program. These deficiencies were observed during a period of an influenza outbreak, further emphasizing the importance of strict adherence to infection control measures.
Deficiency in Restorative Nursing Services Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure sufficient qualified nursing staff to provide restorative nursing services for all 16 residents reviewed for such services. This deficiency was identified through interviews and record reviews, revealing that the facility had stopped providing restorative nursing services six to eight months prior due to staffing issues. The Restorative Nurse had transferred to another position, and the Restorative Aide had left, leading to a lack of restorative staff. Consequently, some restorative programs were transitioned to functional maintenance programs, but no restorative referrals were made during this period due to the absence of restorative staff. Additionally, the Resident Council minutes from June, July, and August 2024, highlighted ongoing resident complaints about staffing issues, including long call light response times and unmet care needs. Call light audits conducted in response to these complaints showed significant delays in response times, with some exceeding 60 minutes. The facility's assessment indicated that restorative aides were responsible for supporting residents' activities of daily living, but the lack of staff led to unmet restorative needs, placing residents at risk for a decline in their physical abilities and quality of life.
Failure to Provide Restorative Nursing Programs Due to Staffing Issues
Penalty
Summary
The facility failed to provide restorative nursing programs (RNPs) to maintain or improve range of motion (ROM), strength, and mobility for 16 residents who were assessed to require them. This deficiency occurred when the facility stopped providing restorative services in December 2023 due to staffing issues, as the Restorative Nurse transferred to another position and the Restorative Aide left. The facility attempted to transition some of the restorative programs to functional maintenance programs (FMP) to be performed by floor aides during activities of daily living (ADL) care, but no assessments or evaluations were conducted to support this transition. Furthermore, the facility was unable to provide documentation of the specific restorative programs each resident required or any evaluations indicating that the programs were no longer necessary. Resident 2, who was admitted with a diagnosis of dementia and osteoarthritis, was identified as requiring a restorative range of motion program to manage and prevent contractures. Despite recommendations from physical therapy and a care plan indicating the need for ROM exercises three to five times a week, Resident 2 did not receive the necessary restorative therapy. The facility's failure to provide these services was attributed to the absence of a Restorative Aide until one was hired, and Resident 2 was not included on the new Restorative Aide's list. This lack of restorative care placed residents at risk for a decline in strength, ROM, contracture formation, increased dependence on staff for ADLs, and decreased quality of life.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store drugs and biologicals in accordance with accepted professional principles, affecting two medication carts and one medication room. During an observation of medication room one, a vial of Tuberculin Purified Protein and a vial of Insulin Lispro were found opened without a date, which is against the protocol that requires these medications to be discarded after a specific period post-opening. Additionally, a Fluticasone-Salmeterol Advair Diskus Inhalation medication on the [NAME] medication cart was found to be expired, as it was opened for more than one month. Staff interviews confirmed these medications were not dated or removed as required, which did not meet the facility's expectations. In the Dungeness medication cart, several medications were found either undated or past their discard date, including Fluticasone propionate aerosol inhalers and Humolog insulin. Furthermore, Resident 27 had a bottle of Nystatin Topical Powder left on their dresser without proper authorization for self-administration, as confirmed by staff interviews. The facility's policy requires medications to be kept in a resident's room only if the resident has been assessed and provided with a lock box and key, which was not the case for Resident 27.
Incomplete Medical Records and Documentation Failures
Penalty
Summary
The facility failed to ensure that residents' medical records were complete, accurate, and readily accessible, affecting 16 residents who required restorative services and one resident receiving hospice care. For the resident receiving hospice services, the facility did not maintain current hospice documentation, including the comprehensive assessment and plan of care, which had expired. There was no documentation in the electronic health record (EHR) to indicate hospice staff visits, assessments, or care provided. Despite multiple requests by the Director of Nursing, the hospice visit notes were not provided, leaving the facility without necessary information about the resident's hospice care. Additionally, the facility discontinued restorative nursing services due to staffing changes, affecting 16 residents who had been assessed to require these services. The facility did not maintain documentation of the restorative programs, assessments, or transitions to functional maintenance programs (FMPs). Staff were unable to locate the restorative binders containing specific programs and associated flowsheets for these residents. This lack of documentation resulted in incomplete and inaccurate health records, placing residents at risk for unmet care needs.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Pre-Admission Screening and Resident Review (PASRR) assessments for three residents, which is crucial for identifying mental health or intellectual disability needs. Resident 25 was admitted with diagnoses of generalized anxiety, major depressive disorder, and bipolar disorder, but the Level I PASRR inaccurately documented a mood disorder without specifying the type and incorrectly included a diagnosis of dementia, which was not present. Staff D, the Social Services Director, acknowledged that the incorrect dementia diagnosis and the omission of anxiety should have been addressed. Staff B, the Director of Nursing Services, indicated that PASRRs were managed by Social Services and agreed that these errors should have been corrected upon admission. Resident 171's PASRR assessment was also inaccurate. The resident, who had diagnoses of dementia and generalized anxiety disorder, was readmitted to the facility with a Level 1 PASRR that did not indicate a serious mental illness, thus not triggering a Level 2 PASRR. The annual MDS noted psychotic disorder and severe cognitive impairment, but these were not reflected in the PASRR. Staff D stated that their process involved reviewing PASRRs within one to two days of admission, and acknowledged that Resident 171 should have been marked as having a mood disorder. Staff B reiterated that Social Services was responsible for correcting PASRR errors.
Deficiency in Behavior Monitoring for Psychotropic Medications
Penalty
Summary
The facility failed to adequately document and monitor the behaviors and side effects associated with the use of psychotropic medications for several residents. For Resident 25, the Medication Administration Records (MAR) and Treatment Administration Record (TAR) indicated anxiety, depressive, and psychotic behaviors on multiple occasions, yet there were no specific behaviors documented, nor were there progress notes in the Electronic Health Records (EHR) on the dates these behaviors were observed. Staff acknowledged the need for documentation of specific behaviors observed. Resident 62 was prescribed mirtazapine and Seroquel without documented consent or an Abnormal Involuntary Movement Scale (AIMS) test, which is necessary for antipsychotic medications. The behavior monitoring care plan included target behaviors that the resident had not demonstrated, such as hallucinations, raising questions about the appropriateness of the medication use. Staff confirmed that target behaviors should reflect the resident's demonstrated behaviors to evaluate the medication's effectiveness. For Residents 63 and 372, there was a lack of behavior monitoring to ensure the effectiveness and side effects of prescribed psychotropic medications. The MAR and TAR did not document specific behaviors, and there were no progress notes in the EHR. Staff were unable to explain or demonstrate how behavior monitoring was conducted, and there was no system in place to track interventions or their effectiveness. Resident 171 was readmitted without an order for behavior monitoring for an antidepressant, which was acknowledged as not meeting expectations by the staff.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were informed of the risks and benefits associated with proposed psychotropic medication therapy and did not obtain consent from the residents or their representatives before administering the medication. This deficiency was identified for two residents, Resident 62 and Resident 63, who were reviewed for unnecessary medications. Resident 62, who was cognitively intact, had diagnoses of depressive and anxiety disorders and was receiving antidepressant and antianxiety medications. The facility's records showed that Resident 62 was prescribed mirtazapine and Seroquel, but there was no documentation indicating that the resident or their representative was informed about the risks and benefits of these medications or that consent was obtained. Similarly, Resident 63, who was also cognitively intact, had diagnoses including generalized anxiety, major depressive disorder, hallucinations, panic disorder, and hydrocephalus. The facility's records indicated that Resident 63 was prescribed sertraline, but again, there was no documentation showing that the resident or their representative was informed of the risks and benefits or that consent was obtained. Interviews with facility staff confirmed the lack of documentation for both residents, highlighting a failure in the facility's process to ensure informed consent for psychotropic medication therapy.
Failure to Provide Adaptive Equipment for Resident's Needs
Penalty
Summary
The facility failed to provide adaptive equipment for a resident, identified as Resident 63, who had specific physical needs due to arthritis in both hands, malnutrition, and other conditions. The resident was admitted with a comprehensive assessment indicating the need for assistance with eating. Despite being alert and oriented, the resident required help with cutting food due to difficulty gripping utensils. An occupational therapist had previously introduced a pizza cutter as an adaptive tool, which the resident found effective and allowed for greater independence. However, the facility removed the pizza cutter without documented assessment or justification, leaving the resident unable to cut their food independently. Observations revealed that the resident was left with uncut food during meals, leading them to eat with their hands, which was not conducive to their dignity or independence. Interviews with staff indicated a lack of communication and documentation regarding the decision to remove the pizza cutter. The occupational therapy assistant confirmed the resident's ability to use the pizza cutter safely, as documented in a therapy progress note. Despite this, the facility did not provide alternative solutions or document any assessment of the resident's safety with the pizza cutter, resulting in a failure to accommodate the resident's needs and preferences.
Failure to Document Advance Directives for Cognitively Impaired Residents
Penalty
Summary
The facility failed to properly document advance directives (AD) for two residents who were severely cognitively impaired. Resident 2 was admitted to the facility and had a care conference note indicating that ADs were established, but no copy of the AD was found in the electronic health record (EHR). Staff D, the Social Services Director, acknowledged not having a copy and admitted to not asking for it during the care conference. Similarly, Resident 40 was admitted with a care conference note stating that ADs were established, yet no AD copy was present in the EHR. Staff D admitted to not following up with the family to obtain the AD. The Director of Nursing expressed that the expectation was for staff to attempt to obtain and document the AD.
Failure to Properly Handle Resident Grievances
Penalty
Summary
The facility failed to properly handle grievances from residents, as evidenced by the lack of initiation, investigation, and logging of grievances. The facility's grievance policy required that grievances be communicated to the administrator and logged, but this was not consistently done. During Resident Council meetings, several grievances were raised, such as insufficient sandwich options, potential fire hazards from piled leaves, long call light wait times, and staff behavior issues. None of these grievances were logged, indicating a failure to adhere to the facility's grievance policy. Additionally, specific grievances from residents were not appropriately addressed. For instance, Resident 27 expressed dissatisfaction with certain CNAs and requested not to receive care from them. However, this grievance was not formally documented or investigated at the time. Similarly, Resident 63 filed a grievance regarding meal setup and assistance, but the facility did not explore alternatives or document a critical review of the grievance to reach a resolution. The grievance was signed off without evidence of a thorough investigation or resolution. The facility's process for handling grievances was further compromised by the use of Resident Response Forms instead of the designated Grievance Forms. This practice led to grievances not being reviewed by the administrator, as required. Staff members, including the Social Services Director and Activities Director, acknowledged the improper handling of grievances and the failure to log them, which prevented the administrator from reviewing and signing off on them. This systemic issue in grievance management placed residents at risk of having their concerns unaddressed, affecting their quality of life.
Failure to Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to report an allegation of abuse and neglect to the state agency for one resident, identified as Resident 46, who was cognitively intact. The resident reported that a night nurse would delay administering pain medication due to personal grievances, stating that the nurse was in control and indifferent to being reported. The resident believed they had informed the Director of Nursing (DNS), Staff B, about the issue, and the nurse in question was no longer employed at the facility. Staff B acknowledged having investigated the allegation in July, treating it as a grievance rather than an abuse allegation, and did not log or report it to the state. It was only after being questioned again that Staff B initiated a formal investigation and reported the incident to the state. This oversight in reporting placed residents at risk for potential abuse and neglect, as the facility did not adhere to its policy of timely reporting such allegations as required by federal regulations.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to properly notify the Office of the State Long-Term Care Ombudsman regarding the transfer of a resident, identified as Resident 40. This deficiency was identified through interviews and record reviews. Resident 40, who was admitted to the facility and assessed as severely cognitively impaired, was transferred on January 1, 2024. However, there was no documentation in the Electronic Health Record indicating that the Ombudsman was notified of this transfer. Staff D, the Social Services Director, confirmed the absence of such documentation, and Staff B, the Director of Nursing, acknowledged that the expectation was for the Ombudsman notification to be documented and completed.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected their health status and care needs for three residents. Resident 11, who had been receiving hospice services since October 2021, was not documented as having a terminal diagnosis on multiple Minimum Data Set (MDS) assessments, despite having a hospice certification and plan of care indicating a terminal illness. This oversight was confirmed by the Assistant Director of Nursing, who acknowledged that the terminal diagnosis should have been coded on the MDS assessments. Resident 2 was incorrectly documented as participating in a restorative nursing program for passive range of motion, despite no evidence in the clinical record supporting this. The MDS coordinator admitted to mistakenly capturing these minutes, and the Director of Nursing Services confirmed that Resident 2 was not on a restorative program. Additionally, Resident 4 was inaccurately coded as being on a prescribed weight loss regimen, although there were no physician or dietitian orders for such a program. Staff, including the Resident Care Manager and Chief Medical Director, confirmed that Resident 4 was not on a weight loss program, and the MDS coding was incorrect.
Failure to Assist Resident with Oral Care
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for Resident 58, who was dependent on staff for personal hygiene due to limited functional range of motion in both upper extremities and arthritis. Despite being cognitively intact and having natural teeth, Resident 58 reported that staff did not assist with oral care, which led to poor oral hygiene. The resident expressed that they were unable to brush their teeth themselves and had resorted to using their fingernail to remove plaque, which was observed as yellowish/white debris under the fingernail and along the upper gum line. Resident 58, who was admitted to the facility earlier in the year, had an ADL self-care deficit care plan indicating the need for one-to-two-person assistance with personal hygiene. However, the resident reported that only one male nursing aide and one male therapist had assisted with brushing their teeth since admission. The resident expressed a preference for oral care to be provided at least once daily, either after breakfast or dinner. The lack of consistent oral care assistance was reported to the Resident Care Manager, but the issue was not confirmed as oral care had been provided by that time.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards for a resident who was at risk for pressure ulcers. The resident, who was severely cognitively impaired and on hospice, had two pressure ulcers, one of which was present upon admission. Despite being at risk, the facility did not have adequate interventions in place to prevent new pressure ulcers. The resident's skin care plan included interventions such as bruise monitoring, encouraging nutrition and hydration, and weekly skin assessments. However, a new unstageable pressure ulcer developed on the resident's right heel, indicating a lapse in preventive measures. The facility's documentation showed inconsistencies and omissions in weekly skin audits, with one audit missing entirely. Staff interviews revealed that typical interventions for pressure ulcer prevention, such as turning, repositioning, and using pressure-relieving devices, were not consistently applied. The Director of Nursing Services acknowledged that there were no interventions in place initially to prevent new pressure ulcers for the resident, and that the weekly skin audits should have documented the new skin issue when it was identified.
Lack of Coordination and Documentation in Hospice Care
Penalty
Summary
The facility failed to ensure effective communication, collaboration, and coordination of care between the facility and the hospice provider for a resident receiving hospice services. The facility did not maintain a current hospice coordinated plan of care for the resident, as the existing plan was expired and a current one was not obtained. Staff members, including the Assistant Director of Nursing (ADON) and the Medical Records Director, acknowledged the absence of the current plan and indicated that it had not been provided by the hospice. Additionally, the facility's electronic health records lacked documentation of hospice staff visits, including details of who visited, when, and what care was provided. The facility's hospice contract identified a Social Services Director as the hospice liaison, but this individual only made initial referrals and did not engage in ongoing communication or coordination of hospice services. Despite requests for hospice visit notes from the Director of Nursing, the facility did not receive the necessary documentation from the hospice provider. The ADON confirmed that there was no documentation in the resident's electronic health record regarding hospice visits, and staff were unable to provide details about recent hospice visits or the care provided. This lack of documentation and communication placed residents at risk for not receiving necessary care and services.
Failure to Maintain Safe Equipment Conditions
Penalty
Summary
The facility failed to maintain essential equipment in working condition, specifically concerning the refrigeration units and water temperature controls. In the facility's kitchen, one refrigerator was observed to have a digital thermometer reading of 47 degrees Fahrenheit, with potentially hazardous foods inside measuring temperatures above the safe range. Staff W, the Kitchen Manager, noted that the refrigerator was not cooling properly, and all foods were subsequently removed. Additionally, the nourishment refrigerators at nursing stations were found to have temperatures logged above the safe range, with potentially hazardous foods like yogurt and cheese stored inside. Staff interviews revealed that the temperature logs used were intended for monitoring COVID-19 vaccines, not food safety. The facility also failed to maintain hot water temperatures at safe levels in several resident rooms and dining areas. Water temperatures were recorded above the recommended safe range, with some readings as high as 122.1 degrees Fahrenheit. The Maintenance Director, Staff V, was present during the temperature checks and acknowledged the discrepancies, noting that the boiler was set at 118 degrees Fahrenheit. However, the facility lacked a formal policy for water temperature testing, and the temperature logs were inadequately documented, with no dates indicating when the temperatures were taken. These deficiencies placed residents at risk for foodborne illness and serious burns, as the facility did not ensure that essential equipment was functioning correctly. The lack of proper monitoring and documentation for both refrigeration and water temperatures contributed to the facility's failure to maintain a safe environment for its residents.
Failure to Adhere to Professional Standards of Practice
Penalty
Summary
The facility failed to adhere to professional standards of practice for several residents, leading to potential risks for medication errors and other health complications. For Resident 62, antihypertensive medications were administered despite the resident's systolic blood pressure being below the threshold specified in the physician's orders. This occurred on multiple occasions, as confirmed by the Assistant Director of Nursing. Resident 30 did not have the ordered compression stockings applied, yet the treatment administration record was signed as if the task had been completed. Similarly, Resident 10's toe separators were not applied as ordered, although the treatment administration record indicated otherwise. Additionally, Resident 42 was fitted with a Wanderguard device without a physician's order, contrary to the facility's expectations. For Resident 54, a wet to dry dressing was applied without a corresponding physician's order when wound vac supplies were unavailable. The Resident Care Manager confirmed that an order should have been obtained for the temporary dressing. These deficiencies highlight a pattern of failing to follow or clarify physician orders and inaccurately documenting care tasks, which could lead to negative health outcomes for the residents involved.
Deficiencies in Resident Care and Service Delivery
Penalty
Summary
The facility failed to provide necessary care and services to four residents according to their comprehensive person-centered care plans. Resident 30, who was admitted without edema, developed pitting edema in both lower extremities. Despite an order for knee-high compression stockings to manage the edema, the resident was found without them, and the compression stockings were not located in the room. The Treatment Administration Record (TAR) inaccurately indicated that the stockings had been applied. Resident 10, with a history of Hallux valgus, had an order for toe spacers to prevent tissue damage. However, the resident reported not wearing the spacers for approximately three months, despite the TAR showing daily application. Resident 62, who was cognitively intact and on antiplatelet medication, had a bruise under the left eye from a fall. The facility did not document assessments or monitoring of the bruise as per their wound management guidelines. Resident 63, with multiple diagnoses including arthritis and malnutrition, required assistance with positioning for meals. Observations showed the resident was frequently slumped in bed with meals out of reach and uncut, contrary to the care plan. Staff acknowledged the resident's dependence on assistance for positioning but failed to ensure proper positioning during meals. The facility's documentation did not reflect any refusals by the resident to get out of bed, and there was a lack of communication between nursing and occupational therapy regarding the resident's positioning needs.
Deficiencies in Nutritional and Fluid Monitoring
Penalty
Summary
The facility failed to accurately document, monitor, and assess the fluid intake and nutritional status of two residents, leading to significant health risks. Resident 4, who was severely cognitively impaired and on hospice care, had a nutritional care plan due to risks associated with COPD and dysphagia. Despite physician orders to obtain weights regularly, the facility did not adhere to the schedule, resulting in missing weight records and a failure to address a significant weight loss of over 20% in 60 days. The facility did not document any follow-up actions or reassessments for this weight loss, and the Registered Dietitian was unavailable for an extended period, leaving nutritional assessments incomplete. Resident 62, who was cognitively intact and had diagnoses of heart failure and kidney disease, was on a fluid restriction of 1800 ml per day. The facility did not reconcile the fluid intake recorded during meals with the intake recorded on the MAR, leading to the resident exceeding the fluid restriction on multiple occasions. There was no documentation indicating that staff identified this non-adherence or provided necessary education to the resident about the risks and benefits of adhering to the fluid restriction. Additionally, there was no evidence of physician notification regarding the resident's fluid intake exceeding the prescribed limit. These deficiencies in monitoring and documentation placed both residents at risk for serious health complications, including fluid volume overload, electrolyte imbalances, and significant weight loss. The facility's failure to implement and evaluate nutritional interventions and fluid restrictions compromised the residents' quality of life and health outcomes.
Failure to Obtain Legal Representation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide necessary social services for a cognitively impaired resident, Resident 171, to assist in obtaining a legal representative. Resident 171, who was admitted with diagnoses of dementia and generalized anxiety disorder, was found to be severely cognitively impaired and unable to recall information. The resident's Health Care Decision Declaration had expired, and there was no advance directive or legal decision-maker in place. Despite the complexity of Resident 171's condition, no efforts had been made to establish guardianship or a power of attorney since the expiration of the previous surrogate decision-maker. Interviews with facility staff revealed a lack of action in addressing the resident's need for a legal representative. The Social Services Director acknowledged that no steps had been taken to pursue guardianship for Resident 171, despite the expiration of the health care declaration form. The Director of Nursing Services confirmed that it was the responsibility of Social Services to obtain a power of attorney or guardian for the resident. This inaction placed Resident 171 at risk of not having someone to make informed decisions on their behalf, potentially affecting their quality of life and care needs.
Medication Order Discrepancy Leads to Incorrect Administration
Penalty
Summary
The facility failed to ensure that medication orders were clarified and accurately entered into the electronic health record (EHR) for a resident, leading to a discrepancy in the administration of a muscle relaxer. The resident, who was cognitively intact and required assistance with activities of daily living, was prescribed cyclobenzaprine 5 mg to be taken by mouth every eight hours as needed. However, the medication was incorrectly entered into the medication administration record (MAR) as being administered routinely three times daily, with scheduled times, rather than as needed. This error persisted from the time the order was received on June 17, 2024, until the resident's admission to the hospital on June 30, 2024. Interviews with facility staff revealed that the order was intended to be administered every eight hours as needed, but was mistakenly entered and confirmed as three times daily. The Director of Nursing acknowledged the discrepancy between the order and the MAR, indicating that there should have been a clarification of the order. Despite multiple reviews of the order by various staff members, including the Resident Care Manager and the Assistant Director of Nursing, the error was not corrected, and the medication continued to be administered incorrectly. The resident's Power of Attorney was informed of the as-needed order, further highlighting the inconsistency in the medication administration.
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A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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