Avamere Rehabilitation At Park West
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 1703 California Avenue Southwest, Seattle, Washington 98116
- CMS Provider Number
- 505270
- Inspections on file
- 30
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 53
Citation history
Health deficiencies cited at Avamere Rehabilitation At Park West during CMS and state inspections, most recent first.
Two residents with complex medical conditions, including kidney failure, pressure ulcers, infections requiring IV antibiotics, and isolation precautions, were transferred to the ED without the required clinical documentation and notices. Despite facility policies and a discharge checklist requiring a hospital transfer form, MAR, care plan, diagnostic results, advance directives, state transfer/discharge notice, and bed-hold information, an LPN sent only a face sheet and lab results and did not call the ED to provide a report. The ED reported receiving no paperwork for one resident and was unable to reach facility staff for a medication list or status report, and the state-required transfer/discharge and bed-hold notices were not provided to either resident or their representatives.
A resident at high risk for pressure ulcers developed five new PU/PIs due to the facility's failure to implement appropriate interventions and accurately assess and document skin conditions. Despite being dependent on staff for mobility and having multiple risk factors, the care plan lacked specific measures to prevent skin injuries. Upon discharge, the resident had multiple PU/PIs that were not documented or communicated to relevant parties.
The facility failed to ensure a homelike environment for residents on two floors and in one elevator. Observations revealed multiple instances of damage, including gouges and exposed drywall in resident rooms, stained ceiling tiles, and a broken trim in the elevator. Staff confirmed these issues and acknowledged the need for repairs.
The facility failed to transmit the required MDS data to CMS within the required time frames for six residents, resulting in delays in care planning and unmet care needs. The MDS assessments for these residents were transmitted between one and twelve days late, as confirmed by the MDS Coordinators.
The facility failed to update PASRR assessments to reflect changes in the mental health status of four residents. The assessments were outdated or incomplete, missing critical diagnoses such as anxiety, depression, and psychosis. The Social Services Director acknowledged the inaccuracies and the need for revisions.
The facility failed to clarify and follow physician's orders for multiple residents, leading to potential medication errors and adverse outcomes. Issues included duplicate and unclear medication orders, failure to monitor blood pressure as required, and not removing pain patches as scheduled. Additionally, orthostatic blood pressure monitoring was not conducted for a resident on antipsychotic medication, as mandated by facility policy.
The facility failed to provide necessary ADL assistance to several residents, including bathing, grooming, and eating assistance. Residents were observed with long, dirty fingernails, unshaved facial hair, and uncombed hair. Staff acknowledged the lack of required care and assistance.
The facility failed to ensure that three residents received the Restorative Nursing Program (RNP) services they were assessed to require, leading to inconsistencies in providing prescribed splinting and passive/active ROM programs. Observations and interviews revealed that staffing issues and workload prevented the consistent provision of these services, placing residents at risk for a decline in ROM and decreased quality of life.
The facility failed to ensure resident safety by not adequately supervising and storing smoking materials for a resident, and by not securing the Central Supply and soiled utility rooms, which contained hazardous materials accessible to residents.
The facility failed to ensure nursing staff had the appropriate competencies and skill sets to provide safe care, particularly for a resident with a tracheostomy. Staff were not trained in specialized CPR for tracheostomy care, and there was no documentation of skills verification or competency evaluations for current staff. This placed residents at risk for incompetent care and harm.
The facility failed to implement an effective Infection Prevention and Control Program, lacking a water management program, having uncleanable resident equipment, improperly handled urinary catheter bags, and inadequate hand hygiene practices. Staff confirmed these deficiencies, which left residents vulnerable to infections.
The facility failed to revise its infection prevention and control policies and implement an updated Antibiotic (ABO) Stewardship program, lacking protocols to monitor, document, and analyze ABO use. This deficiency, spanning three months, placed residents at risk for adverse outcomes and ABO-resistant organisms.
The facility failed to obtain informed consent for psychotropic medication for a resident with severe memory impairment and did not ensure adequate privacy during care for three other residents. Staff provided care without pulling privacy curtains, exposing residents to potential view from the door or other parts of the room.
The facility failed to provide required written transfer/discharge notifications to three residents, including those with kidney failure, heart failure, and malnourishment, due to a misunderstanding of the requirements. Staff interviews confirmed that no notifications were sent after June 2023.
The facility failed to provide written notice of the bed hold policy to residents and/or their representatives at the time of transfer or within 24 hours, as required by their policy. This deficiency was identified for two residents who were transferred to the hospital. Staff confirmed that the bed hold notifications were not provided as required, placing the residents and their representatives at risk of not being informed of their rights and associated costs.
The facility failed to ensure accurate MDS assessments for six residents, leading to omissions and inaccuracies in documenting refusals of care, medication administration, and resident conditions. Staff interviews confirmed these deficiencies.
The facility failed to develop and implement comprehensive care plans for four residents, leading to inconsistent and inadequate care. One resident's dental health needs were not addressed, another's toileting schedule was omitted, a third's antipsychotic medication details were incomplete, and a fourth lacked necessary CPR equipment in their room.
The facility failed to update CPs for two residents and did not provide a care conference for one resident. One resident had an outdated CP for anticoagulant therapy, another had an outdated CP for meal assistance, and a third resident did not have a care conference for over a year due to staffing issues.
The facility failed to provide consistent feeding tube care for a resident with complex medical needs, including inconsistent formula administration, inadequate documentation of fluid intake, and improper labeling of formula bags. Staff interviews confirmed a lack of adherence to facility policies and physician orders.
The facility failed to timely act on medication-related irregularities identified by the consultant pharmacist for a resident with complex medical diagnoses. Recommendations for a lipid panel blood test and a decrease in a steroid nasal inhaler were delayed by several months, placing the resident at risk for medication-related complications.
A resident with kidney failure and shortness of breath continued to receive an antibiotic medication without proper review or adjustment, despite a nephrologist's recommendation to reduce steroid dosage and a pharmacist's recommendation to clarify the necessity of the antibiotic. The facility failed to schedule a follow-up appointment and clarify the medication order.
A resident with severe memory impairment was administered an antipsychotic medication without an appropriate diagnosis. Despite a consultant pharmacist's concern, the resident continued to receive the medication until a new diagnosis was added without clear documentation of the diagnostic process. Interviews confirmed the medication was given without an adequate diagnosis for several months.
The facility failed to secure and dispose of expired medications and biologicals timely. Expired items were found in the medication room, Pyxis machine, and medication carts. Unsecured medications were also observed in resident rooms and on medication carts. Staff interviews confirmed these findings and acknowledged the lapses in protocol.
The facility failed to provide timely dental services for a resident with broken teeth and oral pain. Despite a dental consultation recommending extractions and dentures, no follow-up actions were taken due to staffing shortages, placing the resident at risk for unmet dental needs.
Failure to Provide Required Notices and Clinical Information During Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an effective system for communication and provision of medical records when residents were transferred to the hospital, both for residents expected to return and those not expected to return. Facility policies required that residents transferred for emergency treatment receive a notice of transfer as soon as practicable, that the state agency transfer/discharge notice be completed, and that the facility’s bed-hold policy be provided. Another policy required that specific clinical information be conveyed to the receiving provider, including practitioner and representative contact information, advance directives, care plan, current status and baseline function, diagnoses, allergies, medications, diagnostic tests, and a discharge summary. A facility checklist directed staff to notify the physician, administrator, DON, and resident representative, complete a hospital transfer form, provide the state transfer/discharge notice and bed-hold policy, send a defined packet of clinical documents with the resident, and document all required elements in the medical record. For one resident, the admission MDS showed significant hearing and vision impairment, cognitive impairment, acute kidney failure, history of kidney transplant, pressure ulcers, and other complex diagnoses, with total dependence on staff for personal care and mobility. The comprehensive care plan documented an advance directive with a designated representative, an infected foot wound requiring a mid-line IV antibiotic, and detailed care for the infected pressure ulcer and IV site. The MAR and TAR contained extensive information on medications, including IV antibiotics, isolation requirements, and specific wound care instructions. On the date of transfer, a progress note recorded that the physician evaluated the resident, determined a hospital transfer was necessary, and that the resident was sent by ambulance with no bed hold desired; no additional information was documented. A hospitalist later reported that the ED received no paperwork with the resident, that multiple attempts to obtain a medication list and status report from the facility were unsuccessful, and that the facility did not inform the hospital about the mid-line IV indication or the severe infected foot wound. The hospital pharmacist ultimately had to contact the facility’s pharmacy to obtain the medication and IV information. The LPN assigned to this resident on the day of transfer stated they called the resident representative and arranged transportation, and that they sent only a face sheet and lab results with the resident. The LPN acknowledged they did not call the ED, did not send a hospital transfer sheet, did not complete or provide the state transfer/discharge notice or the bed-hold notice to the resident or representative, and did not use the discharge checklist. The LPN further stated they completed the hospital transfer form after the resident left and did not send it with the resident, and that the MAR, care plan, diagnostic results, advance directives, and change-of-condition form should have been sent but were not. For a second resident, the admission MDS documented cognitive loss, back surgery, bone infection, kidney failure requiring dialysis, and multiple pressure ulcers, with total dependence on staff for personal care and mobility. The comprehensive care plan showed the resident required a specialty mattress, was at high risk for falls, had specific behaviors with defined interventions, required medication monitoring, had an infection, was on IV antibiotics, and required specific isolation precautions. The MAR and TAR contained detailed instructions for routine and IV medications, isolation requirements, and wound care for multiple pressure ulcers. A progress note documented that the resident was sent to the hospital via ambulance for a change in condition, with multiple diagnostic tests and results, vital signs, and contact with the on-call physician who directed transfer to the ED. The LPN reported that, for this transfer, they again did not use the discharge checklist, sent only the face sheet and lab results, did not send a hospital transfer form because it was completed after the resident left, and did not provide the state transfer/discharge notice or bed-hold form to the resident or representative. The resident care manager stated that nurses were expected to follow the discharge checklist, complete the state transfer/discharge notice and bed-hold form when a resident was sent to the hospital, and call the ED to provide a report. The administrator stated that staff did not follow facility policy and that the failure in practice was identified in their system for discharging residents to the hospital. The administrator also stated that nursing staff were expected to complete the hospital transfer form, call the hospital with resident status information, complete all documentation, and send all required documents to the hospital, including the state transfer/discharge notice and bed-hold form to be provided to residents or their representatives and entered into the medical record. These expectations were not met for the two residents reviewed for hospitalization, resulting in noncompliance with WAC 388-97-0120, -0080, and -0140.
Failure to Prevent and Document Pressure Ulcers
Penalty
Summary
The facility failed to implement appropriate interventions to protect a resident's skin from injury, leading to the development of five new pressure ulcers/pressure injuries (PU/PIs) and associated pain. The resident, who was admitted for rehabilitation with multiple diagnoses including a brain disorder, dementia, and diabetes, was assessed at high risk for developing PU/PIs due to factors such as limited mobility, inadequate nutrition, and risk for skin friction and shearing injuries. Despite these risk factors, the facility did not include specific interventions in the care plan to prevent friction and shearing, nor did they accurately assess and document the resident's skin condition. The facility's policy required nursing staff to recognize, assess, and document significant risk factors for developing PUs, as well as to conduct weekly skin assessments. However, the weekly skin assessments for the resident showed no skin impairments, even though the care plan noted redness on the left heel. Additionally, documentation revealed that bed mobility assistance was often provided by only one staff member instead of the required two, and there were instances of incomplete documentation regarding staff assistance with bed mobility. Upon discharge, the resident was found to have multiple PU/PIs, including an unstageable PU/PI on the coccyx and stage two PU/PIs on the buttocks and ankle. The facility failed to document these skin impairments in the discharge notes or communicate them to the resident's representative or the receiving community home. Interviews with facility staff confirmed that the care plan did not address individualized risk factors for PU/PIs, and the nursing staff did not accurately identify, assess, or document the resident's skin injuries, nor did they notify the practitioner or the resident's representative about the PU/PIs.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to ensure a homelike environment for residents on two of its floors and in one of its elevators. Observations revealed multiple instances of damage and disrepair, including deep gouges and exposed drywall in resident rooms, falling and stained ceiling tiles, and scratched paint. Specifically, rooms on the 200 and 300 floors had walls with gouges and missing paint, and ceiling tiles with brown stains. Staff confirmed these observations and acknowledged that the damage should be repaired. Additionally, the elevator had a broken trim with a sharp, jagged edge at thigh level, posing a potential risk to residents, particularly those in wheelchairs. Interviews with staff, including the Director of Nursing, confirmed that the facility's policy was to provide a safe, clean, and homelike environment, and that the observed damages were not in line with this policy. The staff acknowledged the need for repairs and maintenance to ensure the environment met the expected standards. The failure to address these issues left residents at risk for a less-than-homelike environment, contrary to the facility's stated policy and regulatory requirements.
Failure to Timely Transmit MDS Data
Penalty
Summary
The facility failed to transmit the required Minimum Data Set (MDS) data to the Center for Medicare and Medicaid Services (CMS) within the required time frames for six residents. Specifically, the MDS assessments for Residents 33, 69, 57, 17, 73, and 51 were not completed or transmitted within the mandated 14-day period after the Assessment Reference Date (ARD). This delay in submission was confirmed by the MDS Coordinators, Staff J and Staff Q, during an interview, where they acknowledged the failure to meet the required timelines for MDS completion and transmission. Resident 33 had a Significant Change MDS and a Quarterly MDS that were both transmitted late. Resident 69 and Resident 57 each had a Quarterly MDS that was transmitted 12 and 11 days late, respectively. Resident 17's Annual MDS was transmitted two days late, while Resident 73's Quarterly MDS was also two days late. Resident 51 had two Quarterly MDS assessments that were transmitted one and three days late. These delays in MDS submission placed residents at risk for delays in care planning and unmet care needs.
Failure to Update PASRR Assessments
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were updated to reflect changes in the mental health status of four residents. Resident 30's Level 1 PASRR, dated 11/28/2023, did not include diagnoses of anxiety or depression, despite these being noted in the resident's medical records. Staff M, the Social Services Director, acknowledged that the PASRR was inaccurate and needed revision. Similarly, Resident 37's PASRR, dated 10/19/2022, did not reflect the resident's diagnoses of psychosis and difficulty adjusting to changes with mixed anxiety and depressed mood, which were documented in the resident's medical records and medication administration records. Staff M confirmed that the PASRR should have been updated to include these diagnoses. Resident 13's PASRR, completed on 02/20/2024, was found to be incomplete, with one of the three required questions left unanswered. Staff M admitted that all questions should have been answered. Lastly, Resident 69's PASRRs, dated 01/06/2023 and 03/25/2024, did not identify the resident's anxiety disorder, despite this being documented in the resident's medical records and medication orders. Staff M acknowledged that the PASRRs should have reflected the anxiety diagnosis. These deficiencies indicate a failure by the facility to ensure that PASRR assessments were accurately and timely updated to reflect residents' current mental health statuses. This oversight could potentially lead to inappropriate placement and inadequate mental health care services for the affected residents. The facility's policy, dated 03/22/2024, mandates periodic reviews of PASRRs to capture any changes in residents' mental health conditions, a responsibility assigned to the Social Services department. However, the policy was not adhered to in these cases, as evidenced by the outdated and incomplete PASRR assessments for Residents 30, 37, 13, and 69.
Failure to Clarify and Follow Physician's Orders
Penalty
Summary
The facility failed to ensure that physician's orders (POs) were clarified as needed for six residents, leading to potential medication errors and adverse outcomes. For instance, Resident 17 had duplicate orders for a powdered laxative medication, and Resident 33 had a high blood pressure medication order without documentation of blood pressure monitoring prior to administration. Additionally, Resident 13's pain medication patch order lacked specific instructions on the location of application, and Resident 57's high blood pressure medication order did not include parameters for when to hold the medication based on blood pressure or heart rate readings. These unclear and duplicate orders were not clarified with the provider by staff, as confirmed by interviews with staff members. The facility also failed to follow physician's orders for two residents. Resident 69 had a pain medication patch that was not removed as scheduled, and Resident 57's insulin medication was not held when blood sugar levels were below the specified threshold. Furthermore, Resident 57 received a pain medication outside the ordered parameters on multiple occasions. Staff interviews revealed that the expectation was for nursing staff to follow, clarify, and document orders as directed, but this was not consistently done. Additionally, the facility did not ensure that orthostatic blood pressure monitoring was conducted as required for Resident 2, who was on antipsychotic medication. The facility's policy mandated monthly orthostatic blood pressure checks for residents on psychoactive medications, but there was no documentation to show that this monitoring was performed for Resident 2. Staff interviews confirmed that the orthostatic blood pressure checks were not completed and documented as required, indicating a lapse in adherence to the facility's policy and physician's orders.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to ensure residents who were dependent on staff for assistance with Activities of Daily Living (ADLs) received the necessary care. Resident 61, who required substantial to maximal assistance with bathing and personal hygiene, was not provided a shower since admission, and their fingernails were observed to be long and dirty on multiple occasions. The care plan did not include specific instructions for bathing preferences, and there was no documentation of refusals. Staff confirmed the lack of showers and nail care for Resident 61 since admission. Resident 51, who had impaired memory and was totally dependent on staff for personal hygiene, was observed with long, dirty fingernails and facial hair on several occasions. Staff acknowledged that ADL assistance, including personal grooming, was not provided as required. Similarly, Resident 58, who had diagnoses including Parkinson's disease and required maximal assistance with transfers and personal hygiene, was observed lying in bed with long facial hair and wearing a hospital gown. The resident expressed a desire to be out of bed and in their wheelchair, but staff did not assist with transfers or grooming as care planned. Resident 73, who had impaired memory and required maximal assistance with personal hygiene, was observed with long fingernails and facial hair. There was no documentation of the resident's preferences or refusals for care. Staff confirmed the lack of ADL assistance. Resident 55, who had severe memory impairment and required assistance with personal hygiene and eating, was observed with long, dirty fingernails, uncombed hair, and a beard. The resident struggled to open food containers without staff assistance. Staff acknowledged that the resident did not receive the required assistance with grooming and eating as documented in their care plan.
Failure to Provide Required Restorative Nursing Program Services
Penalty
Summary
The facility failed to ensure that three residents received the Restorative Nursing Program (RNP) services they were assessed to require. Resident 57, who had multiple medically complex diagnoses including stroke with impairment of functional limitation in range of motion (ROM) to the upper arm and both lower legs, did not receive the prescribed splint and passive ROM to their right hand daily or three to six times per week as per the care plan. Additionally, the active ROM program for Resident 57's lower legs was not provided as frequently as required. Observations confirmed that the resident was not wearing the hand splint, and interviews with staff revealed that the RNP services were not consistently provided due to staffing issues after the departure of another restorative aide in February. Resident 69, who had functional limitations in ROM to both upper arms and lower legs, also did not receive the recommended RNP programs three to six times per week. Observations showed that the resident was not wearing a splint on their left arm, and documentation indicated that the RNP programs were provided less frequently than required. Interviews with staff confirmed the inconsistency in providing the RNP services and the need for a better restorative system. Resident 51, who had paralysis on one side of their body, a contracture to their right hand, and impairment to both legs, did not receive the prescribed splinting and passive ROM programs as required. Observations showed that the resident was not wearing the splint on multiple occasions, and documentation indicated that the RNP programs were provided less frequently than required. Interviews with staff revealed that the workload with other residents' RNPs prevented the consistent provision of the required services. The facility's failure to provide the necessary RNP services as assessed and documented placed the residents at risk for a decline in ROM, increased dependence on staff, and a decreased quality of life.
Failure to Ensure Safety and Supervision
Penalty
Summary
The facility failed to ensure the safety of its residents by not adequately supervising and storing smoking materials for a resident who smoked, and by not securing the Central Supply and soiled utility rooms. Resident 83, who had impaired vision, used a wheelchair, and required substantial assistance with daily activities, was found to be storing cigarettes in their pocket despite the facility's policy requiring such materials to be stored with the facility. This discrepancy was observed during an interview where the resident admitted to smoking outside the designated smoking times and areas, contrary to the facility's smoking policy and their signed agreement. The facility's staff, including the Director of Nursing and the Administrator, acknowledged the need for better organization and supervision of the smoking process but had not effectively enforced the policy with Resident 83. Additionally, the facility's Central Supply room was observed to be unlocked and unsupervised on multiple occasions, containing potentially hazardous materials such as medical supplies, over-the-counter medications, and chemicals. Staff acknowledged the importance of keeping the room secured but failed to do so consistently. Similarly, the soiled utility rooms on the 1st and 3rd floors were found unsecured, with dangerous chemicals accessible to residents. Staff confirmed that these rooms should be locked at all times to prevent access to hazardous materials, but observations showed that the doors did not secure properly, posing a risk to resident safety.
Failure to Ensure Nursing Staff Competency in Tracheostomy and Stoma Care
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide nursing care and related services that assured resident safety and attained or maintained the resident's highest practicable physical, mental, and psychosocial well-being. This deficiency was identified through observation, interview, and record review, revealing that the facility did not verify skills competency for five Certified Nursing Assistants (CNAs) and one Registered Nurse (RN) interviewed for special focused training for tracheostomy and stoma care. Specifically, the facility did not provide specialized CPR training for staff working with Resident 91, who had a tracheostomy, and staff were unable to explain the specific CPR requirements for this resident. The Director of Nursing acknowledged that the facility policy did not include emergency care for choking or CPR for residents with a tracheostomy and that specialized CPR training should have been provided before staff worked with Resident 91. Additionally, the Staff Development Coordinator, who had been in the position for two months, stated that there was no documentation for skills verification or competency evaluations for any current staff, and no process for staff skills evaluations on hire or annually. The Human Resources staff confirmed that there were no skills verification documents on file for a sample of five staff. The Resident Care Manager also stated that no special focus training was performed for staff on how to care for a tracheostomy or stoma routinely or in an emergency. The facility's failure to validate their nursing staff's knowledge, skills, abilities, behaviors, and other characteristics necessary to perform job-related functions safely and successfully placed residents at risk for incompetent care and harm, specifically placing Resident 91 at risk for injury, harm, and death.
Infection Control Deficiencies
Penalty
Summary
The facility failed to implement an effective Infection Prevention and Control Program, as evidenced by the lack of a water management program, uncleanable resident equipment, improperly handled urinary catheter bags, and inadequate hand hygiene practices. During an interview, the Environmental Director and Administrator confirmed that there was no current water management program to monitor and prevent waterborne pathogens like Legionella. Observations revealed multiple instances of resident equipment, such as mattresses, wheelchairs, walkers, and dining room chairs, with damaged surfaces that were uncleanable, posing a risk for infection spread. Staff interviews corroborated that these items should be intact and cleanable to reduce infection risks. Specific observations included a CNA handling Resident 66's morning hygiene care without changing gloves or performing hand hygiene between dirty and clean tasks, and another CNA providing care to Resident 51 without changing gloves or washing hands between different care activities. These lapses in hand hygiene were acknowledged by the staff involved, who admitted to not following proper hand hygiene protocols. Additionally, Resident 61's catheter bag was observed lying on the floor and dragging on the hall carpet, which was confirmed by staff to be improper handling that could compromise the catheter's integrity and contaminate the environment. The facility's failure to maintain cleanable surfaces on resident equipment and ensure proper hand hygiene practices, along with the absence of a water management program, left residents vulnerable to infections and other negative health outcomes. Staff interviews consistently highlighted the importance of these measures in preventing the spread of infections, yet the observations indicated a significant lapse in adherence to these protocols.
Failure to Implement Updated Antibiotic Stewardship Program
Penalty
Summary
The facility failed to revise its infection prevention and control policies and develop and implement an updated Antibiotic (ABO) Stewardship program to comply with the 10/24/2023 federal requirements. Specifically, the facility did not implement protocols and a system to monitor, document, and analyze the appropriate use of ABOs. This failure included the lack of leadership support and accountability for three months (January, February, and March 2024). The facility did not have an infection surveillance process that gathered data on residents' symptoms, the type of infectious organism, assessment of infections to meet specific criteria for ABO treatment, and tracking the spread of infection through tracing similar organisms. This placed residents at risk for potential adverse outcomes associated with the inappropriate or unnecessary use of ABOs and an increased risk for ABO-resistant organisms. The facility's policies on Surveillance for Infections and Antibiotic Stewardship were outdated and not revised to meet the new federal requirements. The Infection Control Preventionist (ICP), who started in February 2024, was unable to provide infection control surveillance, analysis, data reports, or Quality Assurance Policy Improvement leadership review for January and February 2024. During an interview, the ICP and other staff members acknowledged that the ABO stewardship program was not intact and did not meet the required standards. The surveillance log provided by the ICP lacked documentation on the organism, symptoms, and criteria for ABO use, further indicating the deficiency in the facility's infection control and ABO stewardship program.
Failure to Obtain Consent and Ensure Privacy
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medication to Resident 37. The resident, who had severe memory impairment and exhibited verbal behaviors, was given an antipsychotic medication without proper consent. The consent form in the resident's record was not correctly filled out, as it did not specify which medication the resident was consenting to. The Director of Nursing confirmed that the form should have been properly completed to indicate the specific medication, but it was not, resulting in a lack of informed consent for the treatment provided to Resident 37. Additionally, the facility did not ensure adequate privacy during the provision of care for Residents 3, 76, and 69. Observations showed that staff members provided care without pulling privacy curtains, exposing the residents to potential view from the door or other parts of the room. This lack of privacy was noted during various care activities, including dressing and incontinence care. Staff interviews revealed a lack of awareness about the importance of using privacy curtains to protect residents' dignity and privacy during care. The Resident Care Manager acknowledged the importance of privacy and stated that curtains should be used to ensure residents' rights are protected.
Failure to Provide Required Transfer/Discharge Notifications
Penalty
Summary
The facility failed to ensure that residents received the required written notices at the time of transfer or discharge, or as soon as practicable, for three residents reviewed for hospitalization. Resident 66, who had kidney failure and was on dialysis, was transferred to the hospital from the Kidney Center without receiving a written notification regarding the reason for the transfer. Staff interviews revealed that the Medical Records Assistant stopped sending these notifications after June 2023, mistakenly believing they were no longer required. The Social Services Director acknowledged that the required written notices were not provided to Resident 66 or their representative, nor was the Long-Term Care Ombudsman notified as required. Similarly, Resident 30, who had complex medical diagnoses including heart failure and a vertebrae infection, was transferred to the hospital twice for blood transfusions without receiving written notifications. Resident 97, who had diagnoses including malnourishment, gout, and nausea, was also transferred to the hospital without receiving the required written notification. Staff interviews confirmed that no transfer notifications were sent after June 2023 due to a misunderstanding of the requirements. The facility's failure to provide these notifications was not in alignment with the residents' stated goals for care and preferences.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to residents and/or their representatives at the time of transfer or within 24 hours, as required by their policy. This deficiency was identified for two residents, Resident 66 and Resident 97, who were transferred to the hospital. Resident 66, who had kidney failure and was undergoing dialysis, was transferred to the hospital from the Kidney Center due to a change in condition. The medical record did not show any evidence that the bed hold policy was discussed or offered to Resident 66 or their representative during the transfer. Staff K, responsible for offering bed holds, confirmed that the bed hold was not provided as required. Resident 97, who had diagnoses including malnourishment, gout, and nausea, was transferred to the hospital after experiencing a sudden headache and nausea. The facility did not provide a bed hold due to the resident's altered mental state at the time of transfer. Resident 97 returned to the facility eight days later. Staff M from Social Services stated that nursing typically handled the bed hold process and confirmed that Resident 97 should have received a bed hold, but the resident's record did not show that it was provided. This failure to provide the required bed hold notification placed the residents and their representatives at risk of not being informed of their rights and the cost associated with holding the resident's bed while hospitalized.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for six residents accurately reflected their conditions. For Resident 7, the MDS did not capture the resident's refusal of a knee brace program on two occasions. Similarly, Resident 57's MDS did not reflect the resident's refusal of a Range of Motion (ROM) program and bathing assistance. Staff interviews confirmed that these refusals should have been documented accurately in the MDS assessments. Resident 69's MDS inaccurately indicated that the resident did not receive antianxiety medications, despite the Medication Administration Record (MAR) showing regular administration of such medication. Resident 81's MDS was incomplete and inaccurate, failing to include a resident interview for mood and pain assessment, and incorrectly noting the presence of natural teeth when the resident had none. Staff interviews revealed that the MDS was completed remotely by a corporate nurse, which may have contributed to these inaccuracies. Resident 37's MDS did not include an active psychotic disorder diagnosis, despite the resident receiving antipsychotic medication. Similarly, Resident 2's MDS failed to document the administration of antipsychotic medication for Obsessive-Compulsive Disorder (OCD) and did not include the resident's weight, as staff failed to weigh the resident during the assessment period. Staff interviews confirmed these omissions and inaccuracies in the MDS assessments.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure a person-centered comprehensive care plan (CP) was developed and implemented for four residents, leading to inconsistent and inadequate care. Resident 66, who had kidney and heart failure, and high blood pressure, was observed to have missing teeth and required staff assistance for oral care. However, no CP was developed to address the resident's dental health needs. Staff K confirmed that an oral/dental CP should have been initiated but was not. Resident 73, who had impaired memory and was frequently incontinent, was observed to smell like urine. Despite being a candidate for a scheduled toileting program, no bowel and bladder CP was developed to instruct staff on the toileting schedule. Staff K confirmed the omission of the necessary CP for Resident 73's incontinent care needs. Resident 37, who had severely impaired memory and took antipsychotic medication, had a CP that did not specify which antipsychotic medication was prescribed or the behaviors it was meant to treat. Staff B emphasized the importance of comprehensive and accurate CPs. Resident 91, who had a tracheostomy and required specialized CPR equipment, did not have the necessary Ambu bag or pediatric CPR mask available in their room as directed by their CP. Staff O confirmed the absence of these critical items, which were eventually found on the medical crash cart. Staff B stated that the required suction machine and supplies should have been in the room per the CP directions.
Failure to Update Care Plans and Schedule Care Conferences
Penalty
Summary
The facility failed to ensure Care Plans (CP) were updated and/or revised as needed for two residents and did not provide an opportunity for a care conference for one resident. Resident 83 had a CP that inaccurately included an intervention for anticoagulant therapy, despite not receiving any anticoagulant medication. This discrepancy was confirmed by the Resident Care Manager (RCM) during an interview. Resident 51's CP indicated a need for one-to-one assistance during meals, but observations showed the resident eating without staff assistance. The RCM acknowledged that the CP was outdated and needed revision. Additionally, Resident 59 did not have a care conference for over a year, despite the facility's policy to hold such conferences quarterly and annually. The resident confirmed not having a care conference in a long time, and the Social Services Director admitted to being behind in scheduling due to staffing issues. The last documented care conference for Resident 59 was over a year ago, which was confirmed by staff during interviews and record reviews.
Failure to Implement Proper Feeding Tube Care
Penalty
Summary
The facility failed to implement proper care for a resident with a feeding tube, leading to several deficiencies. The resident, who had multiple medically complex diagnoses including malnutrition, required the use of a feeding tube for more than 51% of their total caloric and fluid intake. The facility did not provide a consistent formula or rate of administration, failed to document the total intake provided over 24 hours, did not clarify and administer the correct amount of water flushing required, and did not label and date the feeding tube formula as required by the facility's policy. These actions were observed over several days, with inconsistencies in the type of formula used, the rate of administration, and the labeling of the formula bags. The resident's physician orders included specific instructions for water flushing and formula administration, but these were not consistently followed. For example, the orders directed staff to flush the feeding tube with 300 mL of water three times a day and to provide a 300 mL bolus feeding four times a day of Isosource formula. However, observations showed that the formula bags were sometimes unlabeled or incorrectly labeled, and the administration rates varied. Additionally, during a medication pass, a nurse administered a total of 238 mL of water, which was not in accordance with the physician's orders. Interviews with staff revealed a lack of adherence to the facility's policies and physician orders. The Resident Care Manager acknowledged that there should be an order identifying the nutritional intake needs for the resident and that the total amount of fluid intake should be documented every 24 hours. The Director of Nursing also stated that feeding tube orders should be followed consistently, with formula bags labeled and dated as required. The failure to follow these protocols placed the resident at risk for complications related to their feeding tube and hydration status.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure timely action on medication-related irregularities identified by the consultant pharmacist for one resident. Resident 33, who had complex medical diagnoses including high blood pressure and hyperlipidemia, had a medication order for hyperlipidemia that required periodic monitoring through a lipid panel blood test. Although the consultant pharmacist recommended this test in October 2023 and the provider agreed, the lipid panel was not obtained until January 2024, three months later. Additionally, a recommendation to decrease a steroid nasal inhaler due to lack of symptoms was made in November 2023 but was not addressed until March 2024, after repeated recommendations and delays in provider approval. The Director of Nursing (Staff B) acknowledged that pharmacy recommendations should be completed and implemented by the end of the month they are made and should be readily available in the resident's records. However, the facility's failure to act on these recommendations in a timely manner placed Resident 33 at risk for medication-related complications. The pharmacy's pending response lists for November and December 2023 showed that the facility had not addressed the recommendations, and the records confirmed the delays in obtaining necessary lab tests and adjusting medication orders.
Failure to Review and Adjust Medication Regimen
Penalty
Summary
The facility failed to ensure that Resident 58's drug regimen was free from unnecessary medications. Resident 58, who had diagnoses including kidney failure and shortness of breath, was receiving an antibiotic (ABO) medication every 48 hours for long-term use of systemic steroids since November 2023. Despite a nephrologist's recommendation in January 2024 to reduce the steroid dosage and follow up in eight weeks, the facility did not schedule the follow-up appointment or clarify the necessity of the ABO medication with the nephrologist. Additionally, a pharmacist's recommendation in February 2024 to clarify the ABO medication with the nephrologist was not followed by the staff. Staff K, the Resident Care Manager, acknowledged that they were responsible for following up with the nephrologist's recommendations but admitted to missing the follow-up appointment and failing to clarify the ABO medication order. This oversight resulted in Resident 58 continuing to receive the ABO medication without proper review or adjustment, contrary to the nephrologist's instructions and the pharmacist's recommendations.
Failure to Ensure Appropriate Diagnosis for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure residents were free of unnecessary medications, specifically for one resident who was administered an antipsychotic (AP) medication without an appropriate diagnosis. The resident, who had severe memory impairment and verbal behaviors, was given an AP medication for vascular dementia with behavioral disturbance and psychosis. However, the facility's consultant pharmacist noted that dementia was not an appropriate indication for the use of an AP medication and that the resident did not have a documented psychosis diagnosis. Despite this, the resident continued to receive the medication until a new diagnosis of unspecified psychosis was added by the facility's medical supply clerk, without clear documentation of who diagnosed the resident or the diagnostic process followed. Interviews with the Director of Nursing and the Regional Nurse Consultant confirmed that the resident received the AP medication without an adequate diagnosis from September 2022 until February 2024. The facility's policy required that psychoactive medications be provided at the lowest effective dose and only with supporting diagnoses. The lack of proper documentation and adherence to this policy left the resident at risk for adverse side effects and unnecessary medication use.
Failure to Secure and Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were secured and expired medications and biologicals were disposed of timely in accordance with professional standards. In the first floor medication room, expired ostomy pouches, IV tubing, and IV fluid were found, along with expired IV antibiotic medication and liquid antacid medication in the refrigerator. Additionally, the refrigerator contained medications for discharged residents that had not been removed. The Pyxis machine also contained expired IV fluid and electrolyte solution. Medication carts on the third and first floors had loose pills and an opened nasal spray with no open date or resident name. Staff interviews confirmed these findings and acknowledged that expired medications should not be kept and that medications for discharged residents should be destroyed within one to two days after discharge, but this was not done. Unsecured medications were also observed in resident rooms and on medication carts. A steroid inhaler, analgesic lotion, and antifungal powder were found unsecured on a resident's bedside table, and a pain patch was left unsecured on another resident's bedside table. Additionally, an unsecured, opened pain patch was observed on top of a medication cart without staff present. Staff interviews confirmed that medications should not be left unsecured at a resident's bedside or on top of medication carts without staff present.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure prompt dental services were provided for Resident 57, who was cognitively intact and had obvious dental issues, including broken teeth and oral pain. Despite a dental consultation in June 2023 recommending x-rays, evaluation, and extraction of all upper and lower teeth, followed by the provision of dentures, no follow-up actions were taken. The resident expressed interest in obtaining dentures, but the necessary dental services were not coordinated or provided in a timely manner. Interviews with staff revealed that the Medical Records Director, responsible for coordinating dental appointments, cited staffing shortages as a reason for the delay in scheduling these appointments. The Director of Nursing stated that referrals should be followed up within a week, but this did not occur for Resident 57. The lack of timely follow-up placed the resident at risk for unmet dental needs and diminished 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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