Avamere Rehabilitation Of Cascade Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Vancouver, Washington.
- Location
- 801 Southeast Park Crest Avenue, Vancouver, Washington 98683
- CMS Provider Number
- 505389
- Inspections on file
- 26
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Cascade Park during CMS and state inspections, most recent first.
A resident with a history of atherosclerosis of coronary artery bypass grafts was issued an emergency discharge for endangering the safety of others, but the facility documented the discharge location only as the resident's personal car with no address and did not secure confirmed housing or access to shelter or hygiene facilities. The discharge notice was delivered with law enforcement present, and the resident packed belongings and left the same day. The SW confirmed that no housing placement was arranged before discharge, and the resident later reported being escorted out by police and relying on a POA to obtain temporary motel lodging before staying with a friend.
A resident with multiple complex medical conditions, including a stage 4 pressure wound and significant care needs, was discharged home without proper supports, services, or equipment in place. The discharge was authorized by a family member without legal authority, and no home health or wound-care arrangements were made. Facility staff and the resident's provider had documented concerns about the safety of the discharge, and the resident was subsequently hospitalized due to complications from inadequate care at home.
Two residents with cognitive impairment were observed with their beds either in a low position or placed against the wall, used as physical restraints, without the required Safety Device Evaluation, physician's order, or care plan intervention. Staff confirmed that these steps were necessary but had not been completed or documented.
Three residents with significant cognitive and medical conditions did not have comprehensive care plans addressing key aspects of their care, including use of physical restraints, PTSD, antianxiety and anticoagulant medications, and dementia. Staff confirmed that these care plan elements were missing or delayed, despite ongoing treatment and diagnoses.
A resident with severe cognitive impairment and multiple diagnoses did not receive restorative aid services as recommended after discharge from physical therapy. Despite documented recommendations for specific restorative interventions, there was no evidence in the medical record that these services were provided, and staff interviews revealed a lack of awareness and follow-through regarding the resident's restorative care needs.
The facility did not follow physician orders and care plans for two residents: one resident did not have a required bed rail installed to assist with mobility, and another resident with CHF did not have daily weights consistently recorded or significant weight gains reported to the physician as ordered. Staff confirmed these omissions and the lack of required documentation.
A resident with severe cognitive impairment and dementia was prescribed Lorazepam for anxiety, but staff failed to document monitoring for adverse side effects after administration. Interviews with the Resident Care Manager and DON confirmed that monitoring was expected but not completed, and the necessary order for monitoring was delayed by over a month.
Two CNAs transferred a resident on contact precautions without wearing required isolation gowns, despite a physician order and facility expectations for PPE use during such care.
Nursing hours were not accurately posted or updated throughout the day, as required. Instead, staffing information was corrected the following morning, and staff were unaware that real-time updates were necessary. This resulted in daily postings that did not reflect actual staffing changes.
A resident with Type 2 Diabetes Mellitus was admitted without blood glucose monitoring orders despite being on oral diabetic medications. The resident experienced severe hypoglycemia, leading to hospitalization. Facility staff typically relied on Hemoglobin A1C levels rather than routine glucose checks, contrary to the facility's policy for monitoring residents on oral medications.
A resident with a healing Stage 2 pressure ulcer experienced worsening of the ulcer and developed a new one due to inadequate monitoring and delayed treatment. The facility failed to conduct timely skin audits and Braden Risk Assessments, and did not provide necessary pressure-relieving equipment promptly. Lack of communication and documentation among staff further contributed to the resident's condition deteriorating, leading to hospitalization and surgical intervention.
The facility failed to obtain necessary assessments, consents, and physician orders for beds placed against the wall and the use of bed rails for four residents. Observations confirmed the improper use of restraints without documentation, and staff acknowledged the oversight.
The facility failed to maintain dignity in catheter care for two residents with indwelling catheters. Both residents were observed with uncovered foley catheter drainage bags, despite care plans requiring them to be covered. Staff acknowledged the expectation for bags to be covered and not placed on the floor, indicating a lapse in following care plans.
The facility did not ensure a resident was offered the opportunity to participate in care conferences, as only one was documented despite expectations for quarterly meetings. The resident was alert and oriented, and staff interviews confirmed the expectation for quarterly care conferences, which were not met.
A facility failed to review and maintain advance directives (AD) and Durable Power of Attorney (DPOA) documentation for a resident. Despite being alert and oriented, the resident's ADs were not reviewed for several months. Staff acknowledged that the AD should have been reviewed during a care conference, but this did not happen.
Two residents experienced unresolved grievances regarding lost items due to the facility's failure to adhere to its grievance policy. One resident's manual wheelchair went missing after a hospital transfer, and despite reporting it, the issue was not promptly addressed. Another resident reported missing laundry items, which were not fully recovered despite her efforts. The facility's lack of timely communication and action resulted in unresolved concerns.
The facility failed to provide written bed-hold notices to two residents or their representatives during hospital transfers. One resident, severely cognitively impaired, was transferred without documentation of a bed-hold notice. Another resident, moderately cognitively impaired, was hospitalized and returned without a bed-hold notice. Staff acknowledged the oversight and lack of compliance with the requirement to inform residents or their representatives.
A facility failed to develop a comprehensive care plan for a resident with skin conditions, including abrasions and blisters on the feet. Despite physician orders for specific wound care, the care plan lacked focus areas, goals, or interventions for these conditions. Staff interviews revealed the absence of a documented care plan, with the Resident Care Manager and DON acknowledging the oversight.
A resident with Inclusion Body Myositis experienced discomfort and safety risks due to improper wheelchair fit and positioning. Despite complaints and a vendor's acknowledgment of a broken part, the facility failed to assess and address the wheelchair's fit and functionality. Staff were unaware of repair plans, and temporary fixes did not resolve the issue.
The facility failed to follow infection control practices during wound care for a resident with a Stage 4 pressure ulcer and catheter care for another resident. An LPN did not wash hands between glove changes during a dressing change, and a catheter drainage bag was found on the floor without proper covering or hanging. Staff acknowledged these practices were against facility policy.
Failure to Arrange Safe and Orderly Emergency Discharge
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a resident when it processed an emergency discharge without securing an appropriate discharge location, supports, or housing. Facility policy on Discharge Planning, dated 01/09/2002, required Social Services to arrange or assist in arranging necessary services, identify the discharge location, supports, and equipment, and, for residents without an identified discharge location, enlist the support of the assigned Medicaid case manager and other public agencies to secure appropriate housing. The resident was admitted with diagnoses including atherosclerosis of coronary artery bypass graft(s). The Nursing Home Transfer or Discharge Notice, dated 01/29/2026, documented an emergency discharge under the reason that the safety of other individuals in the facility was endangered. The discharge location was recorded as "Car (Personal)" with the address listed as "NA," and the record did not identify an established discharge address or confirmed housing placement where the resident could access shelter or hygiene facilities. Interviews and record review confirmed that no confirmed housing placement was secured prior to discharge. The Administrator stated the discharge was processed as an emergency discharge with law enforcement present when the notice was delivered, and that the resident packed his belongings and left the facility the same day. The Social Worker stated the discharge was processed as an immediate discharge and confirmed that the discharge location was documented as the resident's car, with no confirmed housing placement arranged beforehand. The resident later reported being escorted from the facility by police on the date of discharge, and that his POA secured motel lodging for several days following discharge before he went to stay with a friend. The Administrator later acknowledged that discharge to a hotel would have been preferable to discharge to the resident's vehicle.
Failure to Ensure Safe and Appropriate Discharge for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident with complex medical needs, including sepsis, encephalopathy, Parkinson's disease, a stage 4 sacral pressure wound, and adult failure to thrive. The resident was non-verbal, required significant assistance with activities of daily living, and was dependent for toileting and lower-body dressing. Despite documentation from the primary care provider and facility staff indicating that the resident required a higher level of care and that discharge home would be unsafe, the resident was discharged home without adequate supports in place. Discharge planning was insufficient, as the resident's daughter, who did not have legal authority to act on her behalf, signed the discharge paperwork. There was no documentation that the resident participated in or consented to the discharge decision. The facility did not arrange for home health or wound-care services, and necessary equipment such as a low-pressure mattress was not provided. The resident's significant other, identified as the primary caregiver, did not receive training or instruction regarding the resident's care needs, and staff expressed doubt about his ability to provide the required level of care. Following discharge, the resident was found at home without appropriate care, experiencing pain and complications from the existing stage 4 wound, which led to hospitalization. The facility staff, including nursing and the physician, believed the discharge was unsafe, and there was no evidence that guardianship or Medicaid application processes were pursued to ensure the resident's needs were met. The discharge was documented as against medical advice, but the facility did not fulfill its responsibility to ensure a safe and coordinated transition, resulting in harm to the resident.
Failure to Obtain Required Evaluation and Orders for Physical Restraints
Penalty
Summary
The facility failed to obtain a Safety Device Evaluation and Consent and/or physician's order for two residents who were using physical restraints, as required by facility policy. For one resident with severe cognitive impairment, the bed was observed in a low position multiple times, but there was no documentation of a Safety Device Evaluation, physician's order, or care plan intervention related to this practice. Staff confirmed that such documentation and orders were required but not present in the resident's electronic health record or care plan. For another resident with moderate cognitive impairment, the bed was observed placed against the wall on several occasions, but again, there was no Safety Device Evaluation, physician's order, or care plan intervention documented. Staff interviews revealed that the bed was moved against the wall at the resident's request to prevent rolling out, but staff were unaware of the need for evaluation and documentation. The Director of Nursing confirmed that it was expected for evaluations, consents, and physician's orders to be in place for beds in low positions or against the wall, but these were not completed for the residents involved.
Failure to Develop Comprehensive Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents with complex medical and behavioral needs. For one resident with severe cognitive impairment and a diagnosis of PTSD, the care plan did not address the use of a low bed as a physical restraint, nor did it include a focus, goal, or intervention related to PTSD until several months after admission. Staff interviews confirmed that a care plan for the low bed and PTSD should have been in place upon admission, but these were not initiated until much later. Another resident with severe cognitive impairment and a diagnosis of dementia was prescribed an antianxiety medication, Lorazepam, but the care plan did not address the use of this medication or the resident's dementia diagnosis. The care plan for the antianxiety medication was not initiated until over a month after the medication was ordered, and there was no care plan focus on dementia at all. Staff acknowledged that both the medication and dementia diagnosis should have been included in the care plan from the time of prescription and admission, respectively. A third resident, moderately cognitively impaired and diagnosed with chronic atrial fibrillation, was prescribed an anticoagulant medication, Dabigatran Etexilate Mesylate. The care plan did not include any focus or intervention related to the use of this anticoagulant, despite ongoing administration of the medication. Staff interviews confirmed that the anticoagulant should have been addressed in the care plan, but it was not present.
Failure to Provide Restorative Services as Recommended
Penalty
Summary
The facility failed to provide restorative aid (RA) services to a resident with multiple diagnoses who was severely cognitively impaired and required assistance to maintain their current level of function. Documentation showed that the resident had been recommended for a restorative program following discharge from physical therapy, including specific interventions such as sit-to-stand exercises, use of a transfer pole, and sessions with an Omni Cycle. Despite these recommendations, the resident's electronic health record did not show evidence that the RA services were provided as ordered. Interviews with facility staff revealed a lack of awareness and follow-through regarding the resident's need for restorative services. The Resident Care Manager/Restorative Therapy Manager stated the resident did not meet requirements for a restorative program, while the Director of Rehabilitation confirmed that restorative services had been recommended after physical therapy discharge. The Director of Nursing was not aware that the resident was not receiving the restorative program. This failure to implement the recommended restorative interventions was not in accordance with the facility's policy to maintain residents' highest level of self-care and independence.
Failure to Implement Physician Orders for Physical Restraints and Weight Monitoring
Penalty
Summary
The facility failed to implement physician orders and care plans for two residents, resulting in deficiencies related to physical restraints and weight monitoring. For one resident with moderate cognitive impairment and a history of unsteady gait and dizziness, the care plan and physician orders specified the use of a right-sided 1/4 size bed rail (mobility bar) to assist with bed mobility and transfers. Observations on multiple occasions revealed that the bed rail was not installed, and both staff and the resident confirmed that it had never been put in place since admission, despite the documented order and consent. Another resident, also moderately cognitively impaired and diagnosed with congestive heart failure, had a physician order for daily weights with instructions to notify the physician if weight gain exceeded specified thresholds. Record reviews showed multiple instances of significant weight gain without documentation of physician notification, as well as repeated failures to obtain daily weights on numerous days across several months. Staff interviews confirmed the absence of required documentation and acknowledged that the physician had not been notified as ordered.
Failure to Monitor for Adverse Effects of Antianxiety Medication
Penalty
Summary
The facility failed to monitor for adverse side effects in a resident who was prescribed an antianxiety medication, Lorazepam 0.5mg as needed for anxiety. The resident, who had multiple diagnoses including severe cognitive impairment due to dementia, was admitted to the facility and began receiving Lorazepam according to a physician's order. However, review of the electronic medication administration records for October and November showed that while the medication was administered, there was no documentation of monitoring for adverse side effects. Staff interviews confirmed that monitoring was expected but not performed, and the required order for monitoring was not placed until 32 days after the medication was initially ordered.
Failure to Use PPE During Resident Transfer on Contact Precautions
Penalty
Summary
Staff failed to use appropriate personal protective equipment (PPE) when providing care to a resident on contact precautions. Specifically, during an observed transfer of a resident who was alert, oriented, and dependent on staff for transfers using a Hoyer lift, two certified nurse assistants (CNAs) assisted with the transfer without wearing isolation gowns as required for contact precautions. The resident had a physician order for contact precautions in place. The Director of Nursing confirmed in an interview that staff are expected to wear PPE when transferring residents on contact precautions.
Failure to Accurately Post and Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nursing hours were accurately posted and updated daily for all days reviewed. Record review showed that the Daily Staffing Hours postings were not updated throughout the day to reflect actual staffing changes, but instead were taken down and corrected the following morning. Interviews with the staffing coordinator and the DON confirmed that staffing numbers and hours for each shift were not updated as changes occurred, and that the postings provided for review were corrected copies from the next day, not real-time updates. The staff involved were unaware that updates were required throughout the day and acknowledged that the postings were not being completed correctly.
Failure to Monitor Blood Glucose in Diabetic Resident
Penalty
Summary
The facility failed to ensure adequate blood sugar monitoring for a resident receiving oral diabetic medications, which led to a significant health event. The resident, who was cognitively intact and diagnosed with Type 2 Diabetes Mellitus without complications, was admitted without orders for blood glucose monitoring despite being prescribed Metformin and Glipizide. On a particular day, the resident exhibited left-sided weakness, prompting staff to suspect a stroke. However, the resident was later found to have severe hypoglycemia with a blood glucose level of 30 upon being taken to the hospital, where symptoms resolved with normalization of blood sugars. Interviews with facility staff revealed that routine blood glucose checks were not performed for non-insulin dependent diabetic residents unless specifically ordered by a physician. Staff members indicated that they typically relied on Hemoglobin A1C levels for monitoring stable residents. The facility's policy, however, suggested more frequent monitoring for residents on oral medications, especially if poorly controlled. The lack of blood glucose monitoring for this resident, despite the facility's policy and the resident's change in condition, contributed to the oversight and subsequent health event.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper care and monitoring of pressure ulcers for a resident, leading to the worsening of an existing ulcer and the development of a new one. Resident 51, who was admitted with a nearly healed Stage 2 pressure ulcer on the coccyx, did not receive documented weekly skin audits for three weeks following admission. Additionally, the Braden Risk Assessments were not conducted consistently, with a significant gap between December 2023 and June 2024. The care plan for skin integrity and nutrition was not initiated until a month after admission, despite the resident being at risk for pressure ulcers. The new pressure ulcer on the right buttock and upper thigh was documented on December 21, 2023, but treatment was not initiated until January 24, 2024, 34 days later. The facility's Wound Management Guidelines were not followed, as the resident's skin alterations were not promptly investigated or addressed. The resident was not provided with appropriate pressure-relieving equipment, such as a special wheelchair cushion or pressure-relieving mattress, until weeks after admission. Staff interviews revealed a lack of communication and documentation regarding the resident's condition and care needs. The Director of Nursing Services was unable to provide an investigation report for the new pressure ulcer, and the Registered Dietitian was not informed of the resident's nutritional risk upon admission. These oversights contributed to the resident's condition deteriorating, resulting in hospitalization for suspected osteomyelitis and surgical intervention.
Failure to Obtain Required Documentation for Bed Restraints
Penalty
Summary
The facility failed to ensure that an assessment, consent, and physician order were obtained for the use of physical restraints, specifically for beds being placed against the wall and the use of bed rails, for four out of five sampled residents. This deficiency was identified through observations, interviews, and record reviews. The facility's policy on the use of restraints, revised in April 2017, mandates that restraints should only be used upon a physician's written order and after obtaining consent from the resident or their representative. Resident 5, who was alert and oriented, was observed multiple times with their bed against the wall and half-length bed rails raised on both sides. However, their electronic health record (EHR) did not contain any physician orders, assessments, or consents for these arrangements. Similarly, Resident 31, who was moderately cognitively impaired, had their bed against the wall without any documented assessment, consent, or physician orders. Observations confirmed the bed's position against the wall on several occasions. Resident 61, who was alert and oriented, also had their bed against the wall without the necessary documentation. When questioned, the resident was unaware of the reason for this arrangement. Resident 189, another alert and oriented resident, had their bed against the wall without any assessment, consent, or physician orders. Staff members, including the Resident Care Manager and the Director of Nursing, acknowledged the lack of required documentation and expressed that assessments, consents, and physician orders should have been completed for these residents.
Failure to Maintain Dignity in Catheter Care
Penalty
Summary
The facility failed to ensure that care and services were provided in a manner that promoted residents' dignity, specifically concerning urinary catheter care for two residents. Resident 11, who was moderately cognitively impaired and had an indwelling catheter, was observed multiple times with the foley catheter drainage bag uncovered, contrary to the care plan that required the drainage bag to be covered for dignity. Observations included the drainage bag hanging off the side of the bed uncovered and, at one point, lying on the floor without a hook or privacy bag. Staff members acknowledged that the drainage bags should be covered and not placed on the floor, indicating a lapse in following the care plan. Similarly, Resident 39, also moderately cognitively impaired with an indwelling catheter, was observed with the foley catheter drainage bag uncovered on several occasions, both in bed and in the rehabilitation gym. The care plan for Resident 39 also required the drainage bag to remain covered, yet observations showed the bag uncovered and visible from the hallway. Staff, including the Director of Nursing Services, confirmed the expectation that catheter drainage bags should be covered and not placed on the floor, highlighting a consistent failure to adhere to the dignity-promoting measures outlined in the residents' care plans.
Failure to Conduct and Document Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were offered the opportunity to participate in care conferences, specifically for one resident who was part of a sample of six reviewed for the right to participate in planning care. Resident 53, who was alert and oriented, was admitted to the facility and had a quarterly Minimum Data Set (MDS) assessment conducted. However, the electronic health records (EHR) only documented a care conference on one occasion, despite the expectation that care conferences should occur quarterly, as needed, or during significant changes. Interviews with staff, including the Social Services Coordinator, Social Services Director, and Director of Nursing Services, confirmed that care conferences were expected to be conducted quarterly and documented in the EHR, but this was not done for Resident 53.
Failure to Review Advance Directives
Penalty
Summary
The facility failed to have procedures in place to assist with completing advance directives (AD) and maintaining Durable Power of Attorney (DPOA) documentation for a resident. The resident was admitted to the facility and was noted to be alert and oriented during a quarterly assessment. However, the resident's electronic health record did not show any ADs or documentation that ADs were reviewed since March 2024, despite the resident's care plan indicating they did not want to execute an AD at that time. Staff members acknowledged that the AD should have been reviewed during a care conference in June 2024, but this did not occur.
Failure to Address Grievances on Lost Items
Penalty
Summary
The facility failed to ensure a timely response and resolution to grievances regarding lost items for two residents. Resident 50, who was alert and oriented, reported his manual wheelchair missing after returning from a hospital transfer. Despite informing a Certified Nursing Assistant and filling out a Lost, Misplaced, Damaged Item form, the issue was not promptly addressed. The Social Services Coordinator acknowledged the missing wheelchair and forwarded the matter to the Administrator, who only became aware of the issue much later. This delay in addressing the grievance resulted in the resident not having his concerns resolved in a timely manner. Similarly, Resident 286, also alert and oriented, reported missing personal laundry items shortly after admission. Despite her efforts to retrieve some items from the laundry room, several items remained missing. The Resident Care Manager was unaware of the issue until she found a notification slip in her mailbox, indicating a lack of communication and timely action in resolving the resident's grievance. These incidents highlight the facility's failure to adhere to its grievance policy, leading to unresolved resident concerns.
Failure to Provide Bed-Hold Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide a written bed-hold notice to residents or their representatives at the time of transfer to the hospital for two of the six sampled residents. Resident 36, who was severely cognitively impaired, was transferred to an acute hospital, but there was no documentation indicating that contact was made with the resident or their family regarding a bed-hold. Staff F, the Admissions Coordinator, acknowledged that the bed-hold agreement should have been documented in the electronic health records (EHR), but was unable to find any such documentation for Resident 36. Similarly, Resident 31, who was moderately cognitively impaired, was hospitalized and returned to the facility without any documentation of a written bed-hold notice. Staff F stated that the admissions department is responsible for completing the bed-hold form and making a progress note if they cannot reach the resident or their representative. However, no bed-hold notice was found for Resident 31. Staff B, the Director of Nursing Services, admitted that the facility did not comply with the requirement to follow up with the resident's representative and offer a bed-hold notice.
Failure to Implement Comprehensive Care Plan for Skin Conditions
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with skin conditions, specifically abrasions and blisters on the feet. The resident, who was alert and oriented, was admitted with an open lesion on the foot. Physician orders detailed specific wound care instructions for multiple abrasions and a blister on the resident's feet, including cleansing and dressing changes. However, the resident's comprehensive care plan did not include any focus area, goals, or interventions related to these skin conditions. During an observation, the resident was seen with foam dressings on the right foot, and staff interviews revealed a lack of a documented care plan for the resident's skin conditions. The Resident Care Manager acknowledged the absence of a care plan and expressed confusion about why it was missing. The Director of Nursing Services confirmed that it was expected for skin care plans to be in place for residents with such conditions, indicating a lapse in the facility's care planning process.
Failure to Ensure Proper Wheelchair Positioning
Penalty
Summary
The facility failed to provide necessary care and services for proper positioning in a wheelchair for a resident diagnosed with Inclusion Body Myositis (IBM). The resident, who was alert and oriented but had functional impairments, required a motorized wheelchair for mobility. Observations revealed that the resident was leaning to the left side in the wheelchair, with the left armrest misaligned and the wheelchair tilted. The resident reported discomfort and stated that the wheelchair did not fit correctly, causing him to run into his bed and the wall due to the controller's position under his stomach. Despite the resident's complaints and the vendor's acknowledgment of a broken part, no follow-up or assessment was conducted to address the fit and functionality of the wheelchair. Staff interviews indicated a lack of communication and responsibility regarding the resident's wheelchair issues. The Resident Care Manager and Director of Nursing Services were unaware of the plan for wheelchair repair, and the Therapy Director could not find documentation of an assessment for the wheelchair fit. The resident care staff attempted temporary fixes, such as padding the bed frame and removing back support pieces, but these actions did not resolve the underlying issue. The failure to assess and address the resident's wheelchair fit and functionality led to discomfort and potential safety risks for the resident.
Infection Control Deficiencies in Wound and Catheter Care
Penalty
Summary
The facility failed to implement proper infection control and prevention practices during a dressing change for a resident with a pressure ulcer. Resident 51, who was alert and oriented, had a Stage 4 pressure ulcer on the right ischium. During an observation of wound care, a Licensed Practical Nurse (LPN) did not wash her hands after removing the old dressing and before putting on clean gloves to continue with the wound care. This action was contrary to the expected procedure as stated by the Infection Control Nurse and the Director of Nursing Services, who both emphasized the importance of hand hygiene between glove changes during wound care. Additionally, the facility did not adhere to its policy regarding catheter care for Resident 11, who had an indwelling catheter and was moderately cognitively impaired. The resident's catheter drainage bag was observed lying on the floor, folded in thirds, without a hook to hang it or a privacy bag to cover it. This was against the facility's policy, which required catheter bags to be kept off the floor and covered. Staff members, including a Certified Nursing Assistant and the Resident Care Manager, acknowledged that the catheter bag should not have been on the floor and should have been properly secured and covered.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
