Avamere Rehabilitation Of Issaquah
Inspection history, citations, penalties and survey trends for this long-term care facility in Issaquah, Washington.
- Location
- 805 Front Street, Issaquah, Washington 98027
- CMS Provider Number
- 505004
- Inspections on file
- 23
- Latest survey
- March 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Issaquah during CMS and state inspections, most recent first.
The facility did not ensure timely and accurate completion of PASRR assessments for several residents with serious mental illness or intellectual disabilities. Multiple residents were admitted or experienced significant changes in condition without required Level 2 evaluations, despite documented indicators of SMI on Level 1 PASRR screenings. Staff interviews confirmed that necessary referrals and documentation were not completed as required.
The facility did not have a documented water management plan to prevent Legionella, and staff failed to follow hand hygiene and contact precaution protocols during resident care. Staff provided incontinence care without changing gloves or performing HH between dirty and clean tasks, and an Activity Assistant entered a contact precautions room without required PPE or hand hygiene.
The facility did not disburse trust fund balances to several residents or their representatives within the required 30-day period after discharge, with some accounts remaining undistributed for over a month. This failure was confirmed by record review and staff interview, showing that trust funds were not reconciled in accordance with policy and state regulations.
Two residents experienced unresolved grievances related to missing personal items—dentures and a hearing aid—after staff failed to follow the facility's grievance policy, did not log or investigate the concerns, and did not communicate outcomes to the residents or their representatives.
The facility did not ensure accurate MDS assessments for two residents, resulting in one resident's mental health status and skin condition being incorrectly documented, and another resident's discharge destination being inaccurately coded. These errors were confirmed by the MDS Coordinator upon review of clinical records and interviews.
The facility did not update care plans for two residents, resulting in outdated interventions such as incorrect fall prevention measures and tube feeding instructions, and failed to conduct timely care conferences for another resident with multiple diagnoses. Staff confirmed that care plans and care conferences were not maintained according to policy.
Staff failed to consistently follow physician orders and medication administration protocols, including not documenting administered medications, signing off on uncompleted tasks, not clarifying unclear or changed orders, and administering medications outside of prescribed parameters. These actions affected several residents, including those with pain management needs, wound care, and other medical conditions.
Three residents dependent on staff for ADLs did not consistently receive required assistance with personal hygiene, including bathing, shaving, and nail care. One resident was repeatedly observed with long facial stubble and reported not receiving scheduled showers or shaving, while another had long fingernails despite being scheduled for regular nail care. A third resident was observed with long chin hairs and broken nails, with documentation not matching observed care. Staff interviews confirmed expectations for care and documentation were not met.
The facility did not ensure that two residents' code status preferences, as indicated on their POLST forms and physician orders, were accurately reflected in all care documentation. In both cases, documentation such as the care plan and Kardex listed the residents as Full Code, despite their wishes and orders for DNAR status. Staff interviews confirmed reliance on these documents for care decisions, highlighting the inconsistency in records.
Two residents with significant cognitive and physical impairments did not receive individualized activity programs as outlined in their care plans. Documentation and observations showed limited engagement in preferred activities, with one resident mostly found sleeping and another rarely participating in group events. The activity director confirmed inconsistent implementation of activity preferences and a lack of regular reassessment or updates to care plans.
The facility failed to obtain timely and complete laboratory services for two residents, resulting in missed or invalid blood tests that were ordered by physicians to monitor complex medical conditions and medication levels. In both cases, required labs were either not performed or not documented as completed, and staff did not follow expected procedures for addressing missed lab draws.
The facility failed to accurately assess and implement safety measures for three residents, including not obtaining or following physician orders for independent outings, not consistently applying fall prevention interventions for a resident with severe impairments, and not performing required smoking safety assessments or updating care plans for a resident who smoked independently. These lapses resulted in unaddressed accident hazards and inadequate supervision.
Failure to Complete Timely and Accurate PASRR Assessments for Residents with Mental Health Needs
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were accurately completed and obtained prior to admission for several residents with serious mental illness (SMI) or intellectual disabilities. For multiple residents, Level 1 PASRR screenings identified indicators of SMI, such as mood disorders, anxiety, depression, and bipolar disorder, yet no required Level 2 evaluations were completed prior to admission as mandated. In some cases, the PASRR forms were incomplete, unsigned, or not properly indicating the need for further evaluation, and referrals for Level 2 assessments were either delayed or not documented at all. One resident was admitted with a diagnosis of bipolar disorder and required antipsychotic medication, with a Level 1 PASRR indicating SMI, but no Level 2 evaluation was completed before admission. Another resident with anxiety and depression, also requiring psychotropic medications, was admitted without a Level 2 evaluation despite SMI indicators on the PASRR. For a third resident, two separate Level 1 PASRRs over a seven-month period both indicated the need for a Level 2 evaluation due to a mood disorder, but no such evaluation was found in the records. Staff interviews confirmed that these evaluations should have been completed and that documentation was lacking. Additional deficiencies included a resident with dementia and depression whose PASRR form was not signed or dated and lacked a Level 2 evaluation, and another resident who experienced a significant change in health status, including a suicide attempt and use of multiple psychotropic medications, but was not referred for a Level 2 PASRR until eight months after the change. Staff acknowledged these omissions and delays during interviews, confirming that the required processes were not followed as specified.
Failure to Implement Infection Control and Water Management Protocols
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program. Specifically, the facility did not have a documented water management plan to prevent the growth of Legionella and other waterborne pathogens. The Maintenance Director was unable to provide documentation of a water management plan, committee meetings, or testing records, and was unaware of high-risk areas in the water system. The Infection Preventionist provided a policy stating that a water management committee should review the plan quarterly, but there was no evidence this occurred. The Administrator confirmed the absence of a water management plan. Additionally, staff failed to perform proper hand hygiene (HH) and follow contact precaution protocols. During incontinence care for a resident dependent on staff for all activities of daily living and receiving tube feeding, staff did not change gloves or perform HH when moving from dirty to clean tasks, and contaminated clean linens and equipment with soiled gloves. Staff also failed to dispose of dirty linens appropriately. In another instance, an Activity Assistant entered a resident's room on contact precautions without performing HH or donning required personal protective equipment, and did not wash hands upon leaving. Staff interviews confirmed awareness of the correct procedures, but these were not followed during the observed events.
Delayed Disbursement of Resident Trust Funds After Discharge
Penalty
Summary
The facility failed to ensure that resident trust fund balances were reimbursed to the appropriate parties within the required 30-day period following discharge or death, as mandated by both facility policy and state regulations. Specifically, for four out of seven discharged residents reviewed, trust fund balances were either not disbursed within the required timeframe or remained undistributed beyond 30 days. For example, one resident's balance was not closed out and disbursed until 64 days after discharge, another after 59 days, and a third after 34 days. In one case, a resident's trust fund balance remained active and undistributed 33 days after discharge. Facility policy required that trust funds be disbursed within seven days for discharged residents and within 30 days for deceased residents. However, record review and staff interviews confirmed that these timelines were not met for the affected residents. The Business Office Manager acknowledged that the trust accounts for these residents should have been disbursed as required but were not, resulting in delays in reconciling the residents' accounts.
Failure to Initiate and Resolve Grievances for Missing Personal Items
Penalty
Summary
The facility failed to properly initiate, log, investigate, and resolve grievances for two residents who reported missing personal items, as required by their grievance policy. For one resident with moderate cognitive impairment and dental issues, staff documented a grievance regarding ill-fitting dentures and initiated some follow-up with the dental provider. However, when it was discovered that the resident's dentures were missing, staff did not complete a new grievance communication form or inform the administrator, resulting in the issue not being tracked or resolved according to policy. Another resident, who had hearing difficulties and used hearing aids, lost one hearing aid after returning from a hospital stay. Multiple staff members and the resident's representative were aware of the missing hearing aid, and the outside provider also notified staff about the loss. Despite this, there was no documentation in the facility's grievance or investigation logs acknowledging or investigating the missing hearing aid, and the administrator was not made aware of the issue. Interviews with staff revealed that the facility's process for missing items was not followed, as staff failed to initiate grievance forms and did not communicate the outcomes to the residents or their representatives. The lack of oversight and failure to track grievances through to their conclusion resulted in unresolved concerns regarding residents' missing personal items.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the clinical status of two residents. For one resident with multiple complex medical diagnoses, including anxiety disorder and depression, the annual MDS did not indicate the presence of a Serious Mental Illness (SMI) as determined by a prior Level 2 PASRR evaluation, despite documentation showing the resident required specialized behavioral health services. Additionally, a quarterly MDS for the same resident inaccurately reported the presence of a pressure ulcer, scar, or non-removable dressing/device, even though nursing progress notes and a weekly skin audit documented intact skin with no wounds or such devices present during the assessment period. The MDS Coordinator confirmed these inaccuracies during interviews and acknowledged the importance of accurate MDS coding for care planning. For another resident, the discharge MDS was incorrectly coded to indicate discharge to an acute care hospital, while nursing progress notes documented that the resident was actually discharged home in stable condition with their spouse. The MDS Coordinator reviewed the assessment and confirmed the error, stating that the MDS required modification to accurately reflect the resident's discharge disposition.
Failure to Update Care Plans and Conduct Timely Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were updated and revised as needed for two residents and did not conduct timely care conferences for another resident. For one resident who was dependent on staff for toileting and transfers and at risk for falls, the care plan directed staff to keep the bed in the lowest position, but repeated observations showed the bed was not in the lowest position. Additionally, the care plan still included interventions for cellulitis and antibiotic administration, despite the resident no longer having cellulitis or receiving antibiotics. Staff interviews confirmed that the care plans were outdated and needed revision. Another resident with complex medical needs, including a feeding tube, had conflicting care plan interventions regarding the type and amount of tube feeding formula. The care plan was not updated to reflect the current physician order for a fiber formula, as confirmed by staff. For a third resident with multiple diagnoses, including stroke and difficulty swallowing, there was no evidence of quarterly care conferences, and the resident was unaware of any meetings regarding their care plan or denture issues. Staff acknowledged that care conferences should occur quarterly and as needed for significant changes, but documentation was lacking.
Failure to Follow Physician Orders and Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that physician's orders (POs) were followed and medications were administered within the prescribed parameters for multiple residents. In several instances, staff did not document administered medications as required, such as when a charge nurse gave a non-narcotic pain medication to a resident but failed to record the administration in the Medication Administration Record (MAR). Additionally, staff signed off on tasks, such as diabetic nail care, that were not completed as ordered, as evidenced by observations of a resident with long, untrimmed fingernails despite documentation indicating the care had been performed. There were also failures to clarify physician orders when changes occurred. For example, after a resident's wound care order was changed from daily to every other day, staff continued to administer a narcotic pain medication daily without clarifying the order with the prescriber. Another resident had a vitamin order lacking a specified dosage, which was not clarified before administration. In some cases, staff administered medications outside of the ordered parameters, such as giving a suppository without first administering a required liquid laxative, or providing pain medications in dosages or for pain levels not consistent with the physician's instructions. Multiple residents received as-needed (PRN) pain medications in ways that did not align with their prescribed parameters. For instance, residents were given narcotic pain medications for pain scores that did not meet the threshold specified in the orders, or were given lower doses than ordered for higher pain scores. Staff interviews confirmed that medications were not always administered as ordered and that orders were not always clarified when necessary, leaving residents at risk for unmet care needs and other negative health outcomes.
Failure to Provide Required ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were dependent on staff for personal hygiene and grooming. One resident, with cognitive impairment and multiple diagnoses including heart failure and malnutrition, was observed on several occasions with long facial stubble and reported not receiving scheduled showers or shaving assistance. Documentation showed significant gaps between bathing offers, and there was no record of staff reapproaching the resident after refusals or documenting these refusals as required by facility policy. Another resident, who was dependent on staff for personal hygiene and required assistance with nail care, was observed multiple times with long fingernails. The resident stated that staff were supposed to clip their nails but did not do so. Staff interviews confirmed that nail care should be provided weekly and as needed, with refusals documented, but observations indicated this care was not consistently provided. A third resident, also dependent on staff for personal hygiene and requiring weekly diabetic nail care, was observed with long, curly chin hairs and fingernails extending past the fingertips, including broken and jagged nails. Documentation indicated that scheduled nail care was marked as completed, but observations contradicted this, and staff confirmed that shaving and nail care should be provided as needed. There was no documentation of refusals for personal hygiene or bathing, and staff only addressed the long nails after they were noticed during an observation.
Failure to Accurately Reflect Resident CPR Status in Records
Penalty
Summary
The facility failed to ensure that physician orders and resident records accurately reflected the residents' wishes for Cardiopulmonary Resuscitation (CPR) status as indicated on their Physician Orders for Life Sustaining Treatment (POLST) forms. For one resident, the POLST form and physician orders indicated Do Not Attempt Resuscitation (DNAR), but other documentation, including a revised care plan and Kardex, incorrectly listed the resident as Full Code, directing staff to perform CPR. The facility's POLST binder did contain the correct DNAR form, but this was not consistently reflected across all records. Staff interviews confirmed that the records did not match the resident's wishes and required correction. For another resident, a significant change in health status led to a transition from life-prolonging care to hospice care, with a new POLST form indicating DNAR and selective treatment. However, the resident's Kardex still listed them as Full Code. Staff interviews revealed that care staff relied on the Kardex and care plan to determine code status and initiate CPR if indicated. The inconsistency between the POLST, physician orders, and care documentation resulted in a failure to ensure that staff had accurate information regarding the residents' code status.
Failure to Implement Individualized Activity Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized activity plans and ensure activity programs met the needs of each resident for two of five residents reviewed. For one resident with no speech, poor vision, and total dependence on staff for daily activities, the care plan identified preferences such as listening to music, being around pets, group activities, and religious practices. However, activity participation records showed the resident was mostly documented as sleeping during 1:1 activities, with only a few days marked as active. Observations confirmed the resident was consistently found lying in bed with no music playing, and there was no evidence of participation in group or religious activities. The activity director acknowledged that music was not played in the room due to concerns about disturbing the roommate and had not considered alternatives like headphones. The director also admitted that staff did not consistently offer or assist the resident with preferred activities. Another resident with severe memory impairment and dependence on staff for mobility was assessed to enjoy music, animals, news, and religious activities. The care plan directed staff to provide daily activity materials, assistance to group activities, pet visits, and 1:1 activities. Despite this, activity documentation showed minimal participation in group activities, with only a few instances recorded over two months. Observations found the resident lying in bed with only the television on, and there were no activity progress notes or quarterly assessments completed. The activity director stated that reminders for activities were inconsistent and that residents who were sleeping were not disturbed. The director also admitted to not conducting regular assessments or updating care plans as residents' needs changed. The facility's policy required an activities program addressing each resident's intellectual, social, spiritual, creative, and physical needs, promoting self-expression and choice. However, the facility did not consistently implement individualized activity plans or ensure that residents received activities aligned with their preferences and needs, as evidenced by documentation, observations, and staff interviews.
Failure to Obtain Timely Laboratory Services for Two Residents
Penalty
Summary
The facility failed to provide timely laboratory services for two residents who required physician-ordered blood tests. For one resident with multiple complex medical conditions, including anemia, heart failure, kidney, and lung disease, laboratory tests were ordered to monitor inflammation and infection as part of wound care management. The initial blood specimen collected was invalid due to the age of the sample, and the tests were not performed. A subsequent order for the same tests resulted in another invalid specimen for one of the tests, again due to specimen age. Despite repeated orders, one of the required tests was never successfully obtained over a period of more than six weeks. For another resident receiving heart failure medication, there was a standing order for regular blood draws to monitor medication levels. The scheduled lab draw was not completed as ordered, and there was no documentation in the progress notes explaining the missed lab or any follow-up. Staff interviews confirmed that the expected procedures for reattempting lab draws and documenting refusals or missed labs were not followed.
Failure to Ensure Resident Safety and Accident Prevention
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for multiple residents, resulting in deficiencies related to accident hazards and resident safety. One resident with a history of substance abuse and behavioral issues was able to leave the facility independently on two occasions without a physician's order or proper assessment of their ability to do so safely. Documentation showed that staff did not inform the physician when the resident left the facility, and the care plan was only updated after these incidents to include procedures for signing out, notifying representatives and the physician, and following up with the resident while out of the facility. Another resident with severe memory and vision impairment, who was dependent on staff for transfers and at high risk for falls, did not have prescribed fall prevention interventions consistently implemented. Observations revealed that the resident's bed was not kept in the lowest position as ordered, fall mats were not placed on both sides of the bed as directed, and non-skid footwear was not used, despite clear care plan instructions and physician orders. Staff interviews confirmed that these interventions were expected to be in place to prevent falls and injuries. A third resident, who was dependent on staff for transfers and used a wheelchair, was allowed to smoke independently without consistent quarterly safety assessments as required by the care plan. The resident kept smoking supplies at the bedside in a locked drawer, which was not reflected in the care plan, and had not signed a current smoking policy and consent after a change in facility ownership. Staff acknowledged that several required smoking safety assessments were missed, and the facility's smoking policy did not address the practice of keeping supplies at the bedside for independent smokers.
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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