Avamere Rehabilitation Of Shoreline
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 1250 Northeast 145th Street, Seattle, Washington 98155
- CMS Provider Number
- 505009
- Inspections on file
- 34
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Shoreline during CMS and state inspections, most recent first.
The facility failed to follow its abuse reporting guidelines by not documenting or timely reporting multiple resident allegations of rough care and possible misappropriation of property to the State Agency. A resident with dementia reported that another resident repeatedly entered her room and took clothing and other items, including an incident where the intruding resident removed a pillow at night and was removed by nursing staff, yet no incident entries or state reports were made. Another resident with dementia and mobility issues told social services staff that male caregivers were "a little rough" when getting him out of bed, but this was not reported to nursing, investigated, or logged as an incident.
The facility failed to thoroughly investigate multiple abuse-related allegations. A resident with dementia reported that another resident repeatedly entered her room and took clothing and a pillow, but no related incidents were documented in the facility’s logs and the allegation was not reported to the State Agency. The alleged perpetrator had dementia with behavioral disturbance and a care plan noting wandering into other residents’ rooms, yet no incidents involving either resident were logged over several months. Another resident with dementia and mobility issues reported that male staff were rough when getting him out of bed; this concern was documented on a resident interview form but was not reported to nursing, not entered into the incident log, and no investigation was initiated, despite staff training and stated expectations for timely investigation of all reported allegations.
A resident who required substantial assistance with personal hygiene and had diabetes and bilateral below-knee amputations did not have a comprehensive care plan addressing diabetic fingernail care, and observations showed long, dirty fingernails on multiple occasions, including after a shower. Staff interviews confirmed that nail care for residents with diabetes should be performed by nurses and that CNAs rely on the Kardex for ADL instructions, yet no specific fingernail care plan was in place. The same resident had a documented care plan and Kardex instructions for daily prosthesis use and shrinker socks when prostheses were off, but was observed in bed without shrinker socks while the prostheses were off, despite staff acknowledging that shrinker socks should have been applied according to the care plan.
A resident with diabetes who required substantial assistance with personal hygiene did not receive adequate nail care as part of ADLs. Facility policy and the care plan required staff support with hygiene, yet the resident was repeatedly observed with long fingernails and brown material under the nails, even after a shower, and reported that nail trimming was inconsistent. A CNA stated the resident needed total care and confirmed the nails were long and dirty. Nursing staff, including an LPN and Resident Care Manager, indicated that nurses were responsible for nail trimming for residents with diabetes and that a physician order should be present and documented in the MAR, but no such order existed. The DON stated that dependent residents should receive ADLs including nail care and that nails should not be long and dirty, demonstrating that the resident’s ADL and hygiene needs were not met.
Two residents were subjected to physical abuse by another resident with severe cognitive impairment and a history of agitated behavior. In one incident, the aggressor grabbed a resident with severe cognitive impairment by the hair and shook them, an event witnessed by an RCM and later substantiated as abuse, though no injuries were found. Shortly afterward, while the same RCM was present, the aggressor grabbed another resident with intact cognition by the arm as they sat in a wheelchair conversing in the hallway, causing a skin tear and multiple bruises that required treatment and monitoring. Staff reported the aggressor had a temper, rapid mood swings, and had recently refused prescribed psychotropic and antidepressant medications on several consecutive days prior to these events.
A resident admitted under an exempted hospital discharge with documented indicators of SMI, mood disorder, and functional limitations related to behavioral health did not receive a required Level II PASARR when their stay extended beyond 30 days. The Level I PASARR noted no Level II was needed initially due to the exempted status but specified that a Level II must be completed if the planned discharge did not occur. The resident remained in the facility for more than 30 days, yet the EHR contained no Level II PASARR, and the SSD later acknowledged not realizing the resident had been admitted under an exempted hospital discharge, while the administrator confirmed a Level II should have been completed within the 30-day timeframe.
The facility failed to provide adequate supervision and behavioral interventions for a cognitively impaired resident with a known history of aggression, resulting in two resident-to-resident altercations in a hallway. In the first incident, the aggressive resident forcefully pulled another cognitively impaired resident’s hair. About 40 minutes later, while being monitored by an RCM, the same resident suddenly grabbed a cognitively intact resident’s arm as they sat in a wheelchair talking with another resident, causing a significant skin tear and bruising that required basic first aid. Staff interviews described the aggressive resident as having a temper, mood swings, and becoming quickly angry when their wants were not met, and confirmed that staff were unable to stop the second assault despite being present.
A resident with heart failure and impaired kidney function was not informed when their Potassium Chloride supplement was placed on hold for thirteen days due to abnormal lab results. Staff interviews confirmed that residents should be notified of medication changes, but there was no documentation or evidence that this notification occurred.
A resident with venous ulcers and lymphedema did not receive wound care and compression therapy as ordered by the physician. Nursing staff documented treatments as completed in the TAR before actually performing them, and dressings were found unlabeled. Interviews confirmed that staff did not follow facility policy or professional standards regarding treatment administration and documentation.
An LPN performed wound care assessments and documentation for a resident with a severe pressure injury without RN or wound care specialist oversight, and without having completed a competency skills checklist. The LPN was not wound care certified, did not perform full wound assessments or staging, and documented based on previous assessments. Facility leadership confirmed that wound assessment is not within the LPN's scope of practice and that no competency verification was on file.
A resident's abuse allegation was not thoroughly investigated, as required witness interviews were not documented and the implicated staff member was allowed to work before the investigation was completed, contrary to facility protocol and federal guidelines.
The facility did not ensure that services provided met professional standards of quality, as identified by surveyors through observation and review of facility practices. No additional details about the specific actions or individuals involved were provided.
Two residents with Type 2 Diabetes who were prescribed a diabetic diet and scheduled insulin were served and consumed cornbread, which was not permitted according to their dietary orders and the facility's dietary spreadsheet. Staff, including the RD and kitchen cook, confirmed that cornbread should not have been served to these residents, and the DON acknowledged the failure to follow prescribed therapeutic diets.
Expired food was found in a resident refrigerator, the dishwashing machine repeatedly failed to reach the required minimum temperature for sanitation, and a CNA reheated and served a resident's meal without checking or documenting the food temperature as required by policy. Staff interviews confirmed awareness of these requirements, but the deficiencies persisted over time.
Several residents were found self-administering medications and supplements at their bedside without completed assessments, physician orders, or care plan documentation. Staff interviews confirmed that required evaluations and documentation for self-administration were not performed, and medications were accessible to residents without proper authorization.
Surveyors found that several residents' rooms were not maintained in a safe, clean, or homelike manner, with dirty privacy curtains and makeshift pull cords made from plastic bags, fabric strips, and clothing. Staff interviews confirmed these issues had not been properly reported or addressed, resulting in a less than homelike environment.
The facility did not transmit MDS assessments to CMS within the required timeframe for four residents. Discharge MDS assessments were either completed late or not submitted at all, as confirmed by the MDS Coordinator and DON during interviews and record reviews.
Multiple residents were affected by inaccurate MDS assessments, including errors in coding PASARR status, discharge destination, bowel continence, oxygen use, medication administration, urinary catheter use, and bowel patterns. Staff interviews and record reviews confirmed that clinical documentation did not match the MDS entries, resulting in assessment inaccuracies.
Multiple residents did not receive care as outlined in their care plans, including assistance with personal hygiene, diabetic nail care, and urinary catheter management. Observations showed untrimmed nails, unclean eyelids, and overfilled catheter bags, with staff confirming that required interventions were not performed as documented.
The facility did not update or revise care plans for several residents, resulting in missing interventions for range of motion, PASARR recommendations, opioid monitoring, self-administration of medications, and oxygen use. Staff interviews confirmed that care plans were not personalized or reflective of current needs and treatments, contrary to facility policy.
Three residents dependent on staff for ADL support did not receive necessary assistance with personal hygiene, including nail care for a diabetic resident and cleaning of fingernails and eyelids for two others. Staff interviews and observations confirmed that required care was not provided despite care plans and physician orders, resulting in unmet hygiene needs.
Surveyors found that several residents receiving oxygen therapy did not have their oxygen tubing labeled or dated as required by physician orders and facility policy. In addition, a portable oxygen tank was stored unsecured, and one resident was receiving continuous oxygen without any documented physician orders or care plan. Staff interviews confirmed these lapses, and the facility's own policy for oxygen administration was not consistently followed.
The facility did not accurately complete and post daily nurse staffing forms with the current census, actual staff numbers, and hours worked for each shift. Instead, postings displayed outdated information from the previous day, and staff confirmed that the process relied on prior day data rather than real-time updates as required by policy.
The facility did not ensure proper medication administration for four residents, including failure to clarify conflicting medication orders, lack of required mouth rinsing after steroid inhaler use, improper self-administration and storage of inhalers, and failure to prime an insulin pen before injection. Staff did not consistently follow facility policy or manufacturer instructions, resulting in medication management deficiencies.
The facility did not ensure that residents receiving opioids and insulin were monitored for adverse side effects or that non-pharmacological interventions were provided before administering pain medications. For example, a resident on oxycodone lacked documentation of side effect monitoring and non-pharmacological interventions, while another on insulin was not monitored for hypoglycemia or hyperglycemia. Staff confirmed these monitoring practices should have been in place but were not.
Several residents were found with medications and supplements at their bedside without required physician orders or self-administration assessments, and expired medications and supplies were discovered in medication storage areas and crash carts. Staff confirmed these practices did not follow facility policy, and documentation supporting safe self-administration and storage was incomplete or missing.
Surveyors identified that clinical records for several residents were incomplete or inaccurate, including mismatched discharge dates, misfiled hospice documents, a blank medication self-administration evaluation, and missing mental health diagnoses on a PASARR form. Staff confirmed these documentation errors and omissions.
Surveyors identified multiple failures in infection prevention, including staff not performing hand hygiene before and after resident care, not following Enhanced Barrier Precautions for a resident with a urinary catheter, and improper handling of soiled linens. Expired eyewash solutions were found in several locations, and key infection control policies had not been reviewed annually as required. These deficiencies were confirmed through direct observation and staff interviews.
Two residents with urinary catheters were observed to have their catheter drainage bags uncovered and visible from the hallway, contrary to facility policy and individual care plans. Multiple staff, including an LPN, CNA, Resident Care Manager, and DON, confirmed that the bags should have been covered with privacy bags to maintain resident dignity.
A resident's expired guardianship letter was not updated or available in the EHR, and there was no documentation that the facility attempted to obtain current guardianship paperwork. The Administrator confirmed the lapse and the absence of required documentation.
A resident was not given the required Notification of Medicare Non-Coverage (NOMNC) at least two days before the end of their Medicare A coverage. Instead, the NOMNC was provided only one day prior to the last covered day, contrary to facility policy and regulatory requirements. Staff interviews and record review confirmed the notification was not issued within the required timeframe.
Two residents receiving psychotropic medications, including quetiapine, did not have documented non-pharmacological interventions in place as required by facility policy. Staff interviews confirmed that such interventions were expected but not implemented or recorded for these residents.
A resident who began hospice care did not have a Significant Change in Status Assessment (SCSA) MDS completed within the required 14-day timeframe. The MDS Coordinator and DON confirmed the assessment was overdue, resulting in a cited deficiency.
A resident with mental health diagnoses, including schizophrenia and anxiety, had specific interventions recommended in a Level II PASARR evaluation. The facility failed to include these recommendations in the resident's care plan, resulting in a lack of personalized interventions as required by policy.
The facility did not accurately complete PASARR Level I forms or make required Level II referrals for two residents with mental health diagnoses. One resident's depression and anxiety disorder were not documented on the PASARR form, and another resident admitted as an exempted hospital discharge was not referred for Level II screening after remaining in the facility beyond the exemption period. Staff acknowledged these omissions during interviews.
Two residents did not receive care and services in line with professional standards, including missed weekly skin assessments and diabetic nail care for a resident with diabetes and neuropathy, resulting in undocumented wounds, and failure to monitor and manage constipation for another resident, with no administration of prescribed bowel medications or documentation of interventions.
A resident who required substantial assistance with personal hygiene did not receive scheduled podiatry care after returning from a hospital stay, resulting in long, thick, and untrimmed toenails that began to curve into the skin. Staff and the resident confirmed that no podiatry or nail care was provided, despite facility policy and staff acknowledgment that such care was needed.
Two residents with limited ROM did not consistently receive restorative services as care planned. One resident with contractures and cerebral palsy was not on a restorative program and did not receive regular ROM exercises or use of splints, despite staff expectations and care plan directives. Another resident was care planned for daily restorative nursing but had almost no documentation of services provided, with staff citing an EHR error as the cause. Staff interviews confirmed the lack of implementation and documentation of required restorative interventions.
Two residents with urinary catheters did not receive appropriate care as required by physician orders and facility policy. One resident's catheter drainage bag was not emptied as ordered, leading to overflow and a reported UTI, while another resident had a catheter in place without proper care orders or documentation. Staff interviews confirmed expectations for care were not met.
A resident with a colostomy did not have physician orders or documentation for colostomy care, appliance changes, or site monitoring, despite staff and facility policy indicating these were required. Staff interviews and record reviews confirmed the absence of necessary directives in the resident's records.
A resident with a diagnosis of PTSD did not receive a trauma-informed care assessment as required by facility policy. Review of the resident's EHR showed no documentation of such an assessment, and staff confirmed its absence during interviews, despite the expectation that it should have been completed.
A resident reported that another resident entered their room, exposed themselves, and engaged in inappropriate behavior. Staff removed the alleged perpetrator, but the incident was not documented or reported to the state agency or law enforcement as required. Multiple LPNs and the administrator believed the incident had already been reported, resulting in no immediate action.
A resident reported that another resident entered their room and exposed and fondled their private area, but the allegation was not investigated at the time it was reported. Staff believed the incident had already been addressed, and the DNS only initiated an incomplete investigation months later after being informed by a medical provider. Both the DNS and administrator acknowledged the investigation was neither timely nor comprehensive.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a feeding tube, as required by their policy. Observations showed that staff did not wear gowns while administering medications, and there was no EBP signage outside the resident's room. The Interim DON and Resident Care Manager confirmed that EBP should have been in place, increasing the risk of infection.
A resident in a facility did not receive prescribed medications for thyroid and bladder control on two consecutive days. The staff failed to notify the primary care physician about the missed doses, which could have affected the resident's health. Interviews with staff confirmed the oversight in communication.
A resident in an LTC facility missed doses of Levothyroxine and Trospium due to a medication supply issue. Staff confirmed that the medications ran out and were not delivered by the pharmacy in time, leading to significant medication errors. The resident expressed concerns about the potential side effects of missing these medications, which are crucial for managing their thyroid disorder and bladder control.
The facility failed to provide baseline care plans within 48 hours of admission for three residents, as required by policy. Despite being cognitively intact, the residents did not receive their care plans on time, and documentation was incomplete or delayed. Staff interviews confirmed the oversight.
Two residents did not receive scheduled showering assistance as required, despite being cognitively intact and needing total or one-person assistance. The facility's documentation showed no refusals, and staff confirmed the lack of showers on scheduled days.
A facility failed to report an abuse allegation involving a resident to the State Agency within the required timeframe. The resident, who was cognitively intact, reported inappropriate touching by an unknown male to a CNA, who informed an RN. The RN documented the incident and informed the DON, but the report was delayed, placing the resident at risk.
A resident reported being inappropriately touched by an unknown male, but the incident was not logged in the facility's report log within the required timeframe. The investigation was incomplete, lacking necessary staff interviews and a conclusive summary to rule out abuse, despite the facility's policy requiring thorough investigations.
Failure to Timely Report and Document Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to timely report allegations of abuse, neglect, or misappropriation of property to the State Agency and failed to document and investigate these allegations in its incident logs for three residents. One resident with dementia and a need for assistance with personal care reported that another resident repeatedly entered her room, took her nice clothes, and that some clothing sent to laundry never returned. She stated she had informed staff about the intrusions and missing items and indicated that the other resident had again entered her room on the day of the initial interview. In a later interview, she reported that the same resident entered her room around 4:00 a.m., took a pillow from the other bed, and that she called the nurse, who removed the other resident from the room. Despite the administrator being informed of these allegations, there was no corresponding documentation in the incident logs for the months reviewed, and the allegation was not reported to the State Agency as required by the facility’s Purple Book guidelines. Another resident with dementia, gait and mobility abnormalities, and a need for assistance with personal care reported during a documented interview that care from male staff was “a little rough,” specifically mentioning that men were a little rough getting him out of bed. This statement was recorded by the Social Services Coordinator/Assistant, who had been trained on abuse and neglect, but no investigation was initiated, and the allegation was not reported to nursing staff or entered into the incident log. The Social Services staff member acknowledged that the allegation was not reported to nursing, and the interim DON and interim administrator confirmed that the February incident log did not contain this resident’s allegation and that no investigation had been completed. Overall, the facility did not follow its stated responsibilities to report all suspected incidents of abuse, neglect, financial exploitation, or misappropriation of property, to notify the State Hotline immediately or once the resident was protected, and to log such incidents in the state reporting log.
Failure to Investigate Resident Abuse and Rough Care Allegations
Penalty
Summary
The facility failed to ensure that allegations of abuse were thoroughly investigated for three residents. One resident with dementia and a need for assistance with personal care reported that another resident entered her room, took her nice clothes, and that some clothing sent to the laundry never came back. She stated she had informed staff that the other resident came into her room and that she might slap the other resident because staff did not watch her. She later reported that the same resident entered her room around 4:00 a.m. while she was asleep and took a pillow from the other bed, after which she called the nurse and staff removed the other resident from the room. The resident alleged perpetrator had dementia with behavioral disturbance and psychosis, with a care plan problem for problematic behavior including verbal or physical aggression, wandering into other residents’ rooms, self-propelling around the facility, and agitation when she knew she was being monitored. Despite these behaviors and the allegations made by the first resident, review of the facility’s incident logs for December, January, February, and through mid-March showed no documentation of any incidents involving either of these two residents. The Administrator was informed of the allegation that the second resident entered the first resident’s room and that some property was missing, but the allegation was not entered into the incident log or reported to the State Agency when it was reported to the Administrator. A third resident, with dementia, abnormalities of gait and mobility, and a need for assistance with personal care, reported during a documented resident interview that care was “a little rough from the men,” specifying that male staff were a little rough getting him out of bed. The interview was completed by the Social Services Coordinator/Assistant, who stated she had been trained on abuse and neglect and that she sent the completed interview forms to the Social Services Director. However, she did not report the allegation to nursing, and no investigation of the allegation was completed. Review of the February incident log showed no documentation of this resident’s allegation, and facility leadership confirmed that the resident’s name did not appear on the log and that no investigation had been completed, despite expectations that reported allegations would be investigated timely.
Failure to Develop and Implement Comprehensive Care Plan for ADL Nail Care and Prosthesis Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan that addressed all of a resident’s needs, specifically Activities of Daily Living (ADL) nail care for a resident with diabetes and prosthesis/shrinker sock care for a resident with bilateral below-knee amputations. The facility’s policy required a comprehensive care plan with measurable objectives and timetables to meet each resident’s physical, psychosocial, and functional needs. The discharge Minimum Data Set for Resident 1 showed the resident required substantial/maximal assistance with personal hygiene and had a diagnosis of diabetes, yet the comprehensive care plan printed in February 2026 contained no care plan for providing fingernail care appropriate for a resident with diabetes. Surveyor observations on multiple dates showed Resident 1 with long fingernails and brown material underneath the fingernails on both hands, including after the resident reported having had a shower the previous day. The resident stated that it was “hit or miss” whether their fingernails were trimmed. Staff D, a CNA, stated that nail care was included in ADLs for dependent residents and that nurses provided nail care for residents with diabetes, with CNAs responsible for notifying nurses when nails were long or dirty. Staff D also stated that Resident 1 needed total care for personal hygiene and that CNAs determined needed ADL care by checking the Kardex. Joint observations with Staff D and Staff C confirmed that Resident 1’s fingernails were long, dirty, and had brown/black material underneath, and joint record review with Staff C confirmed there was no care plan for providing fingernail care for this resident. The deficiency also included failure to implement the existing care plan for prosthesis and shrinker sock use. Resident 1’s comprehensive care plan and Kardex documented bilateral below-knee amputations and directed that the prostheses be on daily in the morning until bedtime, with shrinker socks on when the prostheses were off. During observation, Resident 1 was in bed with the prostheses off and without shrinker socks, and the resident stated the shrinker socks were supposed to be changed every day. Staff D confirmed via the Kardex that shrinker socks should be on when the prostheses were off, found the shrinker socks in the nightstand, and then applied them, stating they should have been on. Staff C, the RCM, and the DON each stated in interviews that they expected staff to follow care plans, that a licensed nurse should trim the nails of a resident with diabetes, and that shrinker socks should be on when the prostheses were off, confirming that the documented care plan interventions for prosthesis and shrinker sock use were not being consistently implemented.
Failure to Provide Adequate Nail and Personal Hygiene Care for Dependent Diabetic Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically personal hygiene and nail care, for one resident who required substantial to maximal assistance. Facility policy on ADLs stated that appropriate care and services, including hygiene such as bathing, dressing, grooming, and oral care, were to be provided in accordance with the care plan. The resident’s discharge Minimum Data Set indicated a need for substantial/maximal assistance with personal hygiene and documented a diagnosis of diabetes. The resident’s ADL care plan required at least one staff member to assist with personal hygiene. Despite this, observations on multiple days showed the resident with long fingernails and brown material underneath the fingernails on both hands, and the resident reported that nail trimming was inconsistent. Staff interviews and record reviews showed inconsistent practices and missing orders related to nail care for this resident. A CNA stated that nail care was part of ADLs and that nurses were responsible for nail care for residents with diabetes, while CNAs were expected to notify nurses if nails were long or dirty; the CNA also stated that the resident needed total care for personal hygiene and confirmed the nails were long and dirty. An LPN stated that nurses provided nail care for residents with diabetes and that anyone could clean under the nails, but indicated there should be a physician order for nail care; record review showed no such order for this resident. The Resident Care Manager similarly stated that aides could clean fingernails and nurses should trim nails for residents with diabetes, and expected a physician order documented in the MAR, which was not present. The DON stated that staff were expected to provide ADLs, including nail care, for dependent residents, that nurses should provide nail care for residents with diabetes, and that they would not expect a resident’s fingernails to be long and dirty after a shower. These observations and statements demonstrated that the resident’s personal hygiene needs, specifically nail care, were not met in accordance with policy and the care plan.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by another resident, resulting in substantiated abuse incidents involving two residents. Facility policy dated September 2022 states that each resident has the right to be free from abuse, including abuse by other residents, and defines abuse as willful, meaning the individual acted deliberately even if they did not intend to cause harm. Despite this policy, a resident with a history of agitated behaviors (Resident 3), who had severely impaired thinking and memory and was on antipsychotic and antidepressant medications, engaged in two separate physical altercations with other residents on the same day. In the first incident, Resident 3 used both hands to grab another resident (Resident 2), who also had severely impaired thinking and memory, by the hair and shook them hard. A Resident Care Manager (RCM) was present, separated the residents, and questioned Resident 3, who claimed that Resident 2 had stolen their phone. The investigation determined this claim was untrue, as staff had picked up Resident 3’s dropped phone during an activity and returned it shortly thereafter. Resident 2 was assessed and found to have no injuries and no recollection of the incident, but the facility’s investigation substantiated this event as physical abuse. Approximately 40 minutes later, while the RCM remained with and monitored Resident 3, a second incident occurred in which Resident 3 reached out and grabbed another resident (Resident 1) by the left arm while Resident 1 was in a wheelchair talking with a nearby resident. Resident 1, who had intact thinking and memory, reported that they had not been interacting with Resident 3 and only became aware of them when they felt their arm being grabbed and pulled hard. This action caused a skin tear on the left arm measuring 3.5 cm by 3.0 cm and multiple bruises on the same arm, which required wound care and monitoring until resolved. The facility’s incident investigation substantiated this event as physical abuse, and staff interviews noted Resident 3’s history of temper, mood swings, and recent refusals of prescribed psychotropic medications in the days preceding the incidents.
Failure to Complete Required Level II PASARR for Exempted Hospital Discharge Resident
Penalty
Summary
The deficiency involves the facility’s failure to complete a required Level II Preadmission Screening and Resident Review (PASARR) for a resident admitted under an exempted hospital discharge who remained in the facility for more than 30 days. The admission MDS dated 09/24/2025 documented that Resident 3 was admitted on a specified date, and the Level I PASRR form dated 09/22/2025 identified indicators of Serious Mental Illness, known or suspected mood disorders, and functional limitations related to a known or suspected behavioral health disorder. The same Level I PASRR documented that the resident was admitted as an Exempted Hospital Discharge, with the attending physician certifying the individual was likely to require fewer than 30 days of NF services, and it stated that no Level II evaluation was indicated at that time due to the exempted hospital discharge, but that a Level II must be completed if the scheduled discharge did not occur. The discharge MDS showed that the resident was discharged on 11/28/2025, confirming that the resident remained in the facility from 09/22/2025 to 11/28/2025, which exceeded 30 days. Review of the electronic health record showed no evidence that a Level II PASARR evaluation was completed during this stay. In an interview, the Social Services Director stated that when a resident is admitted with an exempted hospital discharge Level I PASRR, the resident must discharge within 30 days or a Level II PASARR must be completed and sent to the PASARR office within 30 days if the resident does not discharge, and acknowledged that Resident 3 did not have a Level II PASARR completed within 30 days. The Social Services Director also stated they did not know the resident had been admitted with an exempted hospital discharge Level I PASARR, and the Administrator confirmed that the Level II PASARR should have been completed within 30 days for this resident.
Failure to Adequately Supervise Resident With Aggressive Behaviors Leading to Two Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and interventions to manage aggressive behaviors for a resident with a known history of agitation and aggression, resulting in resident-to-resident altercations. Resident 3, who had severely impaired thinking and memory per the admission MDS, had previously resided in the facility and had shown agitated and aggressive behaviors during that prior stay. After readmission, some staff, including a CNA, reported that Resident 3 had a temper, could get angry easily, and had mood swings from happy to angry, especially when they did not get what they wanted. On the date of the incident, Resident 3 first used both hands to grab Resident 2 by the hair and shake them hard in a hallway area. Resident 2, who also had severely impaired cognition, was later assessed and found to have no injuries and no recollection of the event. Approximately 40 minutes after the initial hair-pulling incident, while the Resident Care Manager remained with Resident 3 and was monitoring their behavior, Resident 3 reached out and grabbed Resident 1’s left arm as Resident 1 sat in a wheelchair talking with Resident 2 in the hallway. Resident 1, who had intact cognition, reported that the event happened quickly, that they had not been interacting with Resident 3, and that the forceful grabbing caused their skin to tear and immediate bruising. The resulting skin tear measured 3.5 cm by 3.0 cm, with two bruises measuring 2.0 cm by 2.5 cm and 4.0 cm by 4.0 cm on the left arm. Staff interviews indicated that, despite awareness of Resident 3’s prior history of aggressive behavior and the implementation of close staff supervision after the first altercation, staff were unable to prevent Resident 3 from quickly initiating a second physical altercation that caused injury to another resident.
Failure to Notify Resident of Medication Change
Penalty
Summary
The facility failed to notify a resident about a significant change in their medication regimen. Specifically, the resident, who had diagnoses including heart failure and impaired kidney function and was cognitively intact, was not informed that their prescribed Potassium Chloride supplement was placed on hold for thirteen days. The medication was held due to abnormal laboratory results and impaired kidney function, as determined by the primary care physician. Despite this change, there was no documentation or evidence that the resident was notified about the medication being stopped or the reason for the change. Interviews with facility staff, including an LPN/Resident Care Manager, a Registered Nurse, and the Director of Nursing Services, confirmed that residents are supposed to be notified of all medication changes. However, staff were unable to identify any record of notification to the resident regarding the hold on Potassium Chloride. The resident also stated they were unaware of the medication being stopped or restarted and had not been informed by facility staff.
Failure to Follow Physician Orders and Document Wound Care Treatments
Penalty
Summary
The facility failed to follow physician's orders and ensure proper documentation of treatments for a resident with venous ulcers and lymphedema. Staff were observed not changing the resident's dressings as ordered, and the dressings present were unlabeled. The resident had orders for daily wound care and the use of compression stockings or TED hose, but staff confirmed that these were not applied and that the required wound care was not performed as documented. The nurse responsible admitted to documenting the treatment as completed in the Treatment Administration Record (TAR) before actually performing the care, and also stated that the resident had never worn the prescribed compression stockings or TED hose. Interviews with the Resident Care Manager and Director of Nursing Services confirmed that staff are expected to follow physician orders, label dressings with initials and date, and only document treatments after they are completed. The review of facility policy also supported these expectations. The failure to follow these procedures was confirmed through observation, interview, and record review, and was found to be inconsistent with both facility policy and professional standards.
LPN Performed Wound Assessments Without Proper Competency or Oversight
Penalty
Summary
A Licensed Practical Nurse (LPN), identified as Staff E, was responsible for wound care assessments and documentation for a resident with a Stage 4 pressure injury. The facility's policy required that a licensed nurse assess and evaluate all wounds at least weekly, including detailed measurements, staging, and descriptions of the wound and surrounding tissue. However, review of wound care documentation revealed that Staff E completed multiple wound evaluations without co-signature or oversight from a Registered Nurse (RN) or Wound Care Specialist, as required for comprehensive wound assessments. Interviews with Staff E revealed that they did not perform full wound assessments or staging, but rather followed previous wound care provider assessments and documented based on whether the wound appeared unchanged. Staff E admitted to not being wound care certified and was unsure if wound assessment was within their scope of practice as an LPN. The Director of Nursing (DON) confirmed that Staff E was not wound care certified and acknowledged that wound assessment is not within the LPN's scope of practice, and that the evaluations completed by Staff E were classified as full assessments in the facility's software system. Further investigation found that there was no competency skills checklist on file for Staff E, despite their role as the facility's wound nurse. Human Resources was unable to locate any documentation of completed competency assessments for Staff E, who had been employed since July 2023. The lack of appropriate competency verification and oversight placed residents at risk for inaccurate wound assessments and unmet care needs.
Failure to Conduct Thorough Abuse Investigation and Maintain Staff Suspension
Penalty
Summary
The facility failed to conduct a thorough investigation and take appropriate corrective action following an incident involving a resident. According to the facility's own policies and federal guidelines, a comprehensive investigation should include systematic evidence collection, interviews with all potential witnesses, and documentation of the process. In this case, the investigation summary report showed that only the involved caregivers and other residents were interviewed, with no documentation that other potential caregiver witnesses were interviewed. The Director of Nursing confirmed that their process included interviewing only those assigned to the resident or any direct witnesses, and referenced the Purple Book for guidance. However, the investigation did not reflect interviews with an expanded sample of witnesses as required. Additionally, the staff member implicated in the incident was suspended pending investigation, but time card records revealed that this staff member worked several shifts in the facility before the investigation was completed. The Director of Nursing acknowledged that the staff member worked during the data collection phase and prior to the conclusion of the investigation, contrary to the stated protocol that suspended staff should remain out of the facility until the investigation is finished. These actions and omissions resulted in a failure to meet regulatory requirements for abuse investigations.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents or staff involved, were not provided in the report. The report does not include further factual observations or examples related to the deficiency.
Failure to Provide Prescribed Therapeutic Diets to Diabetic Residents
Penalty
Summary
The facility failed to provide therapeutic diets as ordered for two residents diagnosed with Type 2 Diabetes who were prescribed a carbohydrate-controlled (diabetic) diet and received scheduled insulin. Both residents were observed receiving and consuming cornbread as part of their lunch meal, despite their dietary cards and the facility's dietary spreadsheet indicating that cornbread should not be served to individuals on a diabetic diet. Staff interviews confirmed that the dietary spreadsheet specifically marked cornbread as 'No' for diabetic diets, and both the registered dietitian and kitchen cook acknowledged that these residents should not have received cornbread. Record reviews and staff interviews further revealed that the dietary staff were expected to follow the prescribed therapeutic diets and use the dietary spreadsheet to guide meal preparation. However, the failure to adhere to these protocols resulted in the residents receiving food items not permitted on their prescribed diets. The Director of Nursing confirmed that the expectation was for staff to follow the prescribed diets and acknowledged that the residents should not have received cornbread.
Deficiencies in Food Safety, Dishwashing Temperatures, and Reheating Procedures
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in several key areas. During an observation, two cups of yogurt with expired use-by dates were found in the Solarium Room Residents' Refrigerator, and staff confirmed these items should have been discarded according to facility policy. The administrator also acknowledged that expired food items are expected to be removed from refrigerators by their use-by dates. The facility's dishwasher was repeatedly observed and documented to be operating below the required minimum washing temperature of 120°F. Multiple temperature logs and direct observations showed the dishwasher consistently failed to reach the necessary temperature for effective sanitation, with staff and dietary management confirming that the issue had persisted for an extended period. Maintenance staff had been informed, but the problem remained unresolved, and the dish machine logs reflected numerous instances of substandard temperatures over several months. Additionally, a Certified Nursing Assistant reheated a resident's meal in the microwave and served it without checking the food temperature, contrary to facility policy. The staff member was unaware of the requirement to check and document the temperature of reheated food before serving. Both the Resident Care Manager and the Director of Nursing confirmed that the policy mandates temperature checks and documentation, and that the staff member did not follow these procedures.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly evaluated and assessed for self-administration of medications, and did not obtain physician orders or update care plans as required. Multiple residents were observed with medications and supplements at their bedside and reported self-administering these without documented assessments or orders permitting them to do so. Staff interviews confirmed that the required assessments and orders were not completed, and that medications should not have been accessible to residents without these steps. For example, one resident was found with multiple bottles of supplements at their bedside and in their drawer, and stated they took them daily, but there was no documentation of an assessment for self-administration. Another resident was observed using an albuterol inhaler from their nightstand and reported long-term use without ever being assessed for self-administration. Staff confirmed that neither an order nor an assessment was present for these residents, and that this was not in line with facility policy. Additional residents were found with prescription medications such as inhalers and nasal sprays at their bedside, self-administering them without completed assessments, physician orders, or care plan documentation. In several cases, the self-administration evaluation forms were blank or incomplete. Staff, including LPNs, Resident Care Managers, and the Director of Nursing, acknowledged during interviews that the required processes had not been followed and that medications should not have been accessible to residents without proper assessment and documentation.
Resident Rooms Not Maintained in Safe and Homelike Condition
Penalty
Summary
Surveyors observed that the facility failed to maintain resident rooms in a safe, clean, and homelike condition for four residents. Specifically, privacy curtains in one resident's room were found to be dirty with a brown substance, and the pull cord for the overhead light was broken and replaced with plastic bags tied together. Additional observations revealed that other residents' overhead lighting pull cords were extended using makeshift materials such as plastic bags, fabric strips, and a nightgown strip. These conditions were confirmed during joint observations and interviews with facility staff, who acknowledged the presence of these non-homelike and unclean items. Staff interviews indicated that maintenance issues were expected to be reported to nursing staff and then to maintenance, but the use of inappropriate materials for pull cords and the presence of soiled privacy curtains had not been addressed. The Maintenance Director stated that rooms were checked daily and that clean privacy curtains were available, but acknowledged that the observed conditions were not acceptable. The Administrator also confirmed that staff were expected to report maintenance issues and that the use of plastic bags as pull cords was not permitted. The deficiency was cited under WAC 388-97-0880 (1) for failing to provide a homelike environment.
Failure to Timely Transmit MDS Assessments to CMS
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) assessments to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for four out of six residents reviewed. Specifically, discharge MDS assessments for these residents were either completed late or not transmitted at all to CMS' Internet Quality Improvement and Evaluation System (iQIES). For example, one resident's discharge MDS was completed 35 days late and was not transmitted, while another's was completed 26 days late. In other cases, the discharge MDS was completed but not submitted to CMS as required. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the assessments were not completed or transmitted in accordance with regulatory requirements. Both staff members acknowledged that the MDS assessments should have been completed and transmitted in a timely manner after completion. The failure to transmit these assessments was identified through record reviews and staff interviews, with staff confirming the deficiencies for each affected resident.
Inaccurate MDS Assessments Across Multiple Clinical Areas
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for eight residents, resulting in multiple inaccuracies across several assessment areas. These inaccuracies included incorrect coding of Preadmission Screening and Resident Review (PASARR) status, discharge status, bowel continence, oxygen use, medication administration, urinary catheter use, and bowel patterns. For example, one resident with a documented Level II PASARR and diagnoses of serious mental illness was not coded appropriately in the MDS, and another resident's discharge status was incorrectly recorded as a hospital discharge instead of a discharge to home, despite progress notes indicating otherwise. Further review revealed discrepancies between clinical documentation and MDS coding for bowel continence, oxygen therapy, and medication administration. One resident was documented as incontinent of bowel every day during the look-back period, yet was coded as always continent in the MDS. Another resident was receiving continuous oxygen therapy according to nursing notes, but this was not reflected in the MDS. Additionally, several residents were inaccurately coded for receiving injections, insulin, antibiotics, opioids, or antianxiety medications, despite medication administration records and physician orders showing otherwise. The facility also failed to accurately code the use of urinary catheters and the presence of constipation for a resident with a physician order for Foley catheter output monitoring and documented infrequent bowel movements. Interviews with staff, including the MDS Coordinator and Director of Nursing, confirmed that the MDS assessments were not completed accurately in these cases, and staff acknowledged the discrepancies between the clinical records and the MDS coding.
Failure to Develop and Implement Comprehensive Care Plans for ADL and Catheter Care
Penalty
Summary
The facility failed to develop and/or implement comprehensive care plans for five residents, specifically regarding Activities of Daily Living (ADL) and urinary catheter care. For one resident with diabetes who required total assistance with personal hygiene, observations revealed long fingernails with brown matter underneath, despite a care plan intervention for diabetic nail care by a licensed nurse. The resident reported repeatedly requesting nail trimming, and both CNAs and LPNs acknowledged that the nails were too long and should be trimmed by nursing staff, as indicated in the care plan. However, the intervention was not carried out as documented. Another resident with a urinary catheter had a physician's order and care plan intervention to check and empty the catheter drainage bag when it was half full. Despite this, the resident reported that the bag was not emptied as required, leading to overflow and a urinary tract infection. Observations confirmed that the drainage bag was more than half full, and staff acknowledged that the care plan was not followed. Additionally, a resident requiring extensive assistance with personal hygiene was observed multiple times with dark brown matter under their fingernails, and staff confirmed that nail cleaning was part of personal hygiene but had not been performed as needed. Further deficiencies included a resident who required moderate assistance with personal hygiene and was repeatedly observed with yellowish crusty matter on their eyelids. The resident reported that staff did not clean their eyes, and staff interviews confirmed that this care should have been provided according to the care plan. Lastly, a resident with a urinary catheter had no care plan addressing catheter use, despite physician orders for monitoring output. Staff were unaware of the catheter and acknowledged that a care plan should have been in place. These findings demonstrate a pattern of failure to develop and/or implement care plans as required by facility policy and regulatory standards.
Failure to Revise and Update Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to revise and update comprehensive care plans for several residents, resulting in unmet care needs. For a resident with cerebral palsy and contractures, the care plan lacked specific interventions for range of motion exercises, use of splints, and restorative programs, despite staff acknowledging the need for such interventions. The care plan also did not reflect current therapy involvement, and staff interviews confirmed that the resident was not receiving the indicated therapies or monitoring for contractures as outlined in the care plan. Another resident with a Level II PASARR for serious mental illness did not have the recommended interventions from the PASARR evaluation included in their care plan. Staff confirmed that the care plan was generic and not personalized with the required PASARR recommendations, which should have been incorporated word for word according to facility policy. The care plan had not been updated since the PASARR evaluation, despite clear expectations for quarterly review and revision when recommendations are made. Additional deficiencies were identified for residents using opioid pain medications, self-administering medications, and receiving continuous oxygen therapy. The care plans for these residents did not include necessary details such as monitoring for adverse effects of opioids, non-pharmacological pain interventions, authorization and procedures for self-administration of medications, or documentation of oxygen use. Staff interviews consistently indicated that these omissions were contrary to facility policy and expectations for care plan updates.
Failure to Provide Necessary ADL Assistance for Dependent Residents
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. For one resident with diabetes, observations showed long fingernails with brown material underneath, and the resident reported repeatedly requesting nail trimming, which was not provided despite a care plan and physician order specifying weekly diabetic nail care by a licensed nurse. Staff interviews confirmed that both CNAs and nurses were aware of the need for nail care, but the resident's nails remained untrimmed and unclean over several days. Another resident, also requiring substantial assistance for personal hygiene, was observed multiple times with dark brown matter under their fingernails. Staff acknowledged that cleaning and trimming nails was part of personal hygiene responsibilities, and interviews confirmed that the resident needed help with nail care, which was not being provided as expected. The Director of Nursing stated that dependent residents' nails should be clean and trimmed, especially for those unable to perform self-care. A third resident, who required moderate assistance with personal hygiene and had visual impairment, was observed on several occasions with yellowish crusty matter on their eyelids. The resident reported difficulty opening their eyes and stated that staff did not assist with cleaning their eyes, despite being unable to do so independently. Staff interviews confirmed that aides were responsible for daily eye care, but this was not being performed, leaving the resident with ongoing hygiene issues.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Surveyors identified multiple deficiencies in the provision of respiratory care for several residents requiring oxygen therapy. For several residents with physician orders specifying that oxygen tubing should be changed when visibly soiled and labeled with the current date, observations revealed that the oxygen tubing in use was not labeled or dated as required. Staff interviews confirmed that nurses were responsible for labeling and dating the tubing, and staff acknowledged that the tubing should have been labeled according to orders and facility policy. Additionally, a portable oxygen tank was observed stored unsecured on a stool rather than in a proper stand or dolly, contrary to staff expectations and safe storage practices. One resident was observed receiving continuous oxygen therapy via nasal cannula, but there were no corresponding physician orders or care plan documentation for oxygen use in the medical record or medication administration record (MAR). Staff interviews confirmed that orders should have been present, including details such as oxygen flow rate, tubing changes, concentrator filter maintenance, and oxygen saturation monitoring. The absence of these orders and documentation was acknowledged by multiple staff members, including the LPN and Director of Nursing. Similar deficiencies were observed for other residents, including those with diagnoses such as COPD and pneumonia, where oxygen tubing was not labeled or dated despite clear physician orders. Staff consistently stated that the tubing should have been labeled and dated, and that orders for oxygen use should have been present and followed. The facility's own policy required verification of physician orders and adherence to protocols for oxygen administration, which was not consistently implemented for the residents reviewed.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing form was accurately completed and posted with the current census, actual number of staff, and hours worked for each shift on four reviewed days. Observations revealed that the posted staffing information at both the main entrance and nurse's station consistently displayed data from the previous day rather than the current day. This was confirmed on multiple occasions, with postings on each reviewed day reflecting outdated information. Interviews with facility staff, including Human Resources, the DON, and the Administrator, confirmed that the process for filling out the Daily Nursing Staff posting relied on the prior day's census and staff working hours, rather than updating the information per shift as required by facility policy. The policy specified that within two hours of the beginning of each shift, the actual number of licensed and unlicensed nursing staff and their hours worked should be posted in a prominent location. The failure to follow this process prevented residents, family members, and visitors from accessing accurate and current nurse staffing information.
Failure to Follow Medication Administration Standards and Orders
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards for four residents, resulting in multiple medication management deficiencies. For one resident with a G-tube, a LPN administered ondansetron by mouth despite the physician's order specifying administration via G-tube, and the order itself contained conflicting instructions for route of administration. The LPN did not clarify the order with the provider before administering the medication, contrary to facility expectations. Another resident self-administered a steroid inhaler (Arnuity Ellipta) without staff oversight, kept the inhaler at bedside without a locked box, and did not rinse their mouth after use as required by manufacturer instructions. The resident's medication administration record did not include an order for the inhaler, and staff confirmed that the resident should have had an order and should have been instructed to rinse their mouth after use. A third resident received a steroid inhaler (fluticasone-salmeterol) from a LPN, who did not assist or remind the resident to rinse their mouth after administration, and the physician's order lacked this instruction despite manufacturer guidelines. For a fourth resident with diabetes, a LPN administered insulin using a pen device without priming the pen beforehand, which is necessary to ensure proper dosing. Staff interviews confirmed that insulin pens should be primed before each use and that residents using steroid inhalers should be assisted to rinse their mouths after administration. These actions and omissions were inconsistent with facility policy, pharmacy guidelines, and professional standards of practice.
Failure to Monitor Adverse Drug Effects and Provide Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs by not adequately monitoring medications with known adverse side effects and not providing or documenting non-pharmacological interventions prior to administering pain medications. For one resident receiving oxycodone, there was no documentation of monitoring for adverse side effects or the use of non-pharmacological interventions before administration. The resident's pain care plan did not include opioid use, monitoring for side effects, or non-pharmacological interventions, despite staff acknowledging these should have been present. Another resident receiving insulin therapy did not have documented monitoring for hypoglycemia or hyperglycemia in the Medication Administration Record (MAR) or Treatment Administration Record (TAR), even though the care plan referenced monitoring for side effects and effectiveness. Additionally, a resident prescribed hydromorphone was not monitored for side effects, with no documentation present in the MAR or TAR. Staff interviews confirmed that monitoring for side effects and non-pharmacological interventions should have been included for these medications but were not.
Failure to Properly Store, Label, and Dispose of Medications and Biologicals
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with professional standards and facility policy. Multiple residents were found to have medications, including prescription inhalers, nasal sprays, and dietary supplements, stored at their bedside without proper physician orders or completed self-administration assessments. In several cases, residents self-administered these medications without documentation of an evaluation to determine their ability to do so safely, and without orders permitting bedside storage. Staff interviews confirmed that these practices were not in line with facility policy, which requires an assessment and physician order for self-administration and bedside storage of medications. Additionally, the facility did not properly manage the storage and disposal of expired medications and biologicals. Observations in the medication room revealed undated multiuse vials and opened nutritional supplements that were past their use-by or best-by dates. Expired medical supplies, such as normal saline bottles, a PICC line dressing kit, sterile water, and a humidifier adaptor, were found in crash carts on two different halls. Staff acknowledged that these items were expired and should have been discarded according to facility policy, which mandates the removal of outdated or deteriorated medications and supplies. The deficiencies were further evidenced by incomplete documentation, such as a blank self-administration assessment for one resident, and the lack of care plan documentation supporting independent medication storage. Staff interviews consistently indicated an expectation that medications should be locked and only accessible to residents with appropriate orders and assessments. The observed failures in medication storage, labeling, and disposal were not in accordance with the facility's own policies and placed residents at risk for receiving compromised or ineffective medications and supplies.
Deficient Clinical Record Accuracy and Maintenance
Penalty
Summary
The facility failed to ensure the accuracy and proper maintenance of clinical records for several residents, resulting in multiple documentation deficiencies. For one resident, there was a discrepancy between the discharge date listed on the face sheet and the date documented in the nursing progress notes, with staff confirming the face sheet should have matched the progress notes. Another resident's clinical record contained hospice documents that actually belonged to a different resident, and staff acknowledged these documents were incorrectly filed. Additionally, a self-administration of medication evaluation form for another resident was found to be blank and not completed as required after assessment, which staff confirmed should have been done. A further review revealed that a resident's Level I PASARR form did not accurately reflect their diagnoses of depression and anxiety disorder, despite these being listed on the face sheet. Staff involved in the review and interviews confirmed that the PASARR form was incomplete and should have included the resident's mental health diagnoses. These findings demonstrate failures in maintaining accurate, complete, and resident-specific clinical records as required by professional standards.
Infection Control Program Deficiencies and Lapses in Hand Hygiene
Penalty
Summary
Multiple deficiencies were identified in the facility's infection prevention and control program, as evidenced by direct observations and staff interviews. Staff members failed to perform hand hygiene at critical points during resident care, including before entering and after leaving resident rooms, before donning and after removing gloves, and between care tasks. For example, a CNA assisted a resident with mobility and food service without performing hand hygiene, and an LPN failed to sanitize hands before and after handling a resident's environment and administering medication. These lapses were observed across several residents, including those with indwelling medical devices and feeding tubes, where proper hand hygiene is essential. The facility also failed to ensure that infection prevention and control policies and procedures were reviewed annually as required. Several key policies, such as those for surveillance of infections, antibiotic stewardship, and vaccination, had not been updated or reviewed within the required timeframe. The infection preventionist and DON confirmed during interviews that these policies had not been reviewed or discussed in quality assurance meetings, and were not up to date with current standards. Additional deficiencies included improper management of soiled linens and expired eyewash station solutions. Observations showed soiled linens left unbagged on the floor and transported between resident rooms, contrary to facility policy. Eyewash stations in multiple locations contained expired saline solution bottles, which had not been replaced as required. Staff interviews confirmed that these practices did not meet facility expectations or policy requirements. Furthermore, staff failed to follow Enhanced Barrier Precautions for residents with indwelling devices, such as not wearing required PPE during high-contact care activities.
Failure to Provide Privacy for Residents with Urinary Catheters
Penalty
Summary
The facility failed to provide privacy for residents with urinary catheters, as evidenced by observations and interviews involving two residents. For both residents, their urinary catheter drainage bags were not covered with privacy bags and were visible from the hallway on multiple occasions. Staff members, including a Licensed Practical Nurse, a Certified Nursing Assistant, the Resident Care Manager, and the Director of Nursing, all acknowledged during interviews that the catheter bags should have been covered with privacy bags in accordance with facility policy and the residents' care plans. Review of the facility's policies confirmed that residents are to be treated with dignity and respect, and that catheter drainage bags should be kept covered. The care plan for one resident specifically required the drainage bag to remain covered. Despite these requirements, the lack of privacy bag coverage for the catheter drainage bags was directly observed and confirmed by staff, resulting in a failure to honor the residents' rights to dignity and privacy.
Failure to Maintain Updated Guardianship Documentation
Penalty
Summary
The facility failed to ensure that an updated guardianship letter for one resident was readily available in the medical records and accessible to staff. Review of the resident's guardianship letter showed it had expired, and there was no documentation in the electronic health record (EHR) indicating that the facility had attempted to obtain or upload an updated guardianship letter. During an interview and joint record review, the Administrator confirmed that the guardianship letter was expired, acknowledged that there was no current documentation in the EHR, and stated that new paperwork should be present for the resident.
Failure to Provide Timely NOMNC to Resident
Penalty
Summary
The facility failed to issue the required Notification of Medicare Non-Coverage (NOMNC) form to a resident at least two calendar days before the end of their Medicare A coverage, as mandated by facility policy and regulatory requirements. Specifically, the NOMNC was provided only one day prior to the last covered day, rather than the required minimum of two days. This was confirmed through record review and staff interviews, which acknowledged that the notification should have been given earlier. The deficiency was identified for one of three residents reviewed for beneficiary notification, with documentation showing the NOMNC was signed one day before coverage ended.
Lack of Non-Pharmacological Interventions for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were implemented for the management of psychotropic medications for two residents. Review of the facility's policy indicated that non-pharmacological approaches should be used to minimize the need for psychotropic medications, permit the lowest possible dose, and allow for discontinuation when possible. However, for one resident with dementia and another with major depressive disorder and Alzheimer's disease, physician orders included quetiapine, an antipsychotic medication, without documentation of non-pharmacological interventions related to its use. Interviews with the Resident Care Manager and the Director of Nursing confirmed that non-pharmacological interventions were expected to be in place when residents were started on psychotropic medications. Joint record reviews for both residents showed that such interventions were not documented in the physician's orders, despite the facility's policy and staff expectations.
Late Completion of SCSA MDS Following Hospice Enrollment
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) in a timely manner for one resident who began receiving hospice services. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, an SCSA is required when a resident enrolls in hospice, and the assessment must be completed within 14 days of the hospice election. Documentation showed that the resident started hospice services on 03/02/2025, but the SCSA MDS was not completed until 03/26/2025, which was 10 days past the required timeframe. During interviews and record reviews, the MDS Coordinator confirmed that the assessment was completed late and acknowledged that it should have been finalized by 03/16/2025. The Director of Nursing also stated that the expectation was for MDS assessments to be completed on time and agreed that the assessment was overdue. This delay in completing the required assessment was identified during the survey and cited as a deficiency.
Failure to Incorporate PASARR Level II Recommendations into Care Plan
Penalty
Summary
The facility failed to coordinate the Preadmission Screen and Resident Review (PASARR) Level II process for a resident who required mental health services. Specifically, the social services department did not ensure that the recommendations from the resident's Level II PASARR evaluation were included in the resident's care plan, as required by facility policy. The Level II PASARR evaluation, which identified diagnoses such as conversion disorder, schizophrenia, and anxiety, contained specific interventions for the resident's care that were not reflected in the care plan. Record review showed that the resident's care plan did not include the recommended interventions from the Level II PASARR, despite the social services director's statement that such recommendations should be incorporated word for word. The administrator also confirmed the expectation that these recommendations be included in assessments and care plans. This omission was identified through interviews and joint record reviews, which confirmed that the care plan was general and not personalized with the required PASARR recommendations.
Deficient PASARR Screening and Referral for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure accurate completion of Preadmission Screening and Resident Review (PASARR) Level I forms and did not make required Level II PASARR referrals for residents with mental health diagnoses. For one resident with diagnoses of depression and anxiety disorder, these conditions were not marked in the Level I PASARR form, and the form incorrectly indicated that no Level II evaluation was needed. The Social Services Director acknowledged that the Level I PASARR was inaccurate and that a Level II referral should have been made for this resident. Additionally, the facility did not complete a Level I PASARR screening for another resident who was admitted as an exempted hospital discharge and remained in the facility for more than 30 days. The Level I PASARR for this resident was marked as exempted hospital discharge, with a note that a Level II must be completed if the scheduled discharge did not occur. However, the resident remained in the facility, and no Level II referral was made. Both the Social Services Director and the Director of Nursing confirmed that PASARR forms should be completed accurately and that Level II referrals should be made when required.
Failure to Provide Consistent Skin and Bowel Care per Facility Policy
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for two residents, specifically in the areas of skin evaluations, care planning, monitoring, and necessary treatment. For one resident with diagnoses including type 2 diabetes mellitus, polyneuropathy, and protein-calorie malnutrition, there was a lack of consistent weekly skin assessments and diabetic nail care as required by facility policy. The resident was found to have a wound on the bottom of the right foot and a wound on the right ear, neither of which had been previously documented or addressed in the care plan. Staff interviews and record reviews confirmed that weekly skin checks and diabetic nail care were not performed or documented from February to May, except for two isolated dates, despite the resident's high risk for skin breakdown and complications due to their medical conditions. Another resident experienced a failure in the monitoring and management of constipation. Bowel documentation showed that the resident did not have a bowel movement for several days, and although there were physician orders for as-needed bowel management medications, these were not administered during the period of constipation. Nursing progress notes did not address the resident's constipation or indicate whether medications were given or refused. Staff interviews confirmed that the facility's bowel protocol, which should be followed when a resident has not had a bowel movement for three days, was not implemented in this case. These deficiencies were identified through observation, interviews, and record reviews, revealing that the facility did not follow its own policies and professional standards for wound management, diabetic foot care, and bowel management. The lack of consistent assessments, documentation, and timely interventions placed the affected residents at risk for unmet care needs and related complications.
Failure to Provide Timely Podiatry Care and Foot Maintenance
Penalty
Summary
The facility failed to provide appropriate podiatry care and services for one resident who was reviewed for foot care. According to the facility's policy, residents are to receive foot care in accordance with professional standards, including assistance with making appointments and transportation to podiatry specialists. The resident in question was cognitively intact but required substantial to maximal assistance with personal hygiene. The resident was scheduled for a podiatrist visit but was hospitalized at the time and, upon return to the facility, no subsequent podiatrist visits were scheduled or occurred. Multiple observations over several days revealed that the resident's toenails were long, thick, and untrimmed, with one toenail beginning to curve into the skin. Both the resident and staff confirmed that the resident had not seen the podiatrist and that nail care had not been provided. Staff interviews indicated that nail care was typically performed by CNAs or nurses, depending on the resident's medical condition, but in this case, the necessary care was not provided. The Resident Care Manager and Director of Nursing both acknowledged that the resident should have been seen by the podiatrist after returning from the hospital.
Failure to Provide and Document Restorative ROM Services
Penalty
Summary
The facility failed to consistently provide restorative services to maintain or improve range of motion (ROM) for two residents with documented ROM impairments. For one resident with cerebral palsy and contractures in the upper and lower extremities, care plans indicated the need for interventions such as maintaining body alignment, use of braces or splints, and monitoring by occupational and physical therapy. Despite these interventions being documented, observations and interviews revealed that the resident was not on a restorative program, did not use splints, and was not receiving regular ROM exercises. Multiple staff interviews confirmed the absence of a restorative program and lack of documentation or implementation of ROM interventions for this resident. Another resident with an upper extremity ROM impairment was care planned to receive a restorative nursing program 6-7 days a week. However, review of facility documentation showed that the program was only documented as provided on one day over a month-long period. The resident reported that no one was performing exercises with them, and staff interviews confirmed that there was no documentation of the restorative program being carried out. It was further revealed that an error in the electronic health record system prevented prompts for documentation, resulting in a lack of recorded services for approximately a month. Staff interviews, including those with the restorative aide, MDS coordinator, and DON, consistently indicated an expectation that residents with contractures or ROM impairments should be on a restorative program with appropriate documentation. The lack of consistent implementation and documentation of restorative services for these residents constituted a failure to meet the facility's policy and regulatory requirements for maintaining or improving residents' ROM.
Deficient Urinary Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for two residents, resulting in deficiencies related to catheter maintenance and documentation. For one resident with a urinary catheter, there were physician orders and a care plan in place to check and empty the catheter drainage bag twice per shift and when it was half full. However, observations revealed that the drainage bag was more than half full and had not been emptied as required, with a total of 1400 milliliters collected when finally emptied. The resident reported a recent urinary tract infection and stated that the catheter bag had previously overflowed due to lack of monitoring. Staff interviews confirmed that the expectation was to follow the care plan and orders, but the observed practice did not align with these requirements. For another resident with a urinary catheter, there was an order to document catheter output every shift, but no documented orders for catheter care, including frequency of catheter changes, catheter size, or instructions for emptying the drainage bag. Observations showed the resident had a urinary catheter in place, but staff were unaware of the need for specific catheter care orders. The Director of Nursing confirmed that standing orders for catheter use and care were expected but not present in the resident's records.
Failure to Ensure Physician Orders and Documentation for Colostomy Care
Penalty
Summary
The facility failed to provide appropriate colostomy care and services consistent with professional standards for a resident with a colostomy. Review of the resident's care plan confirmed the presence of a colostomy, but there were no corresponding physician orders or directives for colostomy care, appliance changes, or monitoring in the resident's records, including the Medication Administration Record (MAR) and Treatment Administration Record (TAR). Multiple staff interviews confirmed that there should have been specific orders for colostomy care, but none were present for the resident in question. Observations showed the resident had a colostomy bag in place, and staff described the expected procedures for colostomy care, including emptying and changing the bag and monitoring the site. However, both nursing and management staff acknowledged during interviews and record reviews that the required orders and documentation were missing. The facility's own policy required documentation of ostomy care tasks and matching physician orders, which were not found in the resident's records.
Failure to Complete Trauma-Informed Care Assessment for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care and culturally competent services to a resident diagnosed with Post Traumatic Stress Disorder (PTSD). According to the facility's policy, staff are required to conduct universal screening for trauma history and perform an in-depth assessment to identify trauma symptoms and triggers. However, review of the resident's electronic health record (EHR) from June 2024 through May 2025 revealed that no trauma-informed care assessment was completed for the resident, despite their documented PTSD diagnosis. During interviews, the Social Services Director confirmed that there was no trauma-informed care assessment present in the resident's EHR and acknowledged that one should have been completed. The Administrator also stated that a trauma-informed assessment was expected for the resident. This lack of assessment was identified through both record review and staff interviews, indicating noncompliance with the facility's own policy and professional standards of practice.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving one resident, as required by both state regulations and the facility's own abuse policy. The incident occurred when a resident reported that another resident entered their room, exposed themselves, and fondled their private area in front of them. The affected resident stated they yelled, prompting staff to remove the other resident from the room. The incident was not documented in the facility's incident log for the relevant month, nor was it reported to the state agency or law enforcement within the required timeframe. The resident had intact memory and cognition at the time of the incident. Interviews with staff revealed that multiple LPNs and the administrator believed the incident had already been reported, resulting in no further action being taken at the time. The Director of Nursing Services (DNS) at the time of the report was not employed at the facility when the incident occurred and only became aware of the allegation months later, at which point they reported it to the state agency and initiated an investigation. However, law enforcement was not notified due to the time elapsed since the incident.
Failure to Timely Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to ensure a timely investigation of an allegation of sexual abuse involving a resident. According to the report, a resident with intact memory and cognition reported to a medical provider that another resident entered their room around Christmas time, exposed and fondled their private area, and was subsequently removed by staff after the resident yelled. The incident was not investigated at the time it was reported in December, and staff members later indicated they believed the matter had already been addressed or investigated by the previous Director of Nursing Services (DNS). The current DNS only became aware of the allegation months later, after being informed by the resident's medical provider, and initiated an investigation at that time. The investigation was incomplete, as it did not include interviews with other residents or all relevant staff. Both the DNS and the facility administrator acknowledged that the investigation was not conducted in a timely manner and was not comprehensive, as required by facility policy and regulatory guidelines.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that Enhanced Barrier Precautions (EBP) signage was in place and that appropriate Personal Protective Equipment (PPE) was used during medication administration for a resident. The facility's policy on Enhanced Barrier Precautions, dated March 21, 2024, required the use of PPE, including gowns, when performing high-contact care activities such as administering medications via a feeding tube. However, observations revealed that there was no EBP signage posted outside the resident's room, and staff members did not wear gowns while administering medications via the feeding tube. Specifically, on March 5, 2025, a Registered Nurse was observed administering medications to the resident without wearing a gown. Similarly, on March 6, 2025, a Licensed Practical Nurse also administered medications without wearing a gown and acknowledged the absence of EBP signage. The Interim Director of Nursing and the Resident Care Manager confirmed that EBP should have been in place for residents with feeding tubes and that staff should have worn gowns during medication administration. This oversight placed residents, staff, and visitors at an increased risk of infection and related complications.
Failure to Notify Physician of Missed Medications
Penalty
Summary
The facility failed to notify the primary care physician when medications were not administered to a resident, identified as Resident 1, who was being treated for an underactive thyroid and an overactive bladder. The medications in question were Levothyroxine, used for hypothyroidism, and Trospium, used for bladder control. According to the Medication Administration Record (MAR) for July 2024, the medications were not given on two consecutive days, 07/24/2024 and 07/25/2024, as indicated by the number nine documented with staff initials. This lapse in medication administration was confirmed by interviews with the resident and nursing staff. Resident 1 expressed concerns about missing doses of Levothyroxine, fearing an increase in heart rate, a known side effect of not taking the medication. The resident also reported discomfort due to the lack of Trospium, which led to frequent urination. Staff interviews revealed that the primary care physician should have been notified of the missed doses to potentially adjust the treatment plan. The Director of Nursing Services, a Registered Nurse, a Licensed Practical Nurse, and the Administrator all acknowledged the oversight in communication with the physician, which could have impacted the resident's health and quality of life.
Medication Administration Failure
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the non-administration of Levothyroxine and Trospium. The resident, who was admitted with a thyroid disorder and loss of bladder control, reported missing doses of these medications, which are critical for managing their conditions. The Medication Administration Record (MAR) confirmed that Levothyroxine was not given on two consecutive days, and Trospium was missed on three occasions over two days. Interviews with staff revealed that the medications were not administered because they had run out, and the pharmacy did not deliver the replacements in time. Staff members acknowledged the potential adverse effects of missing these medications, particularly the risk of side effects from not taking Levothyroxine. The Director of Nursing Services and the facility's Administrator confirmed the medication omissions, acknowledging that this was not a good practice.
Failure to Provide Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop baseline care plans within 48 hours of admission for three residents, which is a requirement to ensure continuity of care and meet immediate health and safety needs. The facility's policy, revised in March 2022, mandates that a baseline care plan be created within this timeframe, including instructions for effective, person-centered care. However, for Resident 1, there was no documentation that the baseline care plan was offered or provided within 48 hours of admission, and the 72 Hour Huddle document was blank. Resident 1 confirmed not receiving the baseline care plan, and the document was locked without showing when it was provided. Similarly, Resident 3 and Resident 4 did not receive their baseline care plans within the required 48-hour period. Resident 3's baseline care plan was reviewed and provided on a date beyond the 48-hour window, and Resident 3 stated they did not receive it. Resident 4's baseline care plan was also provided late, as confirmed by the nursing progress notes and the 72 Hour Huddle document. Staff interviews corroborated these findings, with the Social Services Director and the Director of Nursing acknowledging the failure to meet the 48-hour requirement.
Failure to Provide Scheduled Showering Assistance
Penalty
Summary
The facility failed to provide necessary assistance for showering and bathing to two residents, leading to unmet care needs. Resident 1, who was cognitively intact and required total assistance with showering, did not receive a shower on the scheduled days of 06/18/2024 and 06/21/2024, as per the facility's shower schedule. Despite being admitted on [DATE], Resident 1 only received a bed bath on 06/25/2024, 11 days after admission. There was no documentation of refusals for showering, and staff confirmed the lack of showering on the scheduled days. Similarly, Resident 2, who required one-person assistance for showering, did not receive showers on the scheduled days of 06/19/2024 and 06/21/2024. The facility's documentation did not indicate any refusals for showering, and staff confirmed the absence of showers on these dates. The Director of Nursing acknowledged that residents should have been provided showers according to the schedule, which was not adhered to in these cases.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Agency within the required timeframe. The facility's policy mandates that any suspicion of abuse, neglect, exploitation, or misappropriation of resident property must be reported immediately to the administrator and relevant authorities. However, in this case, the allegation was not reported promptly. The incident involved a cognitively intact resident who reported that an unknown male individual had inappropriately touched and kissed them. The resident informed a Certified Nurse Assistant about the incident, who then passed the information to a Registered Nurse. The Registered Nurse documented the incident and placed the report in the Director of Nursing Services' inbox. Despite receiving the report on the following day, the Director of Nursing Services did not report the allegation to the State Agency until several days later. The delay in reporting the incident placed the resident at risk for potential unidentified abuse and lack of protection. The facility's incident log for the month did not include the resident's allegation, indicating a lapse in the documentation and reporting process. The Director of Nursing Services acknowledged the failure to report the allegation promptly, which is a violation of the facility's policy and state regulations.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to ensure a thorough investigation and documentation of an abuse allegation involving a resident. The facility's policy requires all allegations to be thoroughly investigated, including interviewing staff members on all shifts who had contact with the resident during the period of the alleged incident. However, the incident involving a resident who reported being inappropriately touched by an unknown male was not logged in the incident report log within the required five days. The investigative report lacked documentation of minimum staff interviews and a conclusive summary to rule out abuse. The incident was initially reported by the resident to a Certified Nurse Assistant, who then informed a Registered Nurse. The Registered Nurse documented the incident and placed the notes in the Director of Nursing Services' inbox. Despite this, the Director of Nursing Services did not log the incident in the report log and failed to conduct a comprehensive investigation, as not all relevant staff were interviewed. The investigation was incomplete, and no conclusive findings were documented to rule out the abuse allegation.
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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