Bellevue Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Bellevue, Washington.
- Location
- 2424 156th Avenue Northeast, Bellevue, Washington 98007
- CMS Provider Number
- 505500
- Inspections on file
- 31
- Latest survey
- January 10, 2026
- Citations (last 12 mo.)
- 65
Citation history
Health deficiencies cited at Bellevue Post Acute during CMS and state inspections, most recent first.
A resident with orders for PT/OT and a PT plan of care specifying treatment twice weekly did not receive PT services for an 18‑day period. The resident reported not having PT for about two weeks, and review of therapy notes confirmed no PT during that time and no documentation of refusals or missed visits. The PT stated residents are to be seen per their treatment plan and that missed visits should be documented, but no such documentation existed. The rehab director acknowledged the gap in services was due to staffing shortages that prevented scheduling, and the administrator confirmed the expectation that residents receive therapy as ordered.
A resident was discharged without receiving the required written notice of transfer/discharge, and neither the resident's representative nor the Office of the State Long Term Care Ombudsman were notified as mandated by facility policy and regulation. Staff interviews confirmed a lack of awareness and documentation regarding the notification process.
Surveyors found that the facility did not ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, resulting in a deficiency.
A resident reported feeling threatened by a staff member described as the head of nurses. Despite facility policy requiring immediate suspension of any accused staff pending investigation, the DON—who matched the initial description—was not suspended and instead conducted the follow-up interview, ultimately ruling themselves out as the alleged perpetrator. Staff interviews confirmed knowledge of the suspension policy, but it was not followed in this case.
A facility failed to notify law enforcement of suspected abuse involving a CNA and a resident. The resident reported feeling powerless and vulnerable after the CNA did not respect her request to stop touching her during a shower. Despite the facility's policy requiring such incidents to be reported, law enforcement was not contacted, as confirmed by interviews with the DON and Executive Administrator.
The facility did not post nurse staffing information on the second floor, as required by policy. Observations showed postings were only on the first floor, and interviews with staff and a resident confirmed the deficiency. Staff G admitted the posting was not in a prominent place accessible to all, and a resident suggested it should be posted on the second floor as well.
The facility failed to maintain food safety standards, with improper labeling and storage of food items, inconsistent hand hygiene and glove use by kitchen staff, and lack of hair coverings. Observations showed food past use-by dates, staff not washing hands after glove removal, and uncovered desserts being delivered to residents' rooms. Staff acknowledged these issues, which were against facility policies.
The facility did not include 2021 recertification and complaint survey results in the survey result binder and failed to post notices about the availability of these reports. This prevented residents and visitors from accessing important information. Two residents were unaware of the survey reports' availability, and observations confirmed the lack of postings. The Executive Director acknowledged the missing documents.
The facility failed to provide baseline care plans and written summaries to several residents within 48 hours of admission, as required by policy. Staff interviews and record reviews revealed that written summaries were not consistently provided, and in one case, a baseline care plan was missing entirely. This placed residents at risk for unmet care needs.
The facility failed to develop and implement comprehensive care plans for four residents, including those using assistive devices and self-administering medications. A resident with dementia used a tilt-in-space wheelchair without a care plan, while another had a Ventolin inhaler at their bedside without a self-administration plan. Additionally, a resident with dysphagia was left unsupervised during meals, contrary to their care plan, risking aspiration.
The facility failed to maintain a safe environment and provide adequate supervision, leading to potential hazards. Bubbling in the first-floor hallway carpet posed a tripping risk, while a resident with dysphagia was left unsupervised with food and fluids, contrary to their care plan. Staff acknowledged these issues, highlighting delays in addressing the carpet problem and the need for strict adherence to supervision protocols.
Expired medications and improperly labeled liquid medications were found in two medication carts at the facility. Observations revealed expired drugs such as Senna plus, Iron, Bisacodyl, Aspirin, Vitamin D3, Fish oil, Fexofenadine hydrochloride, and Melatonin. Additionally, Tylenol and Lactulose solutions lacked proper labeling. Staff acknowledged the oversight, and the DON confirmed the facility's expectations for medication management.
The facility failed to manage its resources effectively, resulting in hazardous carpet conditions in the hallways. Observations showed bubbling in the carpet, posing a risk to residents using mobility aids. Staff confirmed the issue, and the Executive Director acknowledged awareness but cited delays in corporate response to repair requests.
The facility failed to ensure proper hand hygiene and glove use by staff during resident care and meal delivery, as observed with an LPN and a scheduler. Additionally, Enhanced Barrier Precautions (EBP) were not implemented for residents with indwelling catheters, increasing infection risk. Observations showed catheter tubing touching the floor and staff not wearing gowns during high-contact care. Interviews revealed a lack of awareness and policy for EBP, leading to increased infection risk.
A facility failed to obtain informed consent before administering psychotropic medications to a resident with moderately impaired cognition. Despite the facility's policy requiring consent, the resident's EHR lacked documentation of consent for antidepressant and antianxiety medications. Staff confirmed that consent should have been obtained and documented.
Two residents were found with medications at their bedside without completed assessments or physician orders for self-administration. One resident had an incomplete assessment for a Ventolin inhaler and no order for a Stiolto Respimat inhaler, while another had home medications without any documented clearance. Staff confirmed that medications should not be at the bedside without proper assessment and orders.
A resident reported feeling threatened by the food served after complaining about it, but the facility failed to report this allegation of abuse to the State Agency as required. The resident, who was cognitively intact, described receiving 'throw away food' and 'goopy' food, which they considered a threat. The facility's administrator did not report the incident, believing it was unnecessary due to a lack of harm, but later acknowledged the need to report it.
A resident reported feeling threatened after receiving 'throw away food' following complaints about the facility's food. The administrator did not recognize this as an abuse allegation and failed to conduct a thorough investigation, placing the resident at risk for repeated incidents and unidentified abuse.
A facility failed to provide written notice of transfer to a resident, their representative, and the State LTC Ombudsman, as required by policy. Staff interviews revealed that verbal notifications were given instead, and the resident was omitted from the list sent to the Ombudsman. The Executive Director confirmed the oversight.
A facility failed to transmit a resident's assessment data to CMS within the required timeframe. The discharge MDS for a resident was not completed, resulting in an 87-day delay. An MDS RN acknowledged the oversight, and the DON confirmed the expectation for timely completion.
The facility inaccurately assessed two residents using the MDS tool. One resident with an indwelling catheter was incorrectly coded as occasionally incontinent, while another resident's discharge status was wrongly recorded as discharged to an acute hospital instead of an Assisted Living Facility. These errors were identified during record reviews and interviews with the MDS RN and DON.
A facility failed to conduct a required Level II PASARR evaluation for a resident with bipolar disorder, as indicated by a positive Level I PASARR. The oversight occurred despite updated guidance from the Department of Social and Health Services, which staff were aware of but did not implement, placing the resident at risk of not receiving appropriate care.
The facility failed to conduct care conferences for two residents within the required seven days of admission, as per their policy. Both residents confirmed the absence of these conferences, and staff interviews corroborated the oversight. This deficiency placed the residents at risk of not having input on their care goals and unmet needs.
The facility failed to ensure proper medication administration and monitoring, as a nurse did not prime an insulin pen before dosing, and medications were left unattended for a resident. Additionally, vital signs were not consistently checked before administering blood pressure medication to a resident with hypertension, despite specific parameters for withholding the medication. Staff confirmed these practices were against facility expectations.
A resident with diabetes and muscle weakness did not receive necessary nail care or assistance with wheelchair transfers. Observations showed long, untrimmed nails with debris, and no documentation of scheduled care. Staff interviews confirmed the lack of scheduled nail care and assistance, despite the resident's expressed need and care plan requirements.
A facility failed to administer PRN Torsemide for a resident with significant weight gain and did not follow the bowel management protocol for another resident. Despite having orders for diuretic medication and bowel management, the staff did not take appropriate actions, leading to unmet care needs. Interviews revealed a lack of adherence to protocols and physician orders, placing residents at risk of medical complications.
A facility failed to provide consistent restorative services for a resident with limited ROM, as required by their care plan. Documentation showed missing records for active ROM exercises and ambulation training, and interviews revealed that the responsible CNA was often reassigned to other duties, leading to neglect of the restorative program. The DON confirmed the lack of documentation and acknowledged that the program was not carried out, placing the resident at risk for unmet care needs.
A facility failed to properly label, date, and store a nebulizer treatment set and tubing for a resident with COPD, who was prescribed Albuterol Sulfate Nebulization Solution. Observations showed the equipment was left on a chair without proper labeling or storage, contrary to facility policy. A nurse confirmed the equipment should have been labeled and bagged, and the DON stated it should be changed weekly and stored properly.
A facility failed to create and implement a care plan for a resident with dementia, as required by their policy. Despite the resident's diagnosis, their care plan lacked documentation of dementia-specific interventions. Observations showed the resident was placed in front of a TV without personalized care, and staff interviews confirmed the absence of a necessary care plan.
Two residents received unnecessary medications due to failure to adhere to physician orders. A resident with intact cognition was given PRN oxycodone for pain levels below the prescribed threshold, while another resident with hypertension received Carvedilol despite blood pressure and heart rate readings that should have prompted withholding the medication. Nursing staff acknowledged the errors.
A resident with moderately impaired cognition continued to receive unnecessary Mirtazapine despite a pharmacist's recommendation to taper and discontinue it, which was agreed upon by the physician. The facility failed to implement the recommendation within the expected timeframe, as confirmed by the DON.
The facility failed to ensure CNAs received the required 12 hours of annual training, including dementia care, for a staff member. Staff N, hired in early 2023, completed only 7.83 hours of training without any dementia training. Staff Development and the DON confirmed the deficiency.
The facility's assessment failed to include necessary resources for resident care during nights and weekends, lacked documentation of third-party agreements, and did not consider specific staffing needs for each shift. The Executive Director confirmed these omissions, acknowledging the absence of a staffing and retention plan, which placed residents at risk for unmet care needs.
A facility failed to accurately assess a resident's UTI in their MDS assessment. The resident had a positive urine analysis and was treated with ciprofloxacin, but the UTI was not documented in the MDS within the required 30-day look-back period. Both the MDS Nurse and the DON acknowledged the oversight, which placed the resident at risk for unmet care needs.
Failure to Provide Ordered PT Services Due to Staffing Shortages
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services according to a resident’s established treatment plan. The facility’s policy on scheduling therapy services states that therapy is to be scheduled in accordance with the resident’s treatment plan. One cognitively intact resident, identified as Resident 15, was admitted in October 2025 and had a physician’s order dated 12/04/2025 for PT/OT to evaluate and treat, with partial weight bearing as tolerated. A PT Evaluation and Plan of Treatment dated 12/11/2025 specified a frequency of two times per week, with a certification period from 12/11/2025 through 02/23/2026. During an interview on 01/06/2026, the resident reported that the last time they received PT was two weeks prior. Record review of PT notes for Resident 15 showed no documentation of PT services provided between 12/19/2025 and 01/05/2026, an 18‑day gap, despite the ordered frequency. The PT (Staff R) stated that residents are to be seen according to the plan of treatment and that refusals should be documented with missed visit notes, but could not find any documentation explaining why Resident 15 did not receive PT during that period and referred the surveyor to the Director of Rehab. The Director of Rehab (Staff Q) stated that the resident did not receive PT services for two weeks due to staffing shortages and that they were not able to schedule the resident, and confirmed that absent staffing issues, the expectation was PT twice weekly. The Administrator (Staff A) stated they expected residents to receive therapy services per their treatment plan and confirmed that this expectation applied to Resident 15’s ordered twice‑weekly therapy.
Failure to Provide Required Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written notice of transfer or discharge to a resident and/or their representative, as well as to the Office of the State Long Term Care Ombudsman, as required by both facility policy and regulation. Review of the electronic health record for the resident who was discharged showed no documentation that such notice was given. Multiple staff interviews confirmed a lack of awareness or implementation of the process for providing and documenting these notifications. The Social Services Director, who was new to the role, was unsure if the notice had been provided and could not locate any related documentation. The Charge Nurse stated that providing such notice was a new policy and that nothing had been sent to the ombudsman. The Regional Nurse Consultant and the Administrator both acknowledged that the required notifications were not present in the resident's record and confirmed that notification to the ombudsman is a regulatory requirement. The facility's policy, revised in March 2021, specifies that residents and/or their representatives must be notified in writing, in a language and format they understand, of the specific reason for transfer or discharge, the date, the location, and their rights to appeal. It also requires that a copy of the notice be sent to the Office of the State Long-Term Care Ombudsman. Despite these requirements, there was no evidence that the resident or their representative received the required written notice, nor that the ombudsman was notified, at the time of the resident's discharge.
Failure to Maintain Safe Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and there was insufficient oversight to protect residents from potential harm. Specific actions or inactions leading to this deficiency include the presence of accident hazards and a lack of proper supervision, as directly observed by surveyors during their review.
Failure to Suspend Alleged Perpetrator During Abuse Investigation
Penalty
Summary
The facility failed to follow and implement its abuse and neglect policies and procedures during the investigation of an abuse allegation involving a cognitively intact resident. According to the facility's policies, any employee accused of abuse, mistreatment, neglect, or exploitation must be immediately suspended pending the outcome of the investigation. However, when a resident reported feeling threatened and fearful after an interaction with a staff member described as the head of nurses, the staff member fitting that description (the Director of Nursing) was not suspended or ruled out as a possible alleged perpetrator at the outset of the investigation. The investigation report showed that the resident initially described the alleged perpetrator as a tall nurse and the head of nurses, which matched the Director of Nursing. Despite this, the Director of Nursing conducted a follow-up interview with the resident, during which the resident provided a different description. The Director of Nursing then ruled themselves out as the alleged perpetrator based on this new description and their claim of not being present during the alleged incident. There was no documentation that the Director of Nursing was suspended or excluded from the investigation process, as required by policy. Interviews with other staff confirmed their understanding that any staff member accused of making a resident feel threatened or afraid should be suspended pending investigation. Staff also identified the Director of Nursing as the head of nurses, matching the resident's initial description. The Executive Administrator stated that staff are expected to follow the facility's abuse and neglect policies, but the investigation did not reflect adherence to these procedures in this case.
Failure to Report Suspected Abuse to Law Enforcement
Penalty
Summary
The facility failed to notify local law enforcement of a reasonable suspicion of abuse involving a resident. The incident involved a Certified Nursing Assistant (CNA) who allegedly did not respect the resident's request to stop touching her during a shower, making the resident feel powerless and vulnerable. The grievance form filled out by the resident indicated that the CNA's actions were perceived as abusive, yet the facility did not report the incident to law enforcement as required by their policy and state regulations. The facility's policy, as well as state guidelines, mandate that such incidents be reported to law enforcement, especially when involving staff-to-resident concerns. Despite the resident's clear expression of feeling abused and the facility's acknowledgment of the incident as an abuse allegation, there was no documentation of law enforcement being notified. Interviews with the Director of Nursing and the Executive Administrator confirmed that the facility did not contact the police, acknowledging a failure to comply with reporting requirements.
Failure to Post Nurse Staffing Information on All Floors
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in prominent locations on both floors, specifically on the second floor, as required by their policy. The policy, dated August 2018, mandates that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel responsible for patient care should be posted in a prominent location accessible to patients and visitors. Observations on multiple dates revealed that the nurse staffing information was consistently posted only on the first floor by the administration office and not on the second floor. Interviews with staff and a resident confirmed the deficiency. Staff G, responsible for scheduling and staff development, acknowledged that the staffing information was only posted on the first floor and agreed that it was not in a prominent place accessible to all residents and visitors, particularly those on the second floor. Staff A, the administrator, believed the posting location was adequate due to the first floor's central activities and office locations. However, a resident noted that the posting was not easily visible, especially for older individuals, and suggested that it should be posted in other locations, including the second floor.
Food Safety and Hygiene Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards of food safety, as evidenced by improper food handling and storage practices. Observations revealed that food items in the walk-in refrigerator were not labeled with use-by dates, and some items were past their use-by dates, such as sausage gravy, cheese, and egg salad. Staff C, the Dietary Manager, acknowledged these discrepancies and stated that the items should have been discarded. Additionally, in the dry storage room, an opened container of molasses and cinnamon raisin bread were found past their use-by dates, which Staff C also agreed should be discarded. Hand hygiene and glove use were not consistently practiced by the kitchen staff. Staff O, P, and Q were observed not performing hand hygiene after removing gloves, despite handling various food items and equipment. Staff O admitted to not washing hands after glove removal, while Staff P and Q acknowledged that they sometimes forgot to perform hand hygiene. Staff C, the Dietary Manager, and Staff E, the Infection Preventionist, both stated that they expected staff to perform hand hygiene before and after glove use. The use of hair coverings in the kitchen was also neglected. Staff C was observed without a hairnet while handling food, which they admitted was against the facility's policy. Additionally, uncovered food items were delivered to residents' rooms, with desserts being transported without covers, exposing them to potential contamination. Staff AA and Staff X were observed carrying uncovered desserts down hallways, and Staff C admitted that desserts were not covered due to frosting. Staff E and Staff B, the Director of Nursing, expressed concerns about uncovered food being carried long distances, as it could be exposed to contaminants.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to ensure that the survey result binder included the results for the 2021 recertification and complaint surveys that resulted in citations. Additionally, the facility did not post notices of the availability of survey reports in prominent and accessible areas for the public. This oversight prevented residents, their representatives, and visitors from exercising their right to review past survey results and the facility's plan of corrections. During a residents' meeting, two residents who regularly attended monthly meetings stated they were unaware of the availability of survey reports. Observations on the facility's first and second floors confirmed the absence of postings or notices regarding the survey reports. A review of the survey binder revealed missing recertification and complaint survey results for 2021, including specific complaint survey results from February, March, September, and October, as well as the recertification survey result from June. The Executive Director acknowledged the absence of these documents and confirmed that all annual recertification and complaint survey results with citations should be included in the binder.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to develop and provide a baseline care plan and a written summary to residents and/or their representatives within 48 hours of admission, as required by their policy. This deficiency was identified for five residents during the survey. For Resident 94, the baseline care plan was not marked as provided to the resident or their representative, and the staff admitted to not giving a written summary. Similarly, Resident 194 did not recall receiving a written summary, and the staff confirmed that it was not provided unless requested. Resident 15 also expressed uncertainty about receiving the summary, and the records showed it was not provided. Resident 20's records lacked a baseline care plan entirely, and the staff could not locate it. Resident 5 was unsure about receiving the summary, and the records confirmed it was not provided. The Director of Nursing stated that the expectation was for the written summary to be offered and provided to residents, which was not consistently done. This failure to adhere to the facility's policy placed residents at risk for unmet care needs and a diminished quality of life.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to unmet care needs and potential risks. Resident 23, who was admitted with dementia and severely impaired cognition, was observed using a tilt-in-space wheelchair without a corresponding care plan. Staff acknowledged the absence of a care plan for the wheelchair, which was necessary for the resident's positioning. Resident 193 was observed with a Ventolin inhaler at their bedside, but there was no care plan for self-administration of medication, despite an order allowing the inhaler to be kept at the bedside. Staff confirmed that a care plan should have been initiated for self-administration of medication. Similarly, Resident 9 had an Afrin nasal spray for unsupervised self-administration, but no care plan was in place, contrary to the facility's policy. Resident 29, diagnosed with dysphagia following a stroke, had a care plan requiring supervision during meals to prevent aspiration. However, staff left the resident unsupervised with a breakfast tray, contrary to the care plan's directives. Staff interviews confirmed the expectation for one-on-one supervision during meals, which was not followed, placing the resident at risk of aspiration.
Safety and Supervision Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure the safety of the first-floor hallway carpet and provide adequate supervision for a resident, leading to potential accident hazards. Observations revealed multiple areas of bubbling in the carpet, creating bumps that residents had to navigate over, posing a tripping risk. Staff interviews confirmed awareness of the issue, with attempts to address it being delayed due to pending corporate actions. The Executive Director acknowledged the safety concern, noting that the facility primarily serves short-term rehabilitation residents who frequently use the hallways for therapy. Additionally, the facility did not provide the required supervision for Resident 29, who was at high risk for aspiration due to dysphagia following a stroke. Despite care plan instructions for one-on-one supervision during oral intake, Staff N left the resident's breakfast tray unsupervised, allowing the resident to drink independently. Staff interviews confirmed the need for strict adherence to the care plan, emphasizing the importance of supervision to prevent aspiration. The Director of Nursing reiterated the expectation for staff to follow care plans and not leave food or fluids within the resident's reach without supervision.
Expired and Improperly Labeled Medications Found in Medication Carts
Penalty
Summary
The facility failed to ensure that expired medications were disposed of in a timely manner and that drugs were properly labeled and stored according to current accepted professional standards. During an observation of the first floor Team 1 medication cart, several expired medications were found, including Senna plus, Iron, Bisacodyl, Aspirin, Vitamin D3, and Fish oil. Additionally, a bottle of Tylenol liquid was not labeled with the date it was opened or the date it should be discarded. Staff U, an LPN, acknowledged that the expired medications should have been discarded and that liquid medications should have been labeled with the date they were opened. Similarly, an observation of the first floor Team 2 medication cart revealed expired medications such as Vitamin D3, Aspirin, Fexofenadine hydrochloride, and Melatonin. A bottle of Lactulose solution was also found without a label indicating when it was opened or when it should be discarded. Staff V, an RN, confirmed that the expired medications should have been discarded and that liquid medications should have been labeled upon opening. The Director of Nursing, Staff B, stated that the facility's expectation was for expired medications to be discarded and for liquid medications to be labeled when opened.
Facility's Ineffective Resource Management Leads to Hazardous Carpet Conditions
Penalty
Summary
The facility failed to manage its resources effectively to maintain the residents' highest practicable physical, mental, and psychosocial well-being, as evidenced by the poor condition of the carpet in the first-floor hallways. Observations revealed multiple areas of bubbling in the carpet, creating potential hazards for residents, particularly those using mobility aids such as walkers and canes. Staff interviews confirmed the presence of these hazards, with one staff member noting that residents had to lift their feet to navigate the uneven carpet, increasing the risk of tripping. The facility's Executive Director acknowledged awareness of the carpet issue, which had been ongoing for several months. Despite attempts to address the problem, including contacting corporate for quotes to repair or replace the carpet, there was a lack of follow-through, as the corporate office claimed not to have received or could not find the quotes. This inaction left the hazardous carpet condition unaddressed, posing a risk to residents, particularly those undergoing short-term rehabilitation and using the hallways for therapy.
Infection Control Deficiencies in Hand Hygiene and EBP Implementation
Penalty
Summary
The facility failed to ensure proper hand hygiene practices and the use of gloves by staff members during resident care and meal tray delivery. Observations revealed that Staff K, an LPN, did not perform hand hygiene before entering resident rooms or after removing gloves while delivering meal trays. Similarly, Staff G, responsible for scheduling and staff development, did not perform hand hygiene before glove use when assisting residents. Interviews with the staff confirmed their awareness of the hand hygiene protocols, yet these were not consistently followed, as expected by the facility's infection preventionist and director of nursing. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling catheters, which are necessary to protect against multidrug-resistant organisms. Residents 37, 193, and 5, all of whom had indwelling urinary catheters, did not have EBP signage on their doors, and staff did not wear gowns during high-contact care activities. Observations showed that catheter tubing was often touching the floor, contrary to the facility's catheter care policy. Interviews with staff indicated a lack of awareness regarding EBP requirements and the absence of a policy for EBP implementation. Resident 37's catheter tubing was observed touching the floor multiple times, and staff did not wear gowns during high-contact care. Similarly, Resident 193 and Resident 5, both with indwelling catheters, were not placed on EBP, and staff did not consistently perform hand hygiene between glove changes. The facility's failure to adhere to infection control protocols and implement EBP for residents with indwelling catheters increased the risk of infection for residents, staff, and visitors.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform a resident and/or their representative before administering psychotropic medications, specifically antidepressant and antianxiety medications. This deficiency was identified during a review of the facility's policy on psychotropic drug utilization, which mandates obtaining informed consent prior to the administration of such medications. The policy, last updated in November 2017, requires licensed staff to secure informed consent when a psychoactive medication is indicated in the plan of care. Resident 5, who was admitted to the facility with moderately impaired cognition, was receiving both antidepressant and antianxiety medications as per the order summary report. However, a review of the resident's electronic health record revealed that informed consent for these medications was not documented. During interviews, both a Licensed Practical Nurse and the Director of Nursing confirmed that informed consent should have been obtained and documented before administering the medications. Despite a verbal consent being mentioned, it was not recorded in the electronic health record or on a hard copy consent form.
Failure to Assess and Obtain Orders for 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 the necessary physician orders for two residents. Resident 193 was observed with a Ventolin FHA inhaler and Stiolto Respimat inhaler on their bedside table without a completed self-administration assessment or a physician's order for the Stiolto Respimat. Despite the presence of an order for the Ventolin FHA, the assessment was incomplete, and the medications were left at the bedside, contrary to the facility's policy. Similarly, Resident 34 had Aspercreme and Xylimelts on their bedside table, which were their home medications. Although the resident claimed these were cleared by a doctor, there was no documented order or assessment for self-administration in their electronic health record. Staff interviews confirmed that medications should not be at the bedside without an assessment and order, highlighting the facility's failure to adhere to its policy and placing residents at risk for medication errors.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as Resident 7, to the State Agency as required. The facility's policy mandates that all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, or within 24 hours if the violation does not involve abuse and has not resulted in serious injury. Despite this, the facility did not report the incident involving Resident 7, who felt threatened by the food served to them after they complained about it. Resident 7, who was cognitively intact, reported to a registered nurse that they received 'throw away food' and 'goopy' food, which they considered a threat. The resident expressed fear regarding the situation. However, the facility's administrator, Staff A, stated that they were not informed of Resident 7 feeling threatened or afraid. Staff A mentioned that the resident only complained about the quality of the food, such as the casserole and meatloaf having fillers, and did not use terms like 'goopy' or 'throw away food.' The facility's incident log did not document Resident 7's concerns of feeling threatened or afraid, although the grievance log did note a grievance related to food and fear. Staff A admitted that they did not report the incident to the State Agency, as they interpreted the guidelines to mean that it was not necessary due to the lack of harm. However, upon reviewing the guidelines, Staff A acknowledged that the incident should have been reported and logged as an incident.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to identify and thoroughly investigate an abuse allegation involving a resident who was cognitively intact. The resident reported feeling threatened and afraid after receiving what they described as 'throw away food' and 'goopy food' following complaints about the facility's food. The resident communicated these concerns to a registered nurse and later to the dietary manager. However, the administrator, who was aware of the resident's food complaints, did not initially recognize these concerns as an abuse allegation. The administrator stated that the resident never expressed feeling threatened or afraid during their conversations. The facility's incident log did not document the resident's concerns, although the grievance log did note a grievance related to food and fear. The administrator acknowledged that an investigation was not conducted and that the process for reporting and investigating abuse was not followed. The administrator admitted that they should have completed an investigation report and logged the incident in the facility's incident reporting log. The failure to investigate the resident's concerns placed the resident at risk for repeated incidents and unidentified abuse.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to provide written notice of transfer or discharge to a resident and their representative, as well as to the Office of the State Long Term Care Ombudsman, as required by their policy. This deficiency was identified during a review of the case of a resident who was transferred to an acute hospital. The facility's policy, dated June 2018, mandates that written notice be given to the resident and/or their representative, and a copy sent to the Ombudsman, especially when an immediate transfer is necessitated by urgent needs. However, the clinical health record lacked documentation of such written notice for the resident in question. Interviews with various staff members, including registered nurses, licensed practical nurses, and social services personnel, revealed that the facility's practice was to notify families verbally when residents were transferred to the hospital. The staff admitted that they did not provide written notifications. Additionally, the receptionist responsible for notifying the Ombudsman by fax on a monthly basis failed to include the resident in question on the list of discharged residents. The Executive Director confirmed that the nurses were responsible for notifying families and acknowledged that the Ombudsman was not notified about the resident's transfer.
Failure to Timely Transmit Resident Assessment Data
Penalty
Summary
The facility failed to transmit resident assessment data to the Centers for Medicare & Medicaid Services within the required timeframe for one resident, identified as Resident 30, who was reviewed for discharge assessments. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, discharge Minimum Data Set (MDS) assessments must be completed no later than 14 days after the discharge date and submitted within 14 days of the MDS completion date. Resident 30 was discharged to a community, but a review of their MDS schedule on October 9, 2024, revealed that the discharge MDS was not completed, making it 87 days late. In a phone interview, Staff H, an MDS Registered Nurse, acknowledged that the discharge MDS for Resident 30 was not completed and was missed. Staff H stated that typically, the discharge MDS would be completed within 14 days from the discharge date and transmitted within the week. The Director of Nursing, Staff B, confirmed the expectation for timely completion of discharge MDS assessments.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess two residents using the Minimum Data Set (MDS) assessment tool, which is crucial for identifying and meeting residents' care needs. Resident 5, who was admitted with an indwelling catheter, was incorrectly coded as occasionally incontinent in the MDS, contrary to the RAI manual's instructions to code such cases as 'not rated.' This error was identified during a joint record review and interview with the MDS Registered Nurse, who acknowledged the inaccuracy and indicated that the assessment would be modified. Resident 40's discharge status was inaccurately recorded in the MDS as discharged to an acute hospital, while nursing progress notes and a joint record review confirmed the resident was discharged to an Assisted Living Facility. This discrepancy was also recognized by the MDS Registered Nurse during a review of the electronic health record. The Director of Nursing expressed an expectation for staff to adhere to the RAI manual and ensure MDS accuracy, highlighting the facility's responsibility to conduct precise assessments.
Failure to Conduct Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to properly review and validate the Preadmission Screening and Resident Reviews (PASARR) for a resident with a diagnosis of bipolar disorder. The resident's Level I PASARR, dated November 2, 2023, indicated a positive result for Serious Mental Illness/Intellectual Disabilities (SMI/ID) due to the diagnosis of bipolar disorder. However, the PASARR documentation did not show that a Level II evaluation was indicated or that a referral for such an evaluation was sent, as required by the updated guidance from the Department of Social and Health Services. Interviews with facility staff revealed a lack of adherence to the updated PASARR guidance. Staff F, responsible for reviewing PASARRs upon resident admission, did not ensure the accuracy and completion of the Level I PASARR, which should have led to a Level II referral. Additionally, Staff A, the Executive Director, acknowledged awareness of the new PASARR guidance but failed to ensure its implementation, resulting in the oversight. This deficiency placed the resident at risk of not receiving appropriate care and services tailored to their needs.
Failure to Conduct Timely Care Conferences for Residents
Penalty
Summary
The facility failed to conduct care conferences for two residents, which is a requirement to be completed within seven days of admission according to the facility's policy. Resident 37 was admitted to the facility, but a review of their electronic health record showed no documentation of a care conference. Interviews with the resident's representative and staff confirmed that no care conference had been held. Staff F, responsible for scheduling these conferences, acknowledged the oversight and stated that the resident should have had a care conference. The Director of Nursing and the Executive Director both expressed that care conferences are expected to be held within the stipulated timeframe. Similarly, Resident 193, who was admitted to the facility, did not have a care conference documented in their records. The resident confirmed that no care conference had been conducted since their admission. Staff F, during a joint record review, confirmed the absence of a care conference for this resident as well. The Executive Director reiterated the expectation that care conferences should occur within seven days of admission. This failure to conduct timely care conferences placed the residents at risk of not having input regarding their care goals and unmet needs, potentially affecting their quality of life.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration practices were followed, leading to deficiencies in care. A registered nurse, Staff T, did not prime an insulin pen before selecting a dose of 6 units for Resident 195, contrary to the manufacturer's instructions. This oversight was acknowledged by Staff T during an interview, and the Director of Nursing confirmed that the expectation was for nurses to prime the insulin pen before dose selection. Additionally, medications were left unattended for Resident 10, as observed when two medication cups with crushed medications in applesauce were found on the resident's bedside table without a licensed nurse present to ensure the medications were taken. Staff V, an RN, confirmed that leaving medications unattended was not acceptable, and this was reiterated by Staff J, an LPN/Charge Nurse, and Staff B, the Director of Nursing. Furthermore, the facility did not consistently check vital signs before administering blood pressure medication to Resident 25, who had a diagnosis of hypertension. The resident's medication administration record indicated that Carvedilol should be withheld if the systolic blood pressure was less than 100 or the heart rate was less than 55. However, vital signs were only documented once a day, despite the medication being administered twice daily. Staff U, an LPN, and Staff J confirmed that vital signs should be taken before each administration of blood pressure medication, and Staff B stated that this was the facility's expectation.
Failure to Provide Nail Care and Wheelchair Transfer Assistance
Penalty
Summary
The facility failed to provide necessary assistance with nail care and wheelchair transfer for Resident 20, who was admitted with diagnoses including diabetes, muscle weakness, and a need for assistance with personal care. Observations over several days showed that Resident 20's fingernails were long, untrimmed, and had brown debris underneath, with a split nail on the left thumb. Despite Resident 20 expressing discomfort and a desire for nail care, there was no documentation of nail care being scheduled or provided, particularly important due to the resident's diabetes diagnosis, which requires licensed nurses to perform such care. Additionally, the facility did not document any wheelchair transfers for Resident 20, despite the care plan indicating a need for substantial assistance with chair/bed-to-chair transfers. Interviews with staff revealed that fingernail care was not scheduled on the Treatment Administration Record (TAR) for October 2024, and there was no indication that Resident 20 refused care. The Director of Nursing expected nail care to be provided weekly by licensed nurses and for nurse aides to assist with transfers, but these expectations were not met, leading to the deficiency.
Failure to Administer PRN Medication and Follow Bowel Protocol
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for a resident experiencing significant weight gain and the use of diuretic medication. Resident 20, who was admitted with a diagnosis of heart failure, had a significant weight gain of 12 pounds over three days. Despite having a PRN order for Torsemide to address fluid retention, edema, or weight gain, no action was taken to administer the medication or contact the physician. Staff interviews revealed that the order did not specify the amount of weight gain required to administer the medication, and the staff failed to reassess the resident or inform the charge nurse and physician about the significant weight gain. The facility also failed to implement the bowel management protocol for Resident 9, who experienced multiple episodes of constipation. The bowel protocol required the administration of Milk of Magnesia (MOM) if no bowel movement occurred in three days, followed by a Bisacodyl suppository if MOM was ineffective. Resident 9 did not have bowel movements for several days on multiple occasions, yet the MAR showed that MOM or Bisacodyl was not administered as required. Staff interviews confirmed that the bowel protocol was not followed, and there was no documentation of the resident refusing the medication. These deficiencies placed the residents at risk of unmet care needs and potential medical complications. The staff's failure to adhere to the established protocols and physician orders resulted in a lack of appropriate interventions for the residents' conditions. The Director of Nursing acknowledged the expectation for licensed nurses to follow physician orders and the bowel management protocol, highlighting the need for adherence to care standards.
Failure to Provide Consistent Restorative Services for a Resident
Penalty
Summary
The facility failed to consistently provide services to maintain or improve the range of motion (ROM) for Resident 145, who was on a restorative program due to limited ROM in the upper extremity on one side. The facility's policy required treatment and services to prevent further decrease in ROM, but documentation showed missing records for active ROM exercises and ambulation training for an entire week. Observations confirmed that Resident 145 was in bed during the times when exercises should have been conducted, and interviews with the resident revealed that no exercises had been performed with them recently. Interviews with staff highlighted that the Certified Nursing Assistant (CNA)/Restorative Aide responsible for the restorative program was often pulled to cover other duties, leading to the neglect of the restorative program. The Director of Nursing acknowledged the lack of documentation and confirmed that the restorative program was not carried out as required. This oversight placed Resident 145 at risk for a decline in ROM and unmet care needs, as the facility did not adhere to its own policy or the resident's care plan.
Failure to Properly Store and Label Nebulizer Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not labeling, dating, and properly storing the nebulizer treatment set and tubing. This deficiency was observed in the case of a resident with Chronic Obstructive Pulmonary Disease (COPD), who had been prescribed Albuterol Sulfate Nebulization Solution to be administered via nebulizer every four hours as needed. Observations on two separate occasions revealed that the nebulizer machine treatment set and tubing were left on top of the resident's chair without being labeled or stored in a bag, contrary to the facility's policy. During an interview, a Licensed Practical Nurse/Charge Nurse confirmed that the nebulizer treatment set and tubing should have been labeled, dated, and bagged. The Director of Nursing also stated that the nebulizer set should be changed weekly and labeled when changed, and the mouthpiece should be rinsed and stored in a bag after each use. The failure to adhere to these procedures placed the resident at risk for respiratory infections and related complications.
Failure to Implement Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan and interventions for a resident diagnosed with dementia, identified as Resident 25. Despite the facility's policy requiring an interdisciplinary team to create a patient-centered plan for individuals with confirmed dementia, Resident 25's comprehensive care plan lacked any documentation addressing dementia care needs. This oversight was discovered during a review of the resident's records, which showed no dementia care plan or interventions, even though the resident had been diagnosed with dementia. Observations over several days revealed that Resident 25 was placed in a wheelchair in front of a television in the lounge, indicating a lack of personalized care interventions. Interviews with staff, including an LPN and the Director of Nursing, confirmed the expectation that residents with dementia should have a specific care plan. However, the staff acknowledged the absence of such a plan for Resident 25, highlighting a gap in the facility's adherence to its own dementia care policy.
Failure to Adhere to Medication Orders for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications, affecting two residents. Resident 20, who had intact cognition and was prescribed PRN oxycodone for severe pain rated 7 to 10, received the medication for pain levels below 7 on multiple occasions in October 2024. This was contrary to the physician's order, as confirmed by interviews with nursing staff, including a Registered Nurse and a Licensed Practical Nurse, who acknowledged that the medication should not have been administered for pain levels less than 7. Resident 25, diagnosed with hypertension, had an order for Carvedilol to be held if the systolic blood pressure (SBP) was less than 100 or the heart rate (HR) was less than 55. Despite this, the medication was administered on several occasions in July, August, and September 2024, when the resident's SBP was below 100 and HR was below 55. Interviews with nursing staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed that the medication should have been withheld according to the specified parameters.
Failure to Implement Pharmacist's Recommendation for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication, specifically involving the administration of Mirtazapine, an antidepressant. The resident, who had moderately impaired cognition, was admitted to the facility and was receiving both Citalopram and Mirtazapine for depression. A pharmacist recommended tapering and discontinuing Mirtazapine, which the resident's physician agreed to on 09/24/2024. However, the recommendation was not implemented in a timely manner, as the resident continued to receive the full dose of Mirtazapine 21 days after the physician's agreement. During a review and interview, it was confirmed that there was no documentation of the resident refusing the tapering recommendation, and the expectation was that such recommendations should be implemented within 72 hours if agreed upon by the physician. The Director of Nursing stated that the facility's policy required timely implementation of pharmacist recommendations, which was not adhered to in this case, placing the resident at risk of receiving unnecessary medication.
Deficiency in CNA Training Requirements
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required twelve hours of annual training, including dementia management training, for one of its staff members, identified as Staff N. According to the facility's assessment updated on June 14, 2024, CNAs are required to complete at least 12 hours of training per year, which must include dementia care. However, a review of Staff N's employee record revealed that they were hired on January 9, 2023, and had only completed 7.83 hours of training by January 9, 2024, with no documentation of dementia training. During an interview, Staff E from Staff Development confirmed the deficiency, acknowledging that Staff N did not meet the training requirements. Additionally, the Director of Nursing, Staff B, expressed the expectation that all CNAs, including Staff N, should have completed the required training.
Facility Assessment Lacks Resource and Staffing Evaluation
Penalty
Summary
The facility failed to update its facility-wide assessment to accurately determine and identify the resources needed for resident care. The assessment, last updated on June 14, 2024, did not include essential elements such as resources necessary for resident care during nights and weekends, nor did it document contracts or agreements with third parties for services or equipment during normal operations and emergencies. Additionally, the assessment lacked consideration of specific staffing needs for each resident unit and shift, and there was no plan for maximizing recruitment and retention of direct care staff. During an interview, the Executive Director, Staff A, acknowledged the absence of documentation in the facility assessment regarding the evaluation of resources necessary for resident care, including nights and weekends. Staff A also confirmed that the assessment did not include contracts or agreements with third parties, such as hospice, and did not consider specific staffing needs for each shift. Furthermore, Staff A admitted that the facility did not have a staffing and retention plan documented in the assessment. This oversight placed residents at risk for unmet care needs.
Failure to Accurately Assess Resident's UTI in MDS
Penalty
Summary
The facility failed to accurately assess a resident's condition in their Minimum Data Set (MDS) assessment, specifically regarding a diagnosis of a urinary tract infection (UTI). The resident, who was admitted to the facility, had a positive urine analysis and was treated with the antibiotic ciprofloxacin for a UTI starting on May 16, 2024. Despite this, the quarterly MDS assessment with an Assessment Reference Date (ARD) of June 11, 2024, did not include the UTI diagnosis, which was within the 30-day look-back period required for accurate documentation. During a joint record review and interview, the MDS Nurse acknowledged that the resident's MDS assessment was not coded for the UTI, despite the resident receiving treatment for it. The Director of Nursing also confirmed that the MDS should have been accurately completed to reflect the UTI diagnosis. This oversight in the assessment process placed the resident at risk for unidentified or unmet care needs, as the UTI was not documented in the MDS as required by the Long-Term Care Resident Assessment Instrument (RAI) guidelines.
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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