Birch Creek Post Acute & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Tacoma, Washington.
- Location
- 5601 S Orchard Street, Tacoma, Washington 98409
- CMS Provider Number
- 505289
- Inspections on file
- 33
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 37
Citation history
Health deficiencies cited at Birch Creek Post Acute & Rehabilitation during CMS and state inspections, most recent first.
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.
Two residents with dementia did not receive individualized care and services to address their behavioral symptoms, including wandering, exit-seeking, entering other residents' rooms, and yelling out. Care plans lacked specific interventions for these behaviors, and staff responses such as redirection and stop signs were inconsistently applied and ineffective in preventing distress to other residents.
A resident with severe cognitive impairment was found with a raised bump on the forehead and bruising on the back, but staff did not initiate an incident report or conduct a thorough investigation as required by policy. Despite reports from family and visible injuries, documentation and assessment were lacking, and the incident was not entered into facility logs. Staff interviews revealed confusion about the cause of the injuries, and the facility failed to comply with investigation and reporting requirements.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Staff failed to promptly report suspicions of an inappropriate relationship between a staff member and a resident with complex medical needs. Multiple staff members observed or were told about concerning behavior but did not immediately notify administration, resulting in an eight-day delay before the allegation was reported and investigated.
The facility failed to store and prepare food safely, with undated and improperly labeled food items found in the kitchen, and food boxes stored on the freezer floor. Personal items were improperly placed in food preparation areas. Staff were observed not following proper hand hygiene and food temperature protocols, as confirmed by interviews with the Dietary Manager and Administrator.
The facility failed to obtain and periodically review advanced directives (AD) for three residents, denying them the opportunity to direct their healthcare. A resident with diabetes and depression had no follow-up on AD paperwork, another with a stroke and bipolar disorder had no further follow-up on durable power of attorney, and a resident with dementia had no AD documented. The Social Service Director acknowledged the lack of follow-up, and the facility administrator stated that ADs should be discussed quarterly.
The facility failed to properly screen residents with mental health disorders for additional support through the PASARR process. Several residents had PASARR forms that did not accurately reflect their diagnoses, leading to a lack of required level 2 evaluations. The Social Service Director and Administrator acknowledged these discrepancies.
The facility failed to implement baseline care plans within 48 hours for three residents, leading to unmet care needs. A resident with dementia and diabetes did not receive necessary assistance with eating, while another with heart and kidney failure lacked care plans for oral care and bed mobility. A third resident's care plan inaccurately reflected transfer needs. These oversights risked residents' quality of life.
The facility failed to develop comprehensive care plans for six residents, leading to deficiencies in addressing medical needs such as diabetic foot ulcers, ill-fitting dentures, oxygen therapy, feeding tube details, lymphedema, and ADL support. Staff interviews confirmed that care plans did not meet expectations, with outdated or missing interventions and lack of measurable goals.
The facility failed to conduct timely care planning meetings for two residents and did not update care plans for three residents, leading to discrepancies between documented care needs and actual conditions. Staff interviews confirmed these deficiencies, highlighting a failure to revise care plans to reflect current resident needs.
The facility failed to ensure a safe environment for three residents, leading to multiple falls and medication management issues. A resident with a history of falls experienced several incidents without timely interventions, resulting in serious injuries. Another resident had multiple falls without adequate interventions, and a third resident was found with medications left at their bedside without proper assessment. Staff interviews revealed expectations for immediate intervention and care plan updates were not consistently met.
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for three residents. A resident was prescribed Bactrim without reviewing microbiology results, another received Clindamycin despite a negative urinalysis, and a third was on ertapenem with no growth in urinalysis. Staff interviews revealed a lack of procedures to request culture results, contributing to the deficiency.
The facility failed to document that several residents were informed about and offered influenza and pneumococcal vaccines, as required. Residents with various medical conditions, including respiratory failure, diabetes, and kidney failure, had no records of receiving education or being offered the vaccines. Interviews with the DON and Administrator confirmed this was against facility expectations.
The facility failed to document that three residents were informed about the COVID-19 vaccine and offered it, despite having significant medical conditions. Interviews with staff revealed that the lack of documentation and failure to educate and offer the vaccine did not meet facility expectations, placing residents at increased risk.
A facility failed to obtain complete informed consents for psychotropic medications for a resident with dementia, anxiety disorder, and bipolar disorder. The resident was prescribed Clonazepam and Divalproex Sodium, but the consent forms lacked critical information such as dosage, duration, and expected benefits. Interviews with staff confirmed the forms were incomplete, which did not meet facility expectations.
A facility failed to honor a resident's shower preferences, leading to the resident not receiving a shower since admission. The resident, with multiple health conditions, was able to communicate needs but reported no choice in shower scheduling. The care plan lacked shower instructions, and staff confirmed showers were scheduled with make-up days on Sundays. The DON acknowledged the deficiency in meeting resident choice expectations.
The facility failed to maintain a homelike environment in resident rooms on the 200 and 100 halls. Observations revealed torn wallpaper and deep gouges in walls behind beds, with flaking drywall on the floor. A resident reported the disrepair had been present since their arrival, and staff were aware. The Maintenance Director admitted the need for repairs had been known for months, but no timely solution was in place. The Administrator expected maintenance to complete repairs within 30 days.
A facility failed to conduct a criminal background check for a CNA, Staff F, before hire, violating their policy. Staff F was observed working with residents, including one who reported being treated rudely and experiencing pain caused by the CNA. The Administrator in Training confirmed the oversight, acknowledging it as unacceptable.
A resident with multiple health conditions reported abuse and neglect incidents to a lead aide, but these were not documented or reported to the appropriate authorities. Interviews revealed that staff were unaware of the allegations, which were expected to be reported to nurse managers and the administrator. This failure placed the resident at risk of further harm.
A resident with multiple diagnoses, including spinal stenosis, was not wearing a prescribed cervical collar for support and comfort, despite the MAR indicating its use. Observations showed the collar was not worn, and interviews revealed staff failed to educate the resident or notify the provider. The documentation was acknowledged as incorrect by the LPN and DON.
The facility failed to assist three residents with activities of daily living (ADLs), leading to deficiencies in care. A resident dependent on staff for mobility remained in bed for extended periods due to unavailable staff and a missing wheelchair. Another resident, requiring assistance with meals and mobility, was left in bed without help, contrary to their care plan. Additionally, a resident was not offered assistance with personal hygiene, specifically shaving, despite expressing a desire for it. These actions were against the expectations set by the DNS.
The facility failed to provide necessary care for two residents with non-pressure skin conditions. One resident with diabetic foot ulcers did not receive proper treatment due to incorrect application and lack of documentation. Another resident with lymphedema did not have their legs wrapped daily as prescribed, due to an error in order documentation. Staff interviews confirmed these deficiencies.
The facility failed to maintain or improve ROM for two residents. One resident, with respiratory failure and COPD, did not receive recommended restorative care after physical therapy discharge. Another resident, with cognitive deficits and diabetes, did not have a hand splint recommendation implemented. Staff were unaware of these needs, and the facility had not started a formal restorative program.
The facility failed to monitor and document fluid restrictions for two residents, leading to potential medical risks. One resident with muscle disorder and lymphedema had unrestricted access to fluids despite a fluid restriction order, while another with COPD and CHF had inconsistent fluid intake documentation. Additionally, a resident with a feeding tube did not receive required nutritional supplementation due to missing meal intake documentation. Staff interviews revealed a lack of awareness and communication regarding these care plans.
A facility failed to properly document and administer enteral nutrition for a resident with a feeding tube. The resident was supposed to receive Glucerna 1.2 calories at 65 ml per hour with water flushes, but the MAR lacked documentation for the feeding's end time and total volume. Staff interviews confirmed the deficiency, acknowledging the risk of inadequate nutrition and hydration.
The facility failed to provide proper respiratory care for three residents, with discrepancies in oxygen therapy orders and administration. One resident used an oxygen concentrator without orders, while two others received incorrect oxygen levels. Staff did not verify settings as required.
Two residents received pain medications without attempts at non-pharmacological interventions, contrary to facility orders. One resident with anxiety disorder and COPD was given Hydrocodone-Acetaminophen, while another with cervical stenosis and diabetes received tramadol. The DNS confirmed that non-pharmacological interventions should have been attempted first.
A resident with multiple diagnoses, including diabetes and chronic osteomyelitis, had a pustule/boil noted during a skin observation, but the facility failed to document treatment or monitoring orders. Staff confirmed the lack of documentation and notification to the provider and family, highlighting a deficiency in care.
The facility failed to submit accurate and timely direct care staffing information to CMS for Q4 2023. The reported staffing levels were below the mandated requirements, and recalculations still did not meet state minimums. This deficiency affected the accuracy of staffing data and potentially impacted resident care.
A facility failed to prevent and manage a pressure ulcer for a resident by not conducting required weekly skin observations and not documenting or monitoring a newly identified wound. The resident was discharged with a deep wound and without proper wound care instructions. The DON acknowledged the facility's failure to follow their pressure ulcer management process.
The facility failed to follow physician orders for wound care for three residents. A resident with MASD had treatments improperly administered by nursing assistants, and the TAR was signed in advance. Another resident with leg wounds missed two dressing changes, and a third resident had unspecified topical treatments recorded as completed. These actions indicate a lack of adherence to physician orders and professional standards.
A resident with a sacral pressure injury and osteomyelitis was found in urine-soaked briefs and bedding, but the incident was not reported or investigated as neglect. A nursing supervisor was informed but did not recognize it as neglect, and the Director of Nursing was unaware of the situation, leading to a failure in following the facility's policy on abuse and neglect reporting.
The facility failed to prevent and manage pressure injuries for two residents by not developing individualized care plans for incontinence care and repositioning. One resident was found in urine-soaked sheets, and another had recurring skin damage due to inadequate care. Staff interviews revealed a lack of defined care frequencies, and the DON acknowledged the failure to meet professional standards.
The facility failed to provide scheduled showers and shaving for four residents, leading to unmet needs and inadequate personal hygiene. Despite care plans and resident requests, showers and shaving were inconsistently provided, as confirmed by staff interviews and documentation reviews.
The facility failed to provide oxygen therapy per provider orders and ensure oxygen tubing was dated and regularly changed for two residents. One resident received oxygen at a higher rate than prescribed, and another had undated tubing found on the floor. The Director of Nursing Services acknowledged that the oxygen therapy and documentation did not meet expectations.
The facility failed to act on and consistently follow the consultant pharmacist's medication regimen review (MRR) recommendations in a timely manner for three residents, placing them at risk for adverse side effects and decreased quality of life. Issues included delayed or missing documentation and implementation of medication changes.
The facility failed to ensure freedom from unnecessary medications for three residents. One resident was not properly monitored for blood pressure and heart rate before medication administration, and non-pharmacological interventions were not provided before giving PRN pain medications. Another resident on hospice care received PRN oxycodone without documentation of non-pharmacological interventions. A third resident on anticoagulant medication was not monitored for adverse side effects.
The facility failed to provide necessary dental services for two residents. One resident had loose dentures and required adhesive, which was not provided, while another resident with multiple dental issues had not seen a dentist despite having a standing order for a consult. Staff were unaware of these needs, leading to unmet dental care requirements.
The facility failed to follow therapeutic diets for three residents, leading to potential health risks. One resident with dysphagia was served a whole hamburger instead of soft and bite-sized food, while two other residents with no added salt diets were served meal trays with salt packets. Interviews with staff confirmed these lapses in dietary compliance.
The facility failed to ensure an effective infection prevention and control program, with the ICP not analyzing infection data or implementing corrective actions for four months. Additionally, clean linens were improperly stored next to biohazard waste due to space constraints, contrary to facility policy.
The facility failed to resolve grievances brought forward by the resident council for two months. Grievances were recorded but not routinely responded to, and there was no documentation of official responses for March and April 2024. The Administrator was unaware of all the grievances, which did not meet the facility's expectations.
The facility failed to report and investigate an allegation of abuse involving a resident who reported that a woman had thrown ice water on them. Despite the resident informing facility staff and a progress note indicating a verbal altercation, the DON was unaware of any investigations and acknowledged that the incident should have been reported and investigated.
The facility failed to ensure professional standards of care for a resident with congestive heart failure and kidney disease, who was also on anticoagulant therapy. Despite clear admission orders, the resident's EHR lacked necessary monitoring for edema, dyspnea, and bleeding. Observations showed significant swelling and breathing difficulties, which were not documented or addressed in the care plan. Staff acknowledged the oversight and confirmed the expected care plans were not in place.
The facility failed to ensure timely auditory services for a resident with moderate hearing difficulty. Despite having hearing aids documented upon admission, the resident was observed without them and struggled to hear. No audiology consult was made, and the hearing aids were later found in the resident's closet. Staff confirmed that an audiology consult should have been made.
The facility failed to consistently reconcile controlled medications in three medication carts, leading to missing signatures in the controlled substance books for May 2024. Staff members acknowledged the incomplete documentation, and the Director of Nursing Services confirmed that this did not meet the facility's expectations.
The facility failed to provide written notification of the reason for transfer or discharge to the hospital to two residents reviewed for hospitalization. Both residents, admitted with multiple diagnoses including strokes, were transferred without receiving written notice. The Director of Nursing Services confirmed that only verbal notifications were given, and the Administrator acknowledged that written notifications should have been provided.
The facility failed to provide a bed hold notice in writing at the time of transfer to the hospital or within 24 hours for two residents with recent readmissions and multiple diagnoses, including strokes. The Admissions Director confirmed the oversight, and the Administrator acknowledged the expectation to offer and document bed holds, which was not met.
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.
Failure to Provide Individualized Dementia Care and Behavioral Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents diagnosed with dementia who exhibited behavioral symptoms, including wandering, exit-seeking, entering other residents' rooms, and yelling out. For one resident with encephalopathy and non-Alzheimer's dementia, the care plan did not specifically address exit-seeking behaviors, sundowning, or times of increased behaviors, despite repeated incidents of elopement, wandering into other residents' rooms, and taking belongings. Documentation showed frequent refusals of medication and care, but these refusals were not addressed in the care plan. Staff interventions were limited to redirection and the use of stop signs on doors, which were inconsistently applied and not always effective in preventing the resident from entering other rooms or taking items. Multiple progress notes and interviews with staff and other residents confirmed ongoing issues with the resident's behaviors, including distress caused to peers when the resident entered their rooms, sat on their beds, or took personal items. The care plan did not include individualized interventions to prevent the resident from entering other rooms or address the removal of belongings. Staff and residents reported that the use of stop signs was inconsistent, and redirection was not always successful in mitigating the behaviors. The facility's policies required an interdisciplinary approach and person-centered care planning, but these were not fully implemented for this resident. For the second resident with dementia, the care plan addressed some behaviors such as fidgeting and restlessness but did not include targeted interventions for frequent yelling out, which was documented in progress notes and behavior monitoring. The yelling out caused distress to roommates and other residents, as confirmed by interviews. There was no evidence of a detailed assessment or individualized interventions for this behavior in the clinical record. The facility did not ensure that care plans were updated to reflect the residents' current behavioral needs, nor did it implement comprehensive strategies to mitigate the adverse effects of dementia-related behaviors.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its abuse prohibition policy by not thoroughly investigating an injury of unknown origin for a resident with severe cognitive impairment. The resident, who required substantial assistance with bed mobility and transfers, was observed with a raised bump on the forehead and bruising on the back. Documentation showed that the resident was on alert charting and neuro checks following a reported fall, but there was no documented assessment of the forehead bruise, and the incident was not entered into the facility's incident logs. Interviews with collateral contacts revealed that the resident reported falling out of bed and being picked up by a man, but staff interviews indicated that no male staff were working at the time and that the resident was confused and cognitively impaired. Despite these reports and visible injuries, staff did not initiate an incident report or conduct a comprehensive investigation as required by facility policy and state guidelines. The staff focused on determining whether a fall had occurred rather than treating the injuries as incidents of unknown origin requiring thorough investigation. The facility's failure to promptly initiate and thoroughly conduct an investigation into the resident's injuries, as well as the lack of documentation and incident reporting, resulted in noncompliance with both facility policy and state regulations. The absence of a root cause analysis and failure to identify all contributing factors left the injuries unexplained and unaddressed according to established procedures.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Timely Report Alleged Abuse by Staff
Penalty
Summary
The facility failed to identify and timely report an allegation of potential abuse involving a resident with complex medical needs who was cognitively intact and required assistance with activities of daily living. Staff observed and became aware of suspicious interactions between a staff member and the resident, including being found together behind locked doors in the therapy gym when it was closed and unscheduled for therapy. Despite these observations and suspicions, staff did not immediately report the concerns to facility leadership as required by policy. Instead, one staff member confronted the staff involved and discussed the situation with other staff, while others who heard about the suspicions did not report them because they had not personally witnessed inappropriate behavior. The delay in reporting resulted in the administrator being notified of the concern eight days after the initial suspicion was identified. Interviews confirmed that multiple staff members were aware of the situation or had been told about it but failed to report the suspicion of abuse in a timely manner, as required by facility policy and state regulations. The failure to promptly report the allegation placed residents at risk and did not ensure immediate intervention or investigation.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to store and prepare food in a manner that prevents foodborne illness, as observed during a survey. A large undated ham was found in the kitchen refrigerator, along with diced turkey, diced ham, and opened hotdogs labeled only with the month and year, and shredded cheese labeled with a past date. Food boxes were improperly stored on the floor of the kitchen freezer. Personal items such as headphones and a cell phone charger were found on a counter in the kitchen, which also contained food items like peanut butter and condiments. These observations indicate a lack of adherence to proper food storage and labeling protocols. Additionally, the Dietary Manager, Staff BB, and Dietary Aide, Staff CC, were observed not following proper food safety and hygiene practices. Staff CC was seen turning off the water with bare hands after performing hand hygiene and failing to perform hand hygiene after returning from the dining room. Staff BB was observed placing trays of hamburgers and fish on the tray line without taking their temperatures to ensure they were safe for consumption. Interviews with Staff BB and the Administrator confirmed that these practices did not meet the facility's expectations for food safety and hygiene.
Failure to Obtain and Review Advanced Directives
Penalty
Summary
The facility failed to obtain and periodically review advanced directives (AD) for three residents, denying them the opportunity to direct their healthcare in the event they become unable to make decisions. Resident 22, who was admitted with diagnoses including diabetes and depression, had AD paperwork provided to a family member, but there was no documented follow-up. Resident 43, admitted with a stroke and bipolar disorder, had an attempt to contact a family member for durable power of attorney, but no further follow-up or periodic review was documented. Resident 77, with dementia and dysphagia, had no AD documented, and there was a lack of follow-up with the resident's spouse. Interviews with the Social Service Director (SSD) revealed that follow-ups on AD paperwork were not conducted as required. The SSD acknowledged that Resident 43's AD should have been reviewed quarterly, and there was a failure to follow up with Resident 77's spouse. The facility administrator stated that the expectation was for ADs to be discussed at every quarterly care conference, which was not adhered to in these cases.
Deficiency in PASARR Screening for Mental Health Disorders
Penalty
Summary
The facility failed to ensure that residents with mental health disorders were properly screened for the need for additional mental health support through the Preadmission Screening and Resident Review (PASARR) process. This deficiency was identified in five out of nine sampled residents. For instance, Resident 77, who was admitted with diagnoses including dementia with psychosis, anxiety, and insomnia, had a PASARR form that did not reflect these active diagnoses, and a level 2 PASARR was not required. Similarly, Resident 95, diagnosed with PTSD, anxiety, and depression, had a PASARR form that only marked anxiety, and no level 2 PASARR was required. Resident 103, with major depressive disorder, had two PASARR forms that did not indicate depression, and thus, no level 2 PASARR was required. Additionally, Resident 22, who was admitted with depression, had a level 1 PASARR that did not mark any serious mental illness indicators, and no level 2 PASARR was indicated. Resident 26, diagnosed with anxiety disorder and bipolar disorder, had a level 1 PASARR that did not mark anxiety disorder as a serious mental illness, and no level 2 evaluation was indicated. The Social Service Director acknowledged the discrepancies in the PASARR forms and stated that these did not meet expectations. The Administrator also confirmed that the PASARR forms for the residents were incorrect.
Failure to Implement Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for three residents, leading to unmet care needs. Resident 30, who was admitted with diagnoses including colon cancer, dementia, and diabetes, was unable to make their needs known and required assistance with eating. However, the baseline care plan did not include necessary care areas for activities of daily living (ADLs) such as assistance with eating, oral care, hygiene, bed mobility, or dressing. This oversight was highlighted during an interview where it was noted that staff removed the resident's meal tray without providing assistance. Resident 103, admitted with congestive heart failure, kidney failure, and diabetes, was also dependent on staff for ADLs and unable to communicate needs. The baseline care plan lacked provisions for oral care and bed mobility, only addressing transfer needs. Staff interviews revealed that the facility's new care plan library did not automatically include ADLs, and the admission nurse failed to create a comprehensive baseline care plan. Resident 215, with end-stage renal disease and other conditions, had a baseline care plan that inaccurately reflected their transfer needs due to an oversight in updating the care plan. These deficiencies placed residents at risk for unmet care needs and decreased quality of life.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive care plans that accurately reflected the current medical status and needs of six residents, leading to deficiencies in care. Resident 22, who had diabetic foot ulcers, did not have a care plan that addressed the actual skin impairment and necessary wound treatment, despite having a provider's order for iodine application. Staff interviews confirmed that the care plan did not meet expectations as it failed to document the resident's wounds and necessary interventions. Resident 26's care plan lacked documentation regarding ill-fitting dentures and the need for a denturist consultation, despite the resident's complaints and family awareness. Additionally, the cognitive/dementia care plan for Resident 26 did not include measurable goals, which was acknowledged by staff as not meeting expectations. Similarly, Resident 36's care plan included an outdated intervention for oxygen administration, which was no longer ordered, and lacked details about the resident's feeding tube, such as location, type, and size. Resident 70's care plan was outdated, as it included interventions for a palm guard and elbow orthotic that had been discontinued due to resident refusal. The care plan also inaccurately included interventions for a restorative program that the facility did not have. Resident 64's care plan failed to address lymphedema and the application of ACE wraps, which were not being applied as ordered. Lastly, Resident 77's care plan did not provide comprehensive instructions for activities of daily living, despite the resident's dependency on staff for care, and was not developed within the expected timeframe after admission.
Deficiencies in Care Planning and Documentation
Penalty
Summary
The facility failed to conduct timely care planning meetings for two residents, as evidenced by the lack of care conferences for these individuals. Resident 22, who was admitted with diagnoses including diabetes and depression, expressed a desire for a care conference involving a family member, but the facility was unable to contact the family member and did not proceed with the conference. Similarly, Resident 36, admitted with conditions such as diabetes and COPD, did not have a documented care conference, despite the facility's expectation for quarterly meetings. These omissions were acknowledged by the Social Service Director and the Administrator, who confirmed that the facility's expectations were not met. Additionally, the facility failed to update care plans for three residents, leading to discrepancies between documented care needs and actual conditions. Resident 30's care plan included an intervention for catheter management, despite the catheter having been removed per provider orders. Resident 88's care plan also inaccurately reflected the presence of a urinary catheter, which had been discontinued. Furthermore, Resident 77's care plan indicated ongoing isolation for COVID-19, although observations showed no isolation measures in place. These inconsistencies were confirmed by staff interviews, highlighting a failure to revise care plans to reflect current resident needs.
Failure to Implement Fall Interventions and Medication Management
Penalty
Summary
The facility failed to maintain a safe environment for three residents, leading to multiple falls and medication management issues. Resident 22, who had a history of falls and medical conditions such as diabetes and peripheral vascular disease, experienced several falls, including one that resulted in serious injuries requiring hospitalization. Despite these incidents, the facility did not implement new fall interventions promptly, as evidenced by the lack of immediate action following a fall on January 6, 2025, and subsequent falls. Interviews with staff revealed that there was an expectation for immediate intervention and care plan updates after each fall, which were not consistently met. Resident 5, who was independent and had conditions like diabetes and chronic kidney disease, also experienced multiple falls without timely or adequate interventions. The care plan for Resident 5 did not reflect new interventions after falls on January 31, 2025, and February 20, 2025. Although an intervention for a grab bar was suggested after a fall on March 1, 2025, it was not implemented by the time of observation in mid-March. Staff interviews highlighted a lack of communication between nursing and therapy departments, contributing to the failure to implement necessary safety measures. Resident 45, with diagnoses including diabetes and cognitive deficit, was found with medications left at their bedside without a proper self-medication administration assessment or order. This practice was against the facility's expectations, as confirmed by staff interviews, which indicated that residents should have an assessment and order before self-administering medications. The failure to assess and plan for self-medication administration placed Resident 45 at risk for medication errors.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, which led to inappropriate and unnecessary use of antibiotics for three residents. Resident 418 was prescribed Bactrim for a urinary tract infection upon returning from the hospital, but there was no review of microbiology results and susceptibilities. Resident 419 was prescribed Clindamycin for a UTI despite a negative urinalysis, and there was no documentation of a review for microbiology results or antibiotic stewardship. Resident 420 received ertapenem for a suspected UTI related to kidney stones, but hospital documentation showed no growth in urinalysis results, and there was no review for microbiology results or antibiotic stewardship. Interviews with facility staff revealed a lack of procedures to request culture results for residents prescribed antibiotics at the hospital. The Infection Preventionist/Registered Nurse admitted to not requesting culture results, while the Director of Nursing Services expected the infection preventionist to review new antibiotic orders and cultures for susceptibility. This discrepancy in expectations and actions contributed to the facility's failure to effectively monitor and manage antibiotic use, placing residents at risk for potential adverse outcomes.
Failure to Document Vaccine Education and Offerings
Penalty
Summary
The facility failed to ensure and document that four out of five sampled residents were informed about the benefits and risks of influenza and pneumococcal vaccines, and whether they had the opportunity to receive these vaccines unless medically contraindicated, refused, or already immunized. This deficiency was identified through interviews and record reviews, which revealed that Residents 87, 27, 92, and 78 did not have documentation in their electronic health records (EHR) indicating they received education on the vaccines or were offered, provided, refused, or already received the vaccines. Resident 87, admitted with acute respiratory failure, asthma, and diabetes, had no documentation of education or vaccine status. Resident 27, with diabetes and encephalopathy, also lacked documentation of education or vaccine status. Similarly, Resident 92, with liver disease and kidney failure, and Resident 78, with gout and weakness, had no records of being informed or offered the vaccines. Interviews with the Director of Nursing Services and the Administrator confirmed that it was the facility's expectation to provide such education and documentation upon admission and annually, which was not met in these cases.
Failure to Educate and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to ensure and document that three residents were informed about the benefits and risks of the COVID-19 vaccine and had the opportunity to receive it unless medically contraindicated, refused, or already immunized. This deficiency was identified during a review of the electronic health records (EHR) of Residents 87, 27, and 92. Each of these residents had significant medical conditions, such as acute respiratory failure, diabetes, encephalopathy, liver disease, and kidney failure, and were capable of making their needs known. However, there was no documentation in their EHRs indicating that they received education on the COVID-19 vaccine or were offered the vaccine. Interviews with facility staff, including the Director of Nursing Services and the Administrator, revealed that it was the facility's expectation that all residents be provided education on the risks and benefits of the COVID-19 vaccine and be offered the vaccine upon admission and annually. The staff acknowledged that the lack of documentation and failure to educate and offer the vaccine to Residents 87, 27, and 92 did not meet their expectations. This oversight placed the residents at an increased risk of COVID-19 infections and deprived them of the knowledge needed to make informed decisions regarding their health.
Incomplete Informed Consents for Psychotropic Medications
Penalty
Summary
The facility failed to obtain complete informed consents for psychotropic medications for a resident, identified as Resident 26, prior to administering the medications. Resident 26, who had diagnoses of dementia, anxiety disorder, and bipolar disorder, was prescribed Clonazepam and Divalproex Sodium. However, the informed consent forms for these medications were incomplete. The form for Clonazepam, dated 02/21/2024, lacked details such as dose/frequency, duration, medication category, diagnosed condition, clinical indication, expected benefits, and possible side effects. Similarly, the consent form for Divalproex Sodium, dated 04/22/2021, was missing information on the specific condition to be treated, expected benefits, and the proposed course of the medication. Interviews with facility staff, including a Licensed Practical Nurse/Unit Manager and the Director of Nursing Services, confirmed that the informed consent forms for Resident 26 were not filled out completely, which did not meet the facility's expectations. This oversight placed the resident or their legal representatives at risk of not having sufficient knowledge to make informed decisions regarding the use of these medications, potentially affecting the resident's quality of life.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to honor the shower preferences of Resident 216, who was readmitted with diagnoses including bipolar disorder, heart failure, spinal stenosis, and morbid obesity. The resident was capable of communicating their needs but reported not having a choice regarding shower times. The care plan initiated on 03/01/2025 did not include instructions or preferences for showers. During an interview, the resident stated that they had not received a shower since their admission on 03/01/2025, as the only option given was to accept or decline a shower, with no alternative arrangements if they were unwell or busy. Staff L, an LPN/Unit Manager, confirmed that showers were scheduled, and make-up days were on Sundays. The Director of Nursing Services acknowledged that the situation did not meet expectations for resident choice.
Failure to Maintain Homelike Environment in Resident Rooms
Penalty
Summary
The facility failed to provide a homelike environment in resident rooms on two of its hallways, specifically the 200 and 100 halls. Observations conducted on multiple dates revealed that the wall behind the head of the bed in Resident 65's room on the 200 Hall had torn wallpaper and deep gouges, with flaking drywall accumulating on the floor. Resident 65 reported that the wall had been in disrepair since their arrival three weeks prior, and staff were aware of the issue. Similarly, observations in two rooms on the 100 Hall showed walls behind the head of the beds with torn wallpaper and deep gouges. During interviews, the Maintenance Director acknowledged that the rooms had needed repair for months, but the facility lacked a timely solution. The Administrator stated that the expectation was for maintenance staff to complete weekly rounds, enter needed repairs into the system, and complete repairs within 30 days. This deficiency was noted under WAC 388-97-0880(1).
Failure to Conduct Background Check for CNA
Penalty
Summary
The facility failed to complete a criminal background check prior to hiring a Certified Nursing Assistant (CNA), identified as Staff F, which is a violation of their policy titled 'Background Screening Investigations' dated 03/27/2024. This policy mandates that employees cannot work in positions involving direct contact with patients until a criminal background check is completed. Staff F was hired on 09/05/2024, but their employee file lacked documentation of a completed background check. During an interview, the Administrator in Training, Staff C, acknowledged that the background check for Staff F was not conducted, which was deemed unacceptable. Additionally, Resident 216 reported that Staff F was rude and caused them pain by pushing hard on their hip, leading them to scream. Observations confirmed that Staff F was working in the same hallway as Resident 216 during the day shifts on 03/10/2025 and 03/11/2025.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to identify and report an allegation of abuse involving Resident 216, who was readmitted with diagnoses including bipolar disorder, heart failure, spinal stenosis, and morbid obesity. Resident 216, who was able to communicate their needs, reported an incident where a certified nursing assistant was rude and pushed hard on their hip, causing them to scream. Additionally, Resident 216 reported not receiving incontinent care the previous night, resulting in urine on the floor by morning. These concerns were communicated to the lead aide but were not documented in the facility's incident and grievance log. Interviews conducted revealed that the staff, including the Licensed Practical Nurse/Unit Manager and the Administrator, were unaware of Resident 216's allegations. Staff L stated that staff were expected to report such concerns to nurse managers, the state reporting hotline, and the administrator. However, the allegations were not reported, which was acknowledged as unacceptable by Staff A, the Administrator. This oversight placed Resident 216 at risk of further abuse, psychological distress, and diminished quality of life.
Failure to Follow Provider's Order for Cervical Collar
Penalty
Summary
The facility failed to follow the provider's order for a resident, identified as Resident 215, who was reviewed for professional standards of care and services. Resident 215 was admitted with diagnoses including end-stage renal disease, spinal stenosis in the cervical region, diabetes, and urine retention. The resident was capable of communicating their needs. Observations from March 10 to March 14, 2025, showed that Resident 215 was not wearing the prescribed cervical collar, which was intended for support and comfort. Despite this, the medication administration record (MAR) indicated that the cervical collar was signed off as used by multiple nurses from March 9 to March 12, 2025. Interviews revealed that the staff were supposed to educate the resident on the use of the neck collar and notify the provider if it was not used. Staff L, a Licensed Practical Nurse/Unit Manager, acknowledged that the documentation in the MAR was incorrect, as it should not have been signed when the collar was not used. The Director of Nursing Services, Staff B, also confirmed that the documentation did not meet expectations.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in care. Resident 43, who was dependent on staff for mobility due to a stroke and other conditions, expressed a desire to get out of bed more frequently but believed there were not enough staff. Despite having a wheelchair, it was unavailable due to repairs, and staff only assisted the resident out of bed for appointments. Observations showed the resident remained in bed for extended periods, and staff did not prioritize the resident's request to get up, contrary to the Director of Nursing Services' (DNS) expectations. Resident 30, diagnosed with cancer, dementia, and diabetes, required assistance with meals and mobility. However, staff failed to assist the resident with eating, and the resident remained in bed throughout the day without repositioning, as outlined in their care plan. Additionally, Resident 88, who had a cognitive communication deficit and diabetes, was not offered assistance with personal hygiene, specifically shaving, despite expressing a desire to be shaven. The care plan lacked interventions for grooming, and staff did not offer shaving during morning care or showers, contrary to the DNS's expectations.
Failure to Provide Proper Care for Non-Pressure Skin Conditions
Penalty
Summary
The facility failed to provide necessary care and services for two residents with non-pressure skin conditions. Resident 22, who had diabetes, peripheral vascular disease, and atrial fibrillation, was not given proper treatment for diabetic foot ulcers. The treatment administration record showed an order to apply iodine to scabs on the third toes of both feet, but the treatment was incorrectly applied to the right second toe. Weekly skin checks and wound evaluations were not documented as required, and new wounds were discovered without proper documentation or clarification of treatment orders. Staff interviews confirmed that the treatment and documentation did not meet expectations. Resident 64, diagnosed with a disorder of muscle, lymphedema, and difficulty walking, did not receive the prescribed daily leg wrapping for edema management. Observations confirmed that the resident's legs were not wrapped, and the medication administration record showed no documentation of the treatment being applied. Staff interviews revealed that the order was incorrectly entered as requiring no documentation, leading to the treatment not being performed as expected. The Director of Nursing Services acknowledged that the orders were not followed as directed by the provider.
Failure to Maintain or Improve Range of Motion for Residents
Penalty
Summary
The facility failed to provide appropriate treatment or services to maintain or improve the range of motion (ROM) for two residents, leading to a deficiency in care. Resident 80, who was admitted with acute respiratory failure and chronic obstructive pulmonary disease, had impairments in both upper and lower extremities. Despite a recommendation for a restorative program following the discharge from physical therapy, Resident 80 did not receive any restorative care outside of daily activities. Interviews with staff revealed a lack of awareness and implementation of the recommended restorative program, which was only recently initiated. Resident 88, admitted with cognitive communication deficit and diabetes, was observed with a curled left hand and dry skin, unable to move their fingers. Although a hand splint was recommended and fitted to improve functional grasp, there was no provider order or care plan entry for its use. Staff interviews indicated a lack of awareness and implementation of the hand splint recommendation, and the resident confirmed they did not wear the splint. The facility had not yet started a formal restorative program, and the therapy recommendations were not incorporated into the care plan, failing to meet the facility's expectations.
Failure to Monitor Fluid Restrictions and Nutritional Supplementation
Penalty
Summary
The facility failed to monitor and accurately document fluid restrictions for two residents, Resident 64 and Resident 82, which placed them at risk for medical complications. Resident 64, who was admitted with diagnoses including muscle disorder and lymphedema, was observed with multiple sources of fluids at their bedside, despite having a provider's order for a fluid restriction of 2000 ml per day. The care plan specified no fluids at the bedside and required monitoring and documentation of fluid intake, but there was no documentation of fluid intake in the nutrition task. Staff interviews revealed a lack of awareness and communication regarding the resident's fluid restriction. Similarly, Resident 82, diagnosed with COPD and CHF, was observed with a full water pitcher and other drinks at their bedside, despite a fluid restriction order of 2000 ml per day. The medication administration record showed inconsistent documentation of fluid intake, and the nutrition task lacked documentation of fluids consumed with meals. Staff interviews indicated that the resident was not included on the fluid restriction list, and the assigned nurse was unaware of the fluid restriction order. Additionally, the facility failed to follow provider's orders for nutritional supplementation for Resident 36, who had a feeding tube and was diagnosed with diabetes and COPD. The resident's diet order included a regular diet and enteral feed supplementation if oral intake was less than 50% at meals. However, documentation showed missing meal intake percentages and no record of the required bolus supplement administration. Staff interviews confirmed the inconsistency in meal intake documentation and the lack of supplementation, which did not meet the facility's expectations.
Deficiency in Enteral Nutrition Administration and Documentation
Penalty
Summary
The facility failed to administer enteral nutrition to Resident 36 in accordance with the provider's orders and professional standards of practice. Resident 36, who was admitted with diagnoses including diabetes, COPD, and required a feeding tube, was supposed to receive enteral feedings of Glucerna 1.2 calories at 65 ml per hour with 60 cc water flushes every four hours via a PEG tube. The feedings were to start at 7:00 PM and end at 7:00 AM, totaling 780 ml in 24 hours. However, the medication administration records (MAR) for March 2025 did not include documentation for when the feeding was stopped or the total amount of feeding provided in a 24-hour period. Interviews with staff revealed that the documentation did not meet expectations. Staff X, an LPN, confirmed the feeding schedule, but the MAR lacked areas to document the feeding's end time and total volume administered. Staff H, an LPN/Unit Manager, and Staff B, the Director of Nursing Services, acknowledged the deficiency in documentation, stating that it should have included both the start and stop times and the total amount of feeding provided. This oversight placed Resident 36 at risk for inadequate nutrition and hydration.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for three residents. Resident 36, who had a history of COPD, was observed with an oxygen concentrator in their room despite having no active orders for oxygen therapy. The resident used the oxygen concentrator at their discretion, which was not in accordance with any physician's orders. Staff interviews revealed that the oxygen concentrator should not have been in the resident's room, and there were no parameters set for monitoring oxygen saturation levels or guidelines for when to notify a provider. Resident 5, who had diagnoses including congestive heart failure, was observed receiving oxygen at a rate of three liters per minute, contrary to the physician's order of two liters per minute. Staff were signing off on the administration of oxygen without verifying the correct setting. Similarly, Resident 82, with COPD, was receiving oxygen at two liters per minute instead of the ordered three liters per minute. Staff interviews confirmed that the oxygen settings were not being checked as required, leading to discrepancies in the administration of oxygen therapy.
Failure to Provide Non-Pharmacological Interventions Before Pain Medication
Penalty
Summary
The facility failed to provide non-pharmacological interventions for two residents, leading to the administration of unnecessary medications. Resident 26, who was readmitted with anxiety disorder, high blood pressure, and COPD, received Hydrocodone-Acetaminophen multiple times without documented attempts of non-pharmacological interventions prior to administration. The Director of Nursing Services (DNS) acknowledged that non-pharmacological interventions should have been offered before administering as-needed pain medication, and the lack of documentation did not meet expectations. Similarly, Resident 88, admitted with severe cervical stenosis with myelopathy and diabetes, received tramadol for pain on several occasions without attempts at non-pharmacological interventions, despite an existing order to do so. The medication administration records marked these interventions as not applicable, which the DNS confirmed did not align with the facility's expectations. This oversight placed the residents at risk for unnecessary medication use and potential side effects.
Failure to Assess and Monitor Resident's Skin Condition
Penalty
Summary
The facility failed to ensure that a skin condition for a resident was accurately assessed, treated, and monitored. The resident, who was admitted with diagnoses including diabetes, chronic osteomyelitis, high blood pressure, and a diabetic foot ulcer, was noted to have a pustule/boil on the left buttock, an open wound on the right foot, blanchable redness on the sacrum, and a rash/dermatitis in the groin area during a Weekly Skin Observation. However, there were no treatment or monitoring orders related to the pustule/boil documented in the resident's electronic health record for September and October. Staff C, an LPN and Unit Manager, confirmed the absence of documentation regarding notification of the provider about the pustule/boil, as well as the lack of a treatment order or monitoring documentation. Staff B, an RN and Director of Nursing Services, also noted that the pustule/boil was not measured or described beyond the initial entry. Staff B acknowledged that there should have been a treatment order, monitoring, and notification to the provider and the resident's family. The facility's administrator was made aware of these concerns.
Inaccurate and Untimely Staffing Data Submission
Penalty
Summary
The facility failed to ensure that direct care staffing information was accurate and submitted timely to the Centers for Medicare and Medicaid Services (CMS) for the fourth quarter of 2023. The review of the Certification and Survey Provider Enhanced Reports (CASPER) PBJ Data Report indicated that the facility reported staffing data at a level lower than the mandated staffing levels. During an interview, the Administrator acknowledged that the data submitted was not accurate or timely, and even after recalculating the total direct care staffing hours, the facility did not meet the State minimum mandatory requirements for staffing levels. This deficiency affected the accuracy of staffing level data collected by CMS and had the potential to impact resident care and services.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to provide necessary care and services to prevent the occurrence of an avoidable pressure ulcer for a resident. The facility's policy required licensed nurses to conduct weekly skin observations and document findings in the resident's medical record. However, the facility did not complete the required weekly skin observations for the resident, as evidenced by missing documentation in the electronic charting system. A new pressure ulcer was identified on the resident's tailbone, but the facility did not adequately evaluate, document, or monitor the wound's progress, nor did they notify the physician for re-evaluation when there was no improvement. The resident was discharged to an Adult Family Home with a deep wound on the buttocks, and the discharge instructions did not include wound care directions. The facility's Director of Nursing acknowledged that the facility did not follow their process for pressure ulcer management and weekly skin monitoring. The facility failed to conduct a complete skin evaluation on the day of discharge, and the clinical record lacked documentation of the wound's evaluation, cause, and care plan updates for new interventions.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that physician orders were clarified and treatments were provided according to those orders for three residents. Resident 4, who was admitted with diagnoses including diabetes and spinal stenosis, had orders for Moisture Associated Skin Damage (MASD) treatment and antifungal powder application. However, the treatments were improperly administered by nursing assistants instead of licensed nurses, and the Treatment Administration Record (TAR) was signed in advance, indicating treatments were completed when they were not. Additionally, there was confusion regarding the frequency of antifungal powder application, leading to an excessive number of applications. Resident 7, with diabetes and wounds on the left lower leg and foot, did not receive dressing changes as ordered, with two treatments missed. Resident 1, admitted with multiple diagnoses including a sacral pressure injury and osteomyelitis, had physician orders for topical treatments that lacked specificity regarding the body part to be treated. Despite this, the TAR indicated that the treatments were completed. These deficiencies highlight a lack of adherence to physician orders and professional standards of care, as noted by the Director of Nursing Services.
Failure to Report and Investigate Allegation of Neglect
Penalty
Summary
The facility failed to identify, report, and investigate an allegation of neglect involving a resident who was found in urine-soaked briefs and bedding. The incident occurred when a collateral contact discovered the resident in this condition and expressed concern to a nursing supervisor. Despite the concern raised, the nursing supervisor did not recognize this as an allegation of neglect and did not report it to the Director of Nursing Services, the administrator, or the State Agency, nor was an investigation initiated. The resident involved had multiple diagnoses, including a sacral pressure injury and osteomyelitis of the sacrococcygeal region. The facility's policy required all reports of abuse or neglect to be reported and thoroughly investigated by management. However, the incident was not documented in the facility's incident logs, and the Director of Nursing Services was unaware of the situation. This oversight placed residents at risk for unidentified abuse, mistreatment, and a diminished quality of life.
Inadequate Pressure Injury Prevention and Care
Penalty
Summary
The facility failed to provide care and treatment according to professional standards to prevent the development or deterioration of pressure injuries for two residents. Resident 1, who was admitted with a sacral pressure injury and multiple medical conditions, had a care plan that did not include individualized interventions for incontinence care or repositioning, despite recommendations from a wound care provider. The care plan was not updated to reflect changes in Resident 1's condition, such as a new pressure injury after a hospital stay, and there were instances of inadequate incontinence care, as evidenced by a photograph showing Resident 1 in urine-soaked sheets. Resident 4, who was always incontinent, had a care plan that lacked specific interventions for repositioning and incontinence care. Observations revealed that Resident 4 was found with wet clothing and a reddened area on the buttocks, indicating inadequate care. The care plan did not address the resident's specific needs for repositioning and incontinence management, leading to a recurring area of moisture-associated skin damage (MASD) and an open area at the coccyx. Additionally, Resident 3 reported going an entire day without being changed, highlighting a pattern of insufficient incontinence care. Staff interviews revealed that the facility did not define or delineate the frequency of nursing actions for incontinent care or repositioning in the care plans. The Director of Nursing Services acknowledged the expectation for facility practices to follow policy, regulations, and professional standards for pressure injury prevention and treatment, which was not met in these cases.
Failure to Provide Scheduled Showers and Shaving
Penalty
Summary
The facility failed to provide showers as scheduled and/or shaving for four of five sampled residents reviewed for activities of daily living (ADLs). Resident 59, who was admitted with diagnoses of depression and anxiety, did not receive showers consistently as per their care plan. The shower task sheet for April and May 2024 showed that Resident 59 had only received two showers and two partial showers, with four refusals noted. Similarly, Resident 72, who was also diagnosed with depression, reported receiving only one shower a week instead of the scheduled two. The shower task sheet for April and May 2024 indicated that Resident 72 had received one shower and refused six times in two months. Staff interviews confirmed that residents were expected to receive showers/baths throughout the week, but this was not consistently happening. Resident 10, who was readmitted with diagnoses including heart failure and dementia, was observed with substantial facial hair over multiple days and could not recall the last time they had a shower. Despite requesting to be shaved, there was no documentation of showers or baths except for a bed bath on 05/11/2024. Resident 22, diagnosed with chronic obstructive pulmonary disease (COPD), was observed with long facial hair and oily hair. The resident had received only four bed baths in the prior 30 days and no showers. Staff interviews revealed that Resident 22 preferred to be shaved by a male caregiver, but this preference was not accommodated. The Director of Nursing Services confirmed that residents should be offered assistance with bathing and shaving twice a week, or more if needed, and acknowledged that the current level of care was insufficient.
Failure to Provide Proper Oxygen Therapy and Equipment Maintenance
Penalty
Summary
The facility failed to provide oxygen therapy per provider orders and ensure oxygen tubing was dated and regularly changed for two residents. Resident 41, who was admitted with COPD and lung cancer, was observed with an oxygen machine set to deliver four liters per minute, contrary to the provider's order of three liters per minute. The tubing and humidifier were not dated, and there was no documentation in the medication administration record (MAR) or treatment administration record (TAR) to show that the oxygen was being administered as ordered. Staff confirmed that the oxygen therapy and documentation did not meet expectations, and there was no order for the use of a humidifier, which was being used continuously without proper authorization or documentation. Resident 41 also reported that a nurse had increased the oxygen flow without a provider's order when they were having breathing difficulties. The Director of Nursing Services (DNS) acknowledged that the oxygen equipment should have been dated and the provider's orders followed, which was not done in this case. Additionally, the DNS confirmed that the oxygen therapy and documentation did not meet the facility's expectations. Resident 22, who was on hospice care with a diagnosis of COPD, was observed with oxygen tubing that was not dated and was found lying on the floor. The electronic health record (EHR) showed that Resident 22 frequently removed the tubing from their nose, but there was no documentation related to the care of the oxygen equipment, such as changing the tubing. The DNS stated that it was their expectation that oxygen tubing be changed and dated weekly, but this had not been done recently for Resident 22. The DNS acknowledged that there should have been an order in the resident's EHR for the oxygen therapy, but it was not present. The facility's failure to follow provider orders and ensure proper documentation and care of oxygen equipment placed residents at risk for unmet care needs and medical complications.
Failure to Follow Pharmacist's Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to act on and consistently follow the consultant pharmacist's medication regimen review (MRR) recommendations in a timely manner for three residents. Resident 20, who was admitted with coronary artery disease and Parkinson's disease, had multiple MRR recommendations that were not implemented or documented timely. For instance, a recommendation to start Eliquis based on weight was not followed up, and a recommendation to decrease escitalopram was delayed. Additionally, there was no documentation to confirm a diagnosis for the use of Combivent Respimat inhaler or to implement the recommended changes. The Director of Nursing Services acknowledged these lapses during an interview. Resident 22, admitted with chronic obstructive pulmonary disease (COPD), had a pharmacy recommendation to add directions to rinse the mouth after using budesonide inhalation, which was not updated in the electronic health record (EHR). Staff C, an LPN/UM, admitted that the system for following up on pharmacy recommendations was not functioning properly. Resident 11, admitted with heart failure and depression, had a recommendation to decrease levothyroxine, which was not followed up on, as confirmed by Staff B. These failures placed the residents at risk for adverse side effects and decreased quality of life.
Failure to Ensure Freedom from Unnecessary Medications
Penalty
Summary
The facility failed to ensure freedom from unnecessary medications for three residents. Resident 20 was not properly monitored for blood pressure and heart rate before administering medications, and non-pharmacological interventions were not provided before giving PRN pain medications. Specifically, Resident 20 received Losartan Potassium and Carvedilol without proper blood pressure and heart rate checks, and PRN acetaminophen was given without attempting non-pharmacological interventions. Staff interviews confirmed that these actions did not meet the facility's expectations and protocols. Resident 22, who was on hospice care, received liquid oxycodone PRN for pain and difficulty breathing without documentation of non-pharmacological interventions being attempted first. Staff interviews corroborated that non-pharmacological interventions should have been tried and documented. Resident 154, who was on anticoagulant medication, was not monitored for adverse side effects such as abnormal bleeding. Staff interviews confirmed that monitoring for side effects was expected but not documented. These failures placed residents at risk of unnecessary medications and avoidable side effects.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for two residents, Resident 33 and Resident 204. Resident 33 had an upper denture that was too loose and required denture adhesive, which was not provided during their stay. Despite having a care plan that included monitoring and addressing oral/dental health problems, staff were unaware of the resident's need for denture adhesive. This was confirmed through multiple interviews with staff members, including a CNA, LPN/Unit Manager, and the Director of Nursing Services, all of whom were unaware of the resident's need for dental care or adhesive. Resident 204 had multiple missing, cracked, or jagged teeth and had not seen a dentist. Although there was a provider's order for a dental consult and care, the resident's name was not placed into the referral binder for a consult. Staff interviews revealed that the resident had a standing order to see the dentist, but this was not acted upon. The Director of Nursing Services confirmed that it was their expectation that Resident 204 should have received the necessary dental care, especially given the condition of their teeth upon admission.
Failure to Follow Therapeutic Diets
Penalty
Summary
The facility failed to follow therapeutic diets for three residents, leading to potential health risks. Resident 153, who had a diagnosis of dysphagia and a diet order for soft and bite-sized food, was served a whole hamburger by Staff Q. Despite the tray card indicating the need for soft and bite-sized food, Staff Q incorrectly considered the whole hamburger as compliant with the diet order. Similarly, Resident 92, who also had dysphagia and a diet order for no added salt, was served a meal tray with a salt packet by Staff Q. Resident 79, with the same dietary restrictions as Resident 92, was also served a meal tray with a salt packet by Staff R. Both CNAs failed to adhere to the dietary restrictions indicated on the residents' tray cards. Interviews with the Dietary Manager, Registered Dietician, and Administrator confirmed that therapeutic diets should always be followed as ordered. The Dietary Manager and Registered Dietician acknowledged that Resident 153 should not have received a whole hamburger and that Residents 92 and 79 should not have had salt packets on their trays. The Administrator also confirmed that the facility did not meet expectations in providing the correct therapeutic diets for these residents. These failures were observed and documented during a survey, highlighting significant lapses in dietary compliance within the facility.
Infection Control Program and Linen Storage Deficiencies
Penalty
Summary
The facility failed to ensure an effective infection prevention and control program was in place to prevent the transmission of communicable diseases and infections. The infection preventionist (ICP) did not complete the collection and analysis of infection control data, identify trends, or implement follow-up activities in response to those trends for four consecutive months (January to April 2024). The monthly infection surveillance log showed multiple skin/wound infections, but the ICP did not document any analysis or corrective actions. Additionally, the ICP did not have access to laboratory information from a local medical center, which hindered the identification of infectious organisms and the implementation of necessary interventions. The facility also failed to maintain a safe and sanitary storage environment for clean linen. During an observation, clean linens were stored in a room next to biohazard storage bins and full biohazard needle containers, which were placed there due to a lack of space elsewhere. Staff interviews confirmed that the biohazard bins and medical waste needle boxes should not be stored next to clean linen. The Director of Nursing Services stated that it was their expectation that the ICP document their analysis of the facility's monthly infection control program summary and that clean linen should not be stored with biohazard waste.
Failure to Resolve Resident Council Grievances
Penalty
Summary
The facility failed to resolve grievances brought forward by the resident council (RC) for two months, March and April 2024. During an interview, the RC stated that grievances were recorded by the Director of Activities but did not receive responses back. Occasionally, a department head would respond to a grievance, but this was not routine. The RC minutes for March 2024 showed grievances related to medical equipment stored in hallways, healthy options in the vending machine, staff use of walkie-talkies, meat on no meat days, staff attending RC, and meals not served at scheduled times. However, the grievance log for March 2024 only showed one grievance related to meals not served at scheduled times. Similarly, the RC minutes for April 2024 showed various grievances, but the grievance log for April 2024 showed no grievances generated from the RC. Staff P, the Director of Activities, stated that RC grievances were recorded in the RC minutes and followed up on individually, with the RC being informed through the facility activity newsletter. However, there was no documentation of an official facility response to the March or April 2024 RC grievances. The Administrator, who is the facility's grievance official, stated that RC grievances were logged, discussed at daily meetings, referred to the appropriate department head for follow-up, and responded to at the next RC meeting. The Administrator was unaware of all the RC grievances in the RC minutes, which did not meet the facility's expectations.
Failure to Report and Investigate Allegation of Abuse
Penalty
Summary
The facility failed to report and investigate an allegation of abuse involving Resident 19, who was cognitively intact and had multiple diagnoses including high blood pressure, a right lower leg fracture, depression, and asthma. Resident 19 reported that a woman had thrown ice water on them a couple of days prior and had informed facility staff. A progress note dated 05/18/2024 indicated a verbal altercation between Resident 19 and another resident. However, during interviews on 05/22/2024 and 05/23/2024, the Director of Nursing Services stated they were unaware of any investigations involving Resident 19 and acknowledged that the incident should have been reported and investigated. This failure placed residents at risk for unidentified abuse and mistreatment.
Failure to Monitor Congestive Heart Failure and Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure services provided met professional standards for Resident 154, who was diagnosed with congestive heart failure and kidney disease and was receiving an anticoagulant medication daily. Despite the admission orders requiring monitoring for new or worsening lower extremity edema, nighttime dyspnea, and bleeding, the resident's electronic health record (EHR) lacked orders and care plan entries for these conditions. Observations over several days showed the resident experiencing significant swelling in both hands and feet, and difficulty breathing, yet these symptoms were not documented or addressed in the care plan. Interviews with staff revealed that the expected care plans and monitoring orders for congestive heart failure and anticoagulant therapy were not in place for Resident 154. Staff C, a Licensed Practical Nurse/Unit Manager, and Staff B, the Director of Nursing Services, both acknowledged the oversight and confirmed that the necessary care plans and monitoring interventions should have been implemented. This failure placed the resident at risk for decreased comfort and poor clinical outcomes.
Failure to Provide Timely Auditory Services for Resident
Penalty
Summary
The facility failed to ensure that hearing aids were implemented and/or provided necessary auditory services in a timely manner for Resident 33, who was admitted in October 2023. The resident's minimum data set (MDS) dated May 17, 2024, indicated moderate difficulty hearing. Despite having hearing aids documented in their possession upon admission, the resident was observed without hearing devices and struggled to hear, responding by yelling and leaning forward. The care plan dated October 11, 2023, noted communication problems related to being hard of hearing but did not include interventions for hearing aids, only directing staff to raise their voice volume during interactions. Additionally, the multidisciplinary care conference notes from April 15, 2024, acknowledged the resident's hearing difficulty but did not discuss hearing aids or a referral for auditory services. Interviews with staff revealed that no audiology consult had been made for Resident 33, and the hearing aids were eventually found in a plastic bag in the resident's closet. Staff C, an LPN/Unit Manager, and Staff B, the Director of Nursing Services, both confirmed that an audiology consult should have been made if the resident was hard of hearing. The facility's referral binder for the 300/400 wing showed no documentation of an audiology consult for the resident, indicating a lapse in ensuring the resident's auditory needs were met, which placed the resident at risk for diminished independence and quality of life.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to consistently reconcile controlled medications in three medication carts (400, 100, and 300) reviewed for medication storage. On 05/22/2024, it was observed that the 400-hall medication cart's controlled substance books had missing signatures for the shift audit records dated May 2024. Staff L, a Registered Nurse/Agency Staff, confirmed that they had counted the medications with the off-going nurse but had not signed the books. Similar issues were observed on 05/23/2024 with the 100-hall and 300-hall medication carts, where Staff M and Staff N, both Licensed Practical Nurses, noted missing signatures in the controlled substance books for May 2024. Both staff members acknowledged that the documentation was incomplete and should have been properly signed during the shift changes. During an interview on 05/23/2024, the Director of Nursing Services, Staff B, confirmed that the facility's protocol required both the oncoming and off-going nurses to count and document the scheduled medications at every shift change. Staff B acknowledged that the missing signatures in the controlled substance books for the 100, 300, and 400 medication carts did not meet the facility's expectations. This failure placed residents at risk for misappropriation of their medications and the facility at risk for diversion of controlled medications.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of the reason for transfer or discharge to the hospital to the resident or responsible party for two residents reviewed for hospitalization. Resident 7, who was admitted with multiple diagnoses including a stroke, was transferred to the hospital without receiving written notice of the transfer. The Director of Nursing Services confirmed that only verbal notification was given. Similarly, Resident 69, also admitted with multiple diagnoses including a stroke and unable to speak, was transferred to the hospital without written notification. The Director of Nursing Services again confirmed that only verbal notification was provided. During interviews, both the Director of Nursing Services and the Administrator acknowledged that written notification should have been provided to the residents and/or their representatives. The lack of written notification was documented in the electronic health records of both residents, indicating a failure to comply with the required procedures for transfer or discharge notifications. This deficiency placed the residents at risk for diminished protection from inappropriate discharge.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a bed hold notice in writing at the time of transfer to the hospital or within 24 hours of transfer for two residents. Resident 7, who had a recent readmission and multiple diagnoses including a stroke, was discharged to the hospital with return anticipated but was not offered a bed hold notice. This was confirmed by the Admissions Director during an interview, who acknowledged that the bed hold should have been offered but was not documented in the resident's electronic health record (EHR). Similarly, Resident 69, who also had a recent readmission and multiple diagnoses including a stroke, was discharged to the hospital with return anticipated but was not offered a bed hold notice. The Admissions Director was unable to locate any documentation that a bed hold had been offered or provided for this resident's discharge. The Administrator confirmed that it was the facility's expectation to offer bed holds at the time of transfer and to document this in the resident's medical record, which was not done in these cases.
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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