Bremerton Trails Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Bremerton, Washington.
- Location
- 2701 Clare Avenue, Bremerton, Washington 98310
- CMS Provider Number
- 505123
- Inspections on file
- 58
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 52
Citation history
Health deficiencies cited at Bremerton Trails Post Acute during CMS and state inspections, most recent first.
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.
Two residents who were dependent on staff for ADLs, including bed mobility, toileting, and eating, did not receive needed assistance with positioning, hygiene, and meals. One resident with stroke-related hemiparesis, moderate cognitive impairment, and risk for malnutrition was observed in a urine-odorous room with water and meal trays out of reach, unable to use their arms, repeatedly requesting food and fluids, while multiple staff entered and exited without timely feeding assistance or incontinence care. Another resident with severe cognitive impairment and rib and pelvic fractures was repeatedly seen slid down in bed with the head elevated, back unsupported, grimacing and whining, with their brief exposed and visible from the hallway, as staff walked by without repositioning or covering them, despite care plans indicating total dependence for bed mobility and known pain from fractures.
A resident with depression, anxiety, and moderate cognitive impairment reported that a family member had taken their personal cell phone and would not return it. The SSA documented the concern and reported it to the state agency and left a voicemail for the family member but did not initiate or conduct an investigation or attempt to locate the phone. The resident stated the phone was their only way to communicate with the outside world. The Administrator later indicated they were unaware of the allegation and that staff had not followed facility policy for handling an allegation of misappropriation of property.
A resident with chronic pain and spinal stenosis, who was cognitively intact, had physician orders for scheduled and PRN oxycodone but experienced multiple missed doses due to the medication not being available. The MAR and progress notes documented repeated instances where oxycodone was unavailable in automated dispensing systems, only partial doses were on hand, or doses were pending pharmacy delivery. The resident reported that staff frequently told them the facility had run out of oxycodone and gave varying reasons such as ordering issues, shift mix‑ups, unsigned prescriptions, and insurance problems. A medical provider stated they expected medications to be given as ordered, and the DON reported that the pharmacy had not been sending the full amount of oxycodone requested for refills.
A resident's room was found to have missing paint and protruding plaster on the ceiling, which the resident and an LPN confirmed did not meet homelike standards. Additionally, multiple residents and staff reported that a hallway exit door repeatedly slammed and set off a loud alarm, causing ongoing disturbances. Maintenance efforts to reduce the noise were unsuccessful, and residents continued to express dissatisfaction with the environment.
Two residents admitted with fractures did not receive occupational therapy (OT) evaluation and treatment as ordered due to the unavailability of an OT. Although physician orders and provider notes indicated the need for OT, therapy was delayed until an OT became available, and it was unclear if medical providers were notified of the delay. The administrator expected therapy to be provided as ordered but was unaware of the lapse.
Surveyors were not provided with complete access to resident medical records, including MAR, TAR, assessments, care plans, nutritional reports, and lab results, despite multiple requests to the Administrator and DON. The Grievance log was also outdated and missing reported grievances, and facility leadership was unable to resolve the access issues during the survey.
The facility did not report allegations of sexual abuse and physical abuse involving two residents within the required timeframes. In both cases, staff either failed to recognize the need for immediate reporting or delayed notification to management and state authorities, resulting in late submission of mandatory reports.
Surveyors identified that two residents did not receive scheduled medications as ordered, were not promptly informed about medication unavailability, and were not properly observed during medication administration. Additionally, an insulin pen was found in a medication cart without the required open date label. These failures in medication administration, documentation, and storage did not meet professional standards and placed residents at risk.
Multiple residents did not receive timely assistance with ADLs, including dressing, hygiene, toileting, and scheduled showers, due to insufficient CNA staffing. Staff reported being unable to complete required care because of high resident assignments and call-outs, resulting in missed personal care and hygiene for several residents. The DON confirmed that care was missed when staffing was inadequate, and documentation showed no evidence that residents refused care.
Four residents did not receive medications as ordered, including missed or incorrectly timed eye drops for an eye infection, gabapentin given at improper intervals for nerve pain, and insulin administered after meals instead of before. Staff cited transcription errors, lack of follow-up, and time constraints as reasons for these medication errors.
A nurse failed to clean and disinfect a blood glucose monitor and supply container between use on two residents, did not perform hand hygiene before and after resident care, and conducted glucose testing and insulin administration in the dining room, contrary to facility protocols. The infection preventionist confirmed these actions did not follow required infection control procedures.
A resident with dementia, diabetes, and end-stage kidney failure was discharged without proper notification to outside service providers, leading to unmet care needs. The facility failed to document the discharge notification, and necessary assessments were not completed, impacting the resident's care continuity.
A resident with functional limitations and a history of using a power wheelchair for community access had their wheelchair removed after an incident, restricting their mobility and community engagement. Despite assessments showing the resident could operate the wheelchair independently, the facility did not provide alternatives, impacting the resident's socialization and mood.
A facility failed to meet professional standards by discontinuing medications without authorization and not following physician's orders for three residents. One resident missed morning medications due to an EMR error, another had critical medications discontinued without authorization, and a third did not receive daily wound care as ordered. These deficiencies led to missed treatments and discomfort for the residents.
A facility failed to follow infection control standards during wound care for a resident with MRSA. An LPN did not wear a gown and neglected hand hygiene between glove changes while treating the resident's wound, contrary to the facility's policy. The Infection Preventionist confirmed the need for gown use and proper hand hygiene.
The facility failed to ensure staff adhered to CDC guidelines for PPE use during a COVID-19 outbreak. A CNA did not change their N95 respirator after leaving a COVID-19 positive resident's room and continued to interact with other residents. Another CNA used contaminated gloves to search an isolation cart, and an Agency Licensed Nurse also failed to replace their N95 respirator. Despite training, staff actions did not align with infection control protocols.
A resident with a history of skin picking and severe cognitive impairment suffered a maggot infestation in a scalp wound due to the facility's failure to consistently assess, monitor, and provide timely wound care. Despite physician orders for treatment, there was a lack of documentation and communication regarding the wound's condition. Staff noticed a foul odor and drainage but did not report these signs to the medical provider, leading to significant physical harm.
A facility failed to maintain effective pest control, resulting in flies across all resident care units and a resident's wound becoming infested with maggots. Observations showed flies in various areas and open windows and doors without screens. Staff interviews revealed a lack of awareness and action regarding pest control and wound care, with admissions of the absence of screens and propped open doors.
The facility failed to provide sufficient licensed nurses to administer medications timely, resulting in significant delays for three residents. A resident reported inconsistencies in receiving pain medications, with morning doses scheduled for 8:00 AM being administered as late as 7:34 PM. Another resident experienced delays in bedtime medications, sometimes receiving them after midnight. A third resident reported receiving morning medications at noon and evening doses after midnight, especially when staffing was low. Staff interviews confirmed that insufficient staffing contributed to these delays.
The facility failed to maintain clean and sanitary conditions in resident rooms, as observed in five sampled rooms. Issues included unsanitary conditions, chipped paint, dust accumulation, dirt buildup, and broken fixtures. A family member reported finding a room unsanitary and cleaned it themselves. Staff acknowledged the unacceptable conditions.
The facility failed to include 9 out of 10 complaint survey results in the survey results binder, preventing residents, family, and visitors from reviewing past survey results and plans of correction. The DON confirmed the absence of these documents in the binder.
The facility failed to promptly report and investigate abuse allegations for two residents, including a verbal altercation and a staff member causing pain to a resident. The incidents were not reported to the state agency in a timely manner, violating the facility's policy.
The facility failed to provide necessary care for several residents, including delayed bowel care for two residents, inadequate edema management for two others, and inaccessible call bells for two residents. These deficiencies involved not following physician orders, improper documentation, and failure to ensure resident safety.
The facility failed to provide respiratory care according to physician's orders for two residents. One resident received oxygen via an open mask instead of a nasal cannula, with a dirty concentrator filter, and without documented indication for use. BiPAP orders were incomplete, lacking specific settings and humidifier instructions. Another resident received oxygen without documentation in the MAR/TAR, indicating a lack of adherence to proper procedures.
The facility failed to label and date medications properly, and did not discard expired medications in three medication carts. Insulin pens and over-the-counter medications were found undated or expired, posing risks to residents. A RN confirmed the need for discarding these medications.
The facility failed to label and date food items in the Bayshore Dining Room Nourishment Refrigerator/Freezer, including chicken tenders, popcorn chicken, horseradish, salsa, creamer, beef and rice, and cheese. Staff acknowledged the responsibility to check dates and discard undated or expired items, confirming the expectation for immediate labeling and dating.
The facility did not employ a qualified full-time social worker, as required for facilities with over 120 beds. Interviews revealed that neither the Social Services Director nor the Social Services Assistant had the necessary bachelor's degree. This deficiency risked unmet psychosocial needs and diminished quality of life for residents.
The facility's QA&A committee did not meet the requirement of including the Medical Director or their designee at least quarterly. Despite the Administrator's claim that the committee met monthly with the Medical Director, no attendance records could be found to confirm the Medical Director's presence in the past two quarters.
The facility failed to ensure necessary durable medical equipment was ordered and available at discharge for three residents, leading to potential risks. Despite policy requirements, the facility did not provide essential items like shower chairs and benches. Communication issues between the Social Services Director and the case manager resulted in unmet equipment needs, leaving one resident still in need of a shower chair.
A resident with severe cognitive impairment was administered risperidone for dementia with behaviors before informed consent was obtained. The facility's protocol requires explaining the risks and benefits of psychotropic medications and obtaining consent prior to administration. However, the medication was given on two occasions before consent was documented, as acknowledged by the DON.
The facility failed to properly log, investigate, and resolve grievances for several residents, including issues with missing items, staffing concerns, and unaddressed incidents. Residents reported feeling frustrated and powerless due to the lack of response from the facility.
The facility failed to ensure timely PASRR Level II evaluations for two residents. One resident, admitted as an exempted hospital discharge, was not reassessed for a Level II evaluation until 61 days after admission, and the evaluation was still incomplete 70 days later. Another resident with a mental health disorder and suicidal ideations did not receive a required Level II evaluation, as confirmed by facility staff.
The facility failed to update care plans for four residents, leading to unmet care needs. A resident with dental issues and hypotension lacked appropriate care plans, while another with cognitive impairment had no communication or vision plans. A third resident using oxygen did not have this documented, and a fourth needing feeding assistance had an inaccurate care plan. Staff acknowledged these deficiencies.
The facility failed to follow professional standards in medication management for four residents. A resident received oxycodone outside prescribed pain levels, while another had issues with compression wraps and oxygen delivery without proper orders. A third resident was given medications despite low pulse readings, and a fourth received an allergenic powder without an order, leading to a rash. Staff acknowledged these discrepancies.
A resident with cognitive and physical impairments required assistance with grooming, specifically hair care, but was left with matted and tangled hair. Despite informing CNAs multiple times, the issue persisted, affecting the resident's self-esteem. Staff, including a CNA and an LPN Unit Manager, confirmed the unacceptable condition of the resident's hair.
A resident with hemiplegia, diabetes, and an ulcer was not provided with necessary podiatry care, including toenail cutting, since admission. Despite being scheduled for weekly diabetic foot checks, the resident's toenails were observed to be long and thickened. Staff interviews revealed that the resident had not been seen by a podiatrist, and the Unit Manager/LPN expressed discomfort in providing nail care due to the nails' poor condition.
The facility failed to address the nutritional needs of a resident who experienced significant weight loss, as dietary recommendations were not implemented. Additionally, the facility lacked a system to monitor fluid intake for a resident on fluid restriction, leaving adherence unverified.
A facility failed to assess and obtain informed consent for the use of bedrails for a resident with hemiplegia and cognitive impairment. The resident's care plan did not include side rails, and the required safety form was not completed. An LPN confirmed the necessity of including side rails in the care plan and obtaining consent.
A facility failed to create a comprehensive dementia care plan for a resident with severe cognitive impairment, leading to unmet needs. The care plan lacked specific details on the resident's dementia manifestations and did not incorporate family input. The resident's family noted increased confusion and anxiety in the evenings due to sundowning, but this was not addressed in the care plan.
A resident with severe cognitive impairment and non-Alzheimer's dementia was inappropriately started on risperidone for behavior disturbances without documented evidence of hallucinations, delusions, or aggression. The facility failed to consider the resident's normal routine of walking and pacing, especially related to sundowning, and the Director of Nursing admitted the diagnosis and target behaviors were not appropriate indications for the medication.
Two residents with severe cognitive impairments were not assisted to eat their meals in the dining room as per their care plans. Instead, they were observed receiving meals in bed, contrary to the facility's expectations. Staff cited reasons such as allowing relaxation and post-wound care positioning, but these did not align with the care plans that emphasized dining room meals to promote intake.
A resident developed an unstageable pressure ulcer due to the facility's failure to consistently complete pressure ulcer care. Despite having a care plan for repositioning and incontinence management, wound care was not documented as completed on two occasions due to short staffing. The lack of documentation and follow-through contributed to the development of the ulcer, as confirmed by the DON.
A registered nurse failed to follow proper infection control practices during wound care for a resident with an unstageable pressure injury. The nurse did not perform hand hygiene after removing soiled dressings and gloves, and handled a pen without washing hands. This breach was confirmed by the facility's Infection Preventionist and Director of Nursing, who stated that hand hygiene is required after glove removal and before handling personal items.
The staff failed to perform proper hand hygiene and change gloves when providing pressure ulcer care for three residents. For one resident with a stage 4 ulcer, the LPN took a picture of the wound without changing gloves. For two other residents with stage 3 and stage 2 ulcers, the LPN did not change gloves or perform hand hygiene before applying clean dressings. The DON confirmed the expected procedure was not followed.
A facility failed to recognize a clinical change of condition for a resident with complex medical and mental health issues. Despite documented signs of confusion and disorientation, the resident was allowed to discharge to a motel, where they were later found in distress. The staff were not fully aware of the resident's fluctuating mental status prior to discharge.
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.
Failure to Assist Dependent Residents With ADLs, Positioning, and Eating
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), including positioning, eating, toileting, and hygiene, for residents who were unable to perform these tasks independently. Facility policy required staff to provide appropriate care and services for residents needing help with hygiene, mobility, toileting, and dining, and to identify underlying causes when cognitively impaired residents resisted care rather than assuming refusal. Despite this, observations, interviews, and record reviews showed that residents with significant physical and cognitive impairments were left without needed assistance, with call lights and essential items out of reach, and with incontinence and positioning needs unmet. One resident with depression, anorexia, stroke, hemiparesis, moderate cognitive impairment, and risk for malnutrition required substantial to maximal assistance for bed mobility, personal hygiene, dressing, and was dependent for toileting, with frequent incontinence. The Kardex directed that water and needed items, including the call light, be kept within reach, that the resident receive supervision and encouragement with eating, and that staff report refusals of food or fluids to the nurse. During a continuous observation period, the resident was found in bed in a room with a strong urine odor, with an untouched breakfast tray and water out of reach, and the call light pinned behind the head of the bed. The resident reported not having water or food for days and being unable to move their arms. Multiple staff, including a Resident Care Manager, CNAs, an LPN, and a physician, entered the room over the course of nearly two hours, acknowledged the resident’s requests for food, water, and assistance, and noted the urine odor, but assistance with eating and incontinence care was delayed. Water was repeatedly placed out of reach, the lunch tray was delivered and left without timely feeding assistance despite the resident’s repeated statements that they could not move their arms, and incontinent care and repositioning were not provided during the observation. Another resident with severe cognitive impairment, rib and pelvic fractures, and care plans indicating total dependence for bed mobility and transfers and pain related to multiple fractures was repeatedly observed lying in bed with the head of the bed elevated to 90 degrees, having slid down so that their back was unsupported by the mattress. The resident’s legs were moving, their facial expression was a grimace, and they were whining softly, while dressed in a gown with their brief exposed and visible from the hallway. Over multiple observations, staff walked by the room, glanced in, but did not enter to reposition or cover the resident. An occupational therapist later confirmed the resident was not positioned correctly, appeared uncomfortable and in pain, and noted that this position would be painful given the pelvic fractures. A CNA assigned to the resident stated they had repositioned the resident by ensuring the legs were straight and not hanging off the bed and reported that blankets had covered the resident, which conflicted with the observed condition. The Assistant DON stated an expectation that staff correctly position residents in bed and that all staff assist when they observe a resident in an uncomfortable position, which did not occur in this case.
Failure to Investigate Allegation of Misappropriated Cell Phone
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of misappropriation of a resident’s personal cell phone. The resident was admitted with depression and anxiety and had a Minimum Data Set (MDS) indicating moderate cognitive impairment, requiring substantial/maximal assistance for bed mobility and moderate assistance for transfers. On 02/13/2026, progress notes documented that the resident reported a family member had removed their personal phone and would not return it. The Social Service Assistant (SSA) documented a report to the state agency for possible exploitation or control of the resident’s communication device by family members. During an interview on 03/04/2026 at 9:17 AM, the SSA stated that after the resident’s allegation, they reported the concern to the state agency and left a voicemail for the family member but did not initiate or complete any investigation or attempt to locate the phone. The SSA confirmed no further action was taken beyond the report and voicemail. Later that morning, the resident stated that their family member had taken their cell phone and that they wanted it back, describing it as their only way to communicate with the outside world. The Administrator reported being unaware of the allegation and stated that staff should have initiated a grievance for a missing item and an investigation, and acknowledged that staff did not follow the facility’s policy for an allegation of misappropriation.
Failure to Ensure Continuous Supply and Administration of Ordered Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to provide physician‑ordered pain medication as prescribed for a cognitively intact resident with chronic pain and spinal stenosis. Facility policy stated that pharmacy services were available 24/7 and that residents would have a sufficient supply of prescribed medications and receive them in a timely manner. The resident had physician orders for oxycodone 10 mg six times per day and an additional 10 mg every six hours as needed for pain. The MAR for the month reviewed showed multiple missed scheduled oxycodone doses on several dates, including missed doses at midnight, early morning, afternoon, and evening times. Progress notes documented that oxycodone was not available on at least one date due to awaiting pharmacy delivery, and on another date only one tablet was available when two were ordered, with the remainder on order. Additional progress notes showed repeated unavailability of oxycodone in the automated medication storage systems (Pixis/Omnicell), with documentation that staff lacked access to the system at one point and that the pharmacy had been informed of the missing medication on another. Notes also indicated that oxycodone doses were pending pharmacy delivery on multiple occasions. During interview, the resident reported that the facility continually ran out of oxycodone, resulting in missed doses on their every‑four‑hour regimen, and described receiving various explanations from staff, including that the medication was not ordered, agency nurses did not order it, there were mix‑ups between shifts, the physician did not sign the prescription, or insurance would not cover it. A medical provider stated they expected licensed nurses to administer medications per order. The DON reported that an internal review found the pharmacy was not sending the amount of oxycodone requested for refills, though the pharmacy could not explain why.
Failure to Maintain Homelike Environment Due to Room Disrepair and Excessive Noise
Penalty
Summary
The facility failed to maintain a homelike environment for its residents, as evidenced by observations and interviews regarding both the physical condition of a resident's room and the noise levels in a hallway. One cognitively intact resident pointed out multiple areas on their ceiling where paint was missing and plaster was protruding, which was confirmed by a charge nurse who noted the deficiencies did not meet expectations for a homelike setting. The resident expressed dissatisfaction with the room's appearance, indicating it affected their experience. Additionally, residents and staff reported ongoing issues with a hallway exit door that frequently slammed and triggered a loud alarm, disturbing residents in nearby rooms. Multiple residents complained about the noise, both during resident council meetings and in interviews, stating that the door slammed throughout the night and the alarm was disruptive. Observations confirmed repeated slamming and alarm sounds, with residents audibly expressing frustration. Maintenance staff acknowledged attempts to address the noise, such as installing weather stripping, but these measures were ineffective or temporary.
Failure to Provide Timely Occupational Therapy Services as Ordered
Penalty
Summary
The facility failed to provide occupational therapy (OT) services as ordered for two residents who were admitted with fractures. Both residents had physician orders for OT evaluation and treatment upon admission, and their medical provider notes indicated ongoing need for OT. However, the OT evaluations and initiation of therapy were delayed for both residents due to the unavailability of an occupational therapist at the facility. The Director of Rehabilitation confirmed that OT services were not started until several days after admission for both residents, and was unable to confirm whether the medical providers were notified of these delays. Staff interviews revealed that the occupational therapist was not available at the time of the residents' admissions, resulting in a gap between the physician's order and the actual provision of therapy services. The facility administrator stated an expectation that therapy would be provided when ordered and indicated that resources were available to obtain OT services, but was unaware that the residents did not receive timely OT evaluations and treatment as required.
Incomplete Access to Resident Medical Records and Logs During Survey
Penalty
Summary
The facility failed to provide accurate and complete access to all resident medical records during an annual recertification survey. Upon entry, surveyors requested access to the electronic health record (EHR) system and the Grievance log. Although initial access to the EHR was provided, it was incomplete and did not include essential documents such as Medication Administration Records (MAR), Treatment Administration Records (TAR), various assessments, care plans, nutritional reports, and laboratory results. Despite repeated notifications to the Administrator and Director of Nursing Services (DNS) about the incomplete access, the issue persisted over several days. The DNS indicated that the corporate office was hesitant to grant full access to all medical records. Additionally, the Grievance log provided was outdated and, even after requests for an updated version, did not include all reported grievances. The lack of timely and complete access to these records had the potential to delay the survey process and hinder the ability to address resident concerns. The events documented show a pattern of delayed and incomplete responses to surveyor requests for required documentation, as well as uncertainty among facility leadership regarding how to resolve the access issues.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse within the required timeframes for two residents. For one resident with anxiety and post-traumatic stress disorders, a CNA documented that the resident claimed to have received nude photos from staff and to have had romantic relationships with several staff members. The Director of Nursing and the Administrator were unaware of these allegations until they read the progress notes the following day. The Director of Nursing acknowledged that this was an allegation of sexual abuse and should have been reported immediately to management and the state agency, but it was not reported until after the delay was discovered. For another resident with depression, anxiety, and muscle weakness, the resident reported physical abuse by a CNA and neglect by another CNA to an Activities Aide, who then notified the Administrator and Assistant Director of Nursing. The facility's investigation into the abuse allegation began the same day, but the mandatory report to the state was not submitted until the following afternoon, exceeding the 24-hour reporting requirement. The Assistant Director of Nursing stated they did not initially report the allegation because they did not believe it constituted abuse or neglect, and the Director of Nursing believed the next-day reporting was within the appropriate timeframe.
Failure to Meet Professional Standards in Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice in several areas, as evidenced by observations, interviews, and record reviews. For one resident with hypertension and heart failure, there were multiple instances where a prescribed medication, eplerenone, was not administered as scheduled. The Medication Administration Record (MAR) showed blank entries and missed doses without corresponding documentation or progress notes explaining the omission. The resident was not promptly informed about the unavailability of the medication, and there was a lack of timely communication with the provider and pharmacy regarding the medication's status. Staff interviews confirmed that documentation and resident notification were not completed as expected. Another resident, who was cognitively intact, was found to have three melatonin pills in their dresser drawer, despite documentation indicating the medication had been administered on six nights. This indicated that the resident had not taken the medication as intended on three occasions. Staff interviews revealed that the expectation was for nurses to observe residents taking their medications and ensure they had fully swallowed them before leaving the room, which did not occur in this case. Additionally, during a medication cart review, an insulin pen was found in a medication cart without an open date labeled, as required by facility policy. Staff confirmed that insulin pens are to be dated when first used, and the absence of a date meant the insulin could not be verified as safe for use. These failures in medication administration, documentation, and storage practices did not meet professional standards and placed residents at risk.
Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide competent and sufficient nursing staff to meet the personal care needs of multiple residents, as evidenced by direct observations, interviews, and record reviews. Several residents did not receive timely assistance with activities of daily living (ADLs) such as dressing, personal hygiene, toileting, and bathing, as outlined in their care plans. For example, one cognitively intact resident reported waiting since early morning for assistance with getting up and having their brief changed, with staff repeatedly turning off the call light without providing care. Another resident, who was cognitively impaired, was observed multiple times lying in bed in soiled conditions, with a strong odor of urine in the room, and their call light on the floor. Staff assigned to these residents admitted to not having provided complete care due to time constraints and high workload. Additional residents were affected by missed showers and inadequate personal hygiene. One resident reported not receiving scheduled showers because staff stated they were short-staffed and did not have time. Staff confirmed that due to insufficient staffing, they were unable to complete showers and could only provide brief changes and respond to call lights. Another resident expressed frustration at not receiving oral care and having to wait hours for assistance, attributing these delays to staff being too busy. Staff interviews corroborated that the high resident-to-staff ratio prevented them from delivering all required care, especially when scheduled staff called out and replacements were not available. The Director of Nursing acknowledged that the expectation was for nursing assistants to provide comprehensive morning and evening care, including oral care, personal hygiene, and showers as scheduled. However, the DON also stated that when staffing was inadequate, care could be missed despite efforts to have management assist or call in additional staff. Documentation reviewed for the affected residents did not indicate that care was refused by the residents, further supporting that the deficiencies were due to insufficient staffing rather than resident choice.
Failure to Administer Medications per Physician Orders and Guidelines
Penalty
Summary
The facility failed to administer medications according to physician orders and established guidelines for four residents, resulting in significant medication errors. For one resident with a history of bacterial conjunctivitis, the prescribed Maxitrol eye drops were not documented as administered, and a subsequent order for Polytrim eye drops was not resumed after a cancelled ophthalmology appointment, despite ongoing infection. Staff confirmed that transcription errors and lack of follow-up with the provider led to the resident not receiving the required medications as ordered. Another resident, who was prescribed gabapentin three times daily for nerve pain, did not receive the medication at appropriate intervals. The medication was administered at inconsistent times, sometimes with less than the recommended six-hour interval between doses. Staff acknowledged that the medication schedule should have been adjusted to ensure proper spacing, as advised by the facility's pharmacist, but this was not done. Two additional residents with diabetes were prescribed Lispro insulin to be administered before meals. Observations showed that both residents received their insulin injections after they had finished eating, contrary to physician orders. Nursing staff attributed the delay to time constraints, and facility leadership confirmed that medications should be given as ordered. These failures in medication administration were directly observed and confirmed through interviews and record reviews.
Failure to Maintain Infection Control During Glucose Monitoring and Insulin Administration
Penalty
Summary
Staff failed to maintain proper infection control practices during blood glucose monitoring and insulin administration. A registered nurse used a blood glucose monitor on one resident, placing the device and used supplies into a plastic container without cleaning or disinfecting the monitor or the container afterward. The nurse also did not perform hand hygiene after removing gloves and before proceeding to care for another resident. The same glucose monitor and plastic container were used for another resident without cleaning or disinfecting between uses. The nurse also failed to perform hand hygiene before donning gloves and administering care to the second resident. Supplies, including the insulin pen and alcohol wipes, were placed back into the same uncleaned container after use. The infection preventionist confirmed that the facility's protocol required the glucose monitor to be cleaned with disinfecting wipes per manufacturer instructions, and that alcohol wipes were insufficient for disinfection. The infection preventionist also stated that hand hygiene should be performed before and after all resident care and that the plastic container should be cleaned after removing dirty supplies. Additionally, glucose testing and insulin administration were performed in the dining room, which was not in accordance with facility procedures. These actions and inactions were observed and confirmed through interviews and record review.
Failure in Discharge Planning and Notification
Penalty
Summary
The facility failed to ensure proper discharge planning for a resident, identified as Resident 8, who was discharged to home without necessary notifications to outside service providers. Resident 8, who was moderately cognitively impaired and required assistance with daily activities, was discharged without the completion of a required assessment by an outside service provider. The facility's social services department had a protocol for weekly meetings with outside services to discuss potential discharges, but there was no documentation of notification for Resident 8's discharge, which was reportedly communicated verbally only. Collateral Contact 2, an outside service provider, was unaware of the discharge and unable to complete an assessment to resume care services at home. Additionally, Collateral Contact 1 reported no care conferences or discussions about the discharge, and the resident's caregiver was not being paid due to incomplete paperwork. The facility's administrator acknowledged that a form should have been used to notify outside services of the pending discharge, but it was not utilized for Resident 8.
Failure to Accommodate Resident's Mobility Needs
Penalty
Summary
The facility failed to accommodate the mobility needs of a resident, who was cognitively intact and used a power wheelchair due to functional limitations in their extremities. Following an incident where the resident used their power wheelchair defensively against another resident, the facility removed the power wheelchair and provided a manual one, which the resident could not propel independently. This action restricted the resident's ability to access the community, affecting their routine activities such as visiting their girlfriend and shopping, which they previously did using the power wheelchair. Despite a power mobility assessment indicating the resident could operate the power wheelchair independently, the facility did not allow its use outside the facility. Staff members, including the Activity Director and Social Service Director, acknowledged the resident's previous community outings and expressed no concerns about their ability to navigate the community. However, no alternative transportation or plans were arranged to assist the resident in maintaining their community activities, leading to a decline in the resident's mood and socialization opportunities.
Medication and Care Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice, as evidenced by the discontinuation of medications without authorization and failure to follow physician's orders for three residents. Resident 1, who was admitted with complex medical conditions and heart disease, did not receive their prescribed morning medications on the day following their readmission. This was due to an error in the electronic medical record (EMR) where the medication orders were not confirmed, leading to the omission of the medications. Staff involved were aware of the issue but failed to rectify it in a timely manner, and the Director of Nursing was not informed of the missed medications until much later. Resident 2, who had diagnoses including respiratory failure and diabetes, experienced unauthorized discontinuation of critical medications such as insulin, pain medication, and potassium. These medications were discontinued in the EMR without authorization from a medical provider, leading to the resident experiencing pain and not receiving necessary insulin for several days. Additionally, Resident 2 requested a humidifier for their oxygen due to discomfort, but this request was not fulfilled, resulting in continued discomfort and nosebleeds. Resident 3, diagnosed with dementia and multiple pressure ulcers, did not receive daily wound care as ordered by their physician. The wound dressing was not changed for several days, and staff falsely documented that the care had been completed. This oversight was only discovered when a collateral contact noticed the unchanged dressing. The facility's failure to adhere to physician orders and properly document care resulted in a lack of necessary medical treatment for the residents involved.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to infection control standards during wound care for a resident on enhanced barrier precautions (EBP). The facility's policy required staff to wear gowns and gloves when performing wound care on residents with wounds, such as those with methicillin-resistant staphylococcus aureus (MRSA). However, during an observation, a Licensed Practical Nurse (LPN) was seen entering the resident's room, performing hand hygiene, and donning gloves without wearing a gown. The LPN removed the resident's wound dressing, cleansed the wound, discarded the dressing and gloves, but failed to perform hand hygiene before putting on new gloves and applying a clean dressing. The resident involved had been admitted with diagnoses including MRSA and had physician orders indicating the need for EBP due to wounds and MRSA in their eye. The facility's policy also required hand hygiene to be performed after removing gloves and before donning new gloves during wound care. The Infection Preventionist and Assistant Director of Nursing confirmed that the staff should have worn a gown and performed hand hygiene after removing the old dressing and gloves, highlighting the deviation from the established infection control protocols.
Non-compliance with PPE Protocols During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure that three out of six staff members adhered to CDC guidelines for using personal protective equipment (PPE) when caring for residents with confirmed COVID-19 infections. Staff A, a Certified Nursing Assistant (CNA), entered a COVID-19 positive resident's room wearing appropriate PPE but did not remove the N95 respirator after exiting the room. Instead, Staff A proceeded to the nurse's station and later passed trays to other residents without changing the respirator. Similarly, Staff C, another CNA, exited a COVID-19 positive resident's room without changing the N95 respirator and used gloves from the room to search an isolation cart, potentially contaminating it. Staff D, an Agency Licensed Nurse, also failed to replace the N95 respirator after leaving a COVID-19 positive resident's room. The facility's Director of Nursing and the Float Infection Control Licensed Nurse confirmed that the expectation was for staff to remove all PPE, including the N95 respirator, after leaving a COVID-19 positive room and to perform hand hygiene before donning new PPE. Despite this, the staff did not comply with these protocols, which were intended to prevent the spread of COVID-19 within the facility. The report indicates that all staff had been trained on the correct usage of PPE, yet the observed actions did not align with the established guidelines.
Failure to Monitor and Treat Scalp Wound Leads to Maggot Infestation
Penalty
Summary
The facility failed to consistently assess, monitor, and provide timely wound care for a resident with a scalp wound, leading to a maggot infestation. The resident, who was severely cognitively impaired and dependent on staff for transfers, had a history of skin picking and was at risk of infection. Despite having physician orders for antibiotic ointment and ammonium lactate solution to be applied to the scalp wound, there was a lack of documentation and monitoring of the wound's condition from early August 2024 onwards. The wound specialist's last documented assessment was on July 30, 2024, and subsequent weekly skin evaluations failed to document the status of the scalp wound. Staff members reported noticing a foul odor and drainage from the wound, but these signs were not communicated to the medical provider. On September 2, 2024, emergency services were called when the resident was found with a maggot-infested scalp wound, indicating a severe lapse in wound care and monitoring. Interviews with staff revealed that the licensed nurses did not follow the facility's wound care policy, which required weekly monitoring and documentation of wounds. The facility's infection preventionist noted the presence of flies in resident care areas due to open windows without screens, which may have contributed to the infestation. The lack of proper wound care and failure to notify the medical provider of changes in the wound condition resulted in significant physical harm to the resident.
Pest Control Deficiency Leads to Resident Wound Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant deficiency involving the presence of flies across all four resident care units. Observations revealed flies in various locations, including hallways, doorways, and light fixtures, as well as open windows and doors without screens, which facilitated the entry of flies into the facility. The facility's policy on pest control emphasized the responsibility of staff to report pests immediately and take steps to prevent harm, but this was not effectively implemented. A resident with medically complex conditions and dementia was found with a maggot-infested wound on their scalp, indicating a severe lapse in wound care and pest control. The resident was dependent on staff for care and had a severe cognitive impairment. Staff interviews revealed a lack of awareness and action regarding the resident's wound care and the presence of flies, with staff acknowledging the absence of screens on windows and the propping open of doors. The facility's maintenance director admitted to the presence of flies and the lack of screens, while the director of clinical operations highlighted the need for wound care and preventative measures to reduce flies.
Medication Administration Delays Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure sufficient licensed nurses were available to administer medications timely for three residents, leading to delays in medication administration. Resident 1, who was cognitively intact, reported inconsistencies in receiving medications on time, particularly for pain management. The Medication Administration Audit Report for Resident 1 showed significant delays, with morning medications scheduled for 8:00 AM being administered as late as 7:34 PM on some days, and evening medications scheduled for 7:00 PM being administered after midnight. Resident 2, also cognitively intact, expressed frustration over receiving bedtime medications inconsistently, sometimes after midnight. The audit report for Resident 2 indicated similar delays, with medications scheduled for 7:00 PM being administered as late as 12:52 AM. Resident 3 reported not receiving morning medications until noon and evening medications after midnight, especially when staffing was low. The audit report confirmed these delays, with morning medications scheduled for 8:00 AM being administered as late as 8:25 PM. Interviews with staff revealed that the facility often operated with insufficient nursing staff, particularly during night shifts, which contributed to the delays in medication administration. Staff C, a Resident Care Manager, acknowledged that having only two nurses and a medication tech made it challenging to administer medications on time. The Director of Nursing, Staff B, confirmed the discrepancies in medication administration times and attributed them to a shortage of licensed nurses, acknowledging that the facility did not have enough staff to meet residents' needs timely.
Facility Fails to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in resident rooms, as observed in five sampled rooms. In one instance, a family member visiting a newly admitted resident found the room unsanitary, with red liquid splattered on the walls, a dusty fan, a dirty baseboard heater, a stained guest chair, and grime in the corners. The family member ended up cleaning the room and the fan themselves. Observations of the rooms revealed various issues, including chipped paint, dust accumulation, dirt buildup, and broken fixtures. Specific observations included a room with a large chip in the door, paint scraped off the wall, and a bathroom with an odor of urine and a soiled brief in the garbage can. Another room had a brown substance on the floor, missing paint on door frames, and a broken toilet paper holder. Additional rooms showed dirt on walls, cracked baseboards, rust on the floor, and broken furniture. Staff acknowledged the unacceptable conditions, with an administrator designee noting that the rooms did not meet their standards.
Missing Survey Results in Facility Binder
Penalty
Summary
The facility failed to ensure that the survey results book included the results for 9 out of 10 abbreviated complaint surveys that resulted in citations since the previous recertification survey. This deficiency was identified through observation, interview, and record review. On July 9, 2024, the survey results binder was observed in a wall-mounted receptacle across from the reception desk in the front lobby. Upon review, it was found that the binder did not contain the survey results and associated plans of correction for the complaint surveys conducted on several dates between September 2023 and May 2024. Staff B, the Director of Nursing, confirmed that the survey results were not available in the facility's survey binder, thus preventing residents, family members, and visitors from exercising their right to review past survey results and evaluate the quality of care provided by the facility.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to report and investigate allegations of abuse for two residents, placing them at risk for further abuse and lack of protection. For Resident 60, the facility's incident log showed a verbal altercation occurred on a Saturday but was not reported to the state until the following Monday. The Director of Nursing Services acknowledged that the incident should have been reported immediately when it occurred. This delay in reporting violated the facility's policy, which mandates immediate reporting of such incidents. For Resident 20, who was moderately cognitively impaired, an allegation was made that a staff member caused pain by patting the resident's arm despite being asked to stop. The facility administrator was informed of this allegation but did not immediately suspend the staff member or report the incident to the State Agency, as required by the facility's policy. The administrator acknowledged the failure to report the incident promptly and did not provide further documentation regarding the investigation of the allegation.
Deficiencies in Resident Care and Safety Protocols
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable level of well-being for several residents. Resident 9, who was moderately cognitively impaired, did not receive bowel care as per physician's orders, resulting in a delay in administering Milk of Magnesia for constipation. Similarly, Resident 59 experienced a delay in bowel protocol initiation, going six days without a bowel movement before receiving the necessary medication. For Residents 87 and 37, the facility did not adequately monitor and manage edema. Resident 87's increased edema was not reported to the provider as required, and Resident 37 did not receive the prescribed compression wraps consistently. Instead, tubular gauze was used without proper orders, and documentation inaccurately reflected that the prescribed wraps were applied. Additionally, Resident 37's bruising, likely due to anticoagulant therapy, was not assessed or monitored as part of the facility's skin checks. The facility also failed to ensure that call bells were within reach for Residents 40 and 44, which could prevent them from contacting staff in emergencies. In both cases, the call bells were found out of reach, contrary to the facility's expectations that they should be accessible to residents. These deficiencies highlight lapses in following care protocols and ensuring resident safety.
Deficiencies in Respiratory Care and Documentation
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with physician's orders and accepted professional standards for two residents. Resident 37, who was cognitively intact and had diagnoses of heart failure and chronic lung disease, was observed receiving oxygen via an open mask instead of the ordered nasal cannula, without a humidifier bottle, and with a dirty oxygen concentrator filter. Despite maintaining adequate oxygen saturation levels on room air, the resident continued to receive supplemental oxygen without documented indication for use. Additionally, the facility did not document any communication with the physician regarding the resident's ability to maintain oxygen saturation without supplemental oxygen. The facility also failed to provide complete and clear BiPAP orders for Resident 37. The orders did not specify the BiPAP settings, whether supplemental oxygen should be attached, or instructions for checking and filling the humidifier reservoir. The resident expressed a preference for humidified oxygen, but this was not communicated to the staff. The BiPAP settings were only available in the electronic health record under documents, which was not easily accessible for agency nurses. Resident 48 was observed receiving oxygen via nasal cannula without any corresponding entries in the medication and treatment administration records for June and July. The Director of Nursing confirmed that oxygen use required an order and should be documented in the MAR and TAR. The lack of documentation and communication regarding oxygen use for Resident 48 indicates a failure to adhere to proper procedures for respiratory care.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and dated when opened, and expired medications were discarded, as observed in three medication carts: Olympic, Cove 1, and Cove 2. During an inspection of the Cove 2 medication cart, several insulin pens and over-the-counter medications were found to be either undated or expired. Specifically, insulin pens for multiple residents were opened and not dated, or had been opened for more than 28 days, which is beyond the recommended usage period. Additionally, bottles of Vitamin E, multivitamins, and ferrous gluconate were found to be past their best-by dates. In the Cove 1 medication cart, a basaglar insulin pen was found to be opened for more than 28 days. The Olympic medication cart contained eye drops and an insulin pen that were undated and not labeled with a resident's name, and some were opened beyond the manufacturer's recommended usage period. These observations were confirmed by Staff O, a Registered Nurse, who acknowledged that the medications needed to be discarded. The failure to properly label, date, and discard expired medications placed residents at risk of receiving expired medications and potential negative health outcomes.
Failure to Label and Date Food Items in Refrigerator
Penalty
Summary
The facility failed to ensure that food items in the Bayshore Dining Room Nourishment Refrigerator/Freezer were labeled and dated when opened. During an observation, several items were found undated, unlabeled, and opened, including bags of Tyson chicken tenders and Foster Farm popcorn chicken, a glass bottle of horseradish, two bottles of salsa, a bottle of Peppermint Califa creamer with a manufacturer expiration date, a Tupperware container with beef and rice, and slices of American cheese. Staff Z, the Dietary Manager, acknowledged that kitchen aids were responsible for checking the dates and temperatures of the nourishment fridges and discarding items without a date or that were expired. Staff B, the Director of Nursing Services, confirmed the expectation that all food in refrigerators and freezers should be dated and labeled immediately upon storage.
Facility Lacks Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time social worker, as required for facilities with more than 120 beds. During interviews, both the Social Services Director and the Social Services Assistant admitted they did not possess a bachelor's degree, which is a minimum qualification for the role. This deficiency was identified during a survey conducted on 07/09/2024, and it placed residents at risk for unmet psychosocial needs and a diminished quality of life. The lack of a qualified social worker was noted in relation to the coordination of PASRR and assessments, as well as the management of unnecessary psychotropic medications.
QA&A Committee Lacks Required Medical Director Attendance
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QA&A) committee that met at least quarterly and included the Medical Director or their designee, as required for conducting Quality Assurance and Performance Improvement (QAPI) activities. During an interview on 07/13/2024, the Administrator, Staff A, stated that the QA&A committee met monthly and included various department heads and the Medical Director. However, when asked to provide attendance records to confirm the Medical Director's participation in the past two quarters, Staff A was unable to locate them. An email sent by Staff A on 07/16/2024 included an attendance sheet for a meeting on 07/03/2024, which did not list the Medical Director as present. Further attempts to find attendance records showing the Medical Director's participation were unsuccessful, as confirmed by Staff A in a telephone interview on 07/17/2024.
Failure in Discharge Planning for Medical Equipment
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for three residents, resulting in the absence of necessary durable medical equipment (DME) at the time of their discharge. The facility's policy required a discharge summary to include a recapitulation of the resident's stay, a final summary of the resident's status, and a post-discharge plan of care. However, the facility did not ensure that the required medical equipment, such as shower chairs and benches, was ordered and available for Residents 144, 145, and 146, placing them at risk for accidents and injuries. Resident 144 was discharged without a bariatric raised toilet seat and shower bench, despite being assessed to need these items. Email communications revealed that the case manager had requested updates on the prescriptions for these items before and after the discharge, but they were not provided. Similarly, Resident 145 was discharged without a four-wheeled walker and other bathroom equipment, such as grab bars and a bath bench, which were identified as necessary. The case manager had requested a prescription for these items prior to discharge, but it was not coordinated. Resident 146 was also discharged without a shower chair, which was identified as necessary for their safe transition. Despite multiple email communications between the case manager and the Social Services Director (SSD) requesting a prescription for the shower chair, it was not obtained. The SSD acknowledged being aware of the requests but did not understand what a prescription for a shower chair entailed and did not seek clarification. As a result, the residents were discharged without the necessary equipment, and Resident 146 remained in need of a shower chair.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to inform a resident and/or their legal representative about the risks and benefits associated with the use of antipsychotic medications, specifically risperidone, and did not obtain informed consent before administering the medication. This deficiency was identified for one resident who was reviewed for unnecessary medications. The resident, who was admitted to the facility with severe cognitive impairment and no prior mental health diagnoses or psychotropic medication use, was prescribed risperidone for dementia with behaviors. However, the medication was administered on two occasions before informed consent was obtained. The Director of Nursing acknowledged that the facility's protocol requires staff to explain the risks and benefits of psychotropic medications and obtain informed consent before administration. Despite this protocol, the facility nurses administered risperidone to the resident on two separate days before the informed consent was documented. This oversight prevented the resident and/or their legal representative from making an informed decision regarding the medication and exercising their right to refuse it.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure grievances were properly initiated, logged, investigated, and resolved for six out of twelve residents reviewed. Resident 33 reported a lack of linens during a Resident Council meeting, but no entry was made in the grievance log, and the resident did not receive a response. Resident 10 filed a grievance about being called a liar and missing items, but there was no record of the grievance in the log, and the resident did not receive a response. Resident 29 reported missing blankets during a Resident Council meeting, but no entry was made in the grievance log, and the resident did not receive a follow-up. Resident 54 also reported missing blankets, with no corresponding entry in the grievance log. Resident 46 expressed concerns about call lights not being answered promptly and staffing issues, but their grievances were not logged or responded to. Resident 37 reported an incident involving another resident taking food from their tray, but the grievance was not logged, and staff failed to follow up. Staff members, including the Administrator and Activities Director, acknowledged the expectation of providing explanations to residents once a solution was found, but this was not consistently done. The facility's failure to address these grievances left residents feeling frustrated and powerless, impacting their quality of life.
Failure to Complete Timely PASRR Level II Evaluations
Penalty
Summary
The facility failed to ensure timely completion and referral for Pre-Admission Screening and Resident Review (PASRR) Level II evaluations for two residents, which is a requirement under federal regulations. Resident 37 was admitted as an exempted hospital discharge and was not reassessed for a Level II PASRR evaluation until 61 days after admission, despite remaining in the facility beyond the initially projected 30 days. As of 70 days post-admission, the Level II evaluation had still not been completed. Staff X, a Social Service Assistant, confirmed that the referral was only made after a new Level I PASRR was completed, indicating the need for a Level II evaluation. Resident 9, who was admitted with a diagnosis of paranoid personality disorder and suicidal ideations, also did not receive a timely Level II PASRR evaluation. The resident's medical record indicated a Level II referral was required due to a significant change, but no such evaluation was found in the chart. Both the Social Services Director and the Director of Nursing Services acknowledged the absence of the required Level II evaluation in Resident 9's records, despite the 2020 PASRR indicating its necessity.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that care plans were reviewed, revised, and accurately reflected the care needs of four residents. Resident 37, who was cognitively intact, had dental issues and was on supplemental oxygen and midodrine for hypotension, did not have a care plan addressing these needs. The Director of Nursing Services (DNS) acknowledged the absence of a dental care plan and a plan for hypotension management. Additionally, the resident's nutritional risk care plan lacked specific goals, and there was contradictory information regarding weight monitoring frequency. Resident 87, with severe cognitive impairment and sensory deficits, did not have care plans for communication or vision needs. The DNS confirmed that these care plans should have been developed. Furthermore, the resident's care plan included an inappropriate goal related to PASRR recommendations, which was not applicable as the resident had a level II PASRR evaluation. Resident 48, who was observed using oxygen, did not have this documented in their respiratory care plan. Staff acknowledged that the care plan should have been updated to reflect the use of oxygen. Resident 27, with hemiplegia and cognitive impairment, required 1:1 feeding assistance, but the care plan inaccurately stated supervision was needed. Staff confirmed that the care plan should have been updated to reflect the resident's need for feeding assistance.
Medication Management and Treatment Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice in medication management for four residents. For Resident 87, oxycodone was administered outside the prescribed parameters for pain levels, with instances of administration for pain levels lower than the ordered threshold. Staff D, the Resident Care Manager, confirmed these deviations from the physician's orders. Resident 37 experienced issues with the application of compression wraps and oxygen delivery. The facility nurses applied tubular gauze instead of the ordered compression wraps without obtaining a physician's order and inaccurately documented the application of the wraps. Additionally, oxygen was administered via an open face mask instead of the ordered nasal cannula, again without proper documentation or physician approval. Staff D acknowledged these discrepancies in treatment and documentation. Resident 13 received medications that should have been withheld due to low pulse readings, contrary to physician orders. The medications involved were furosemide, losartan, and metoprolol, all of which were administered despite the resident's pulse being below the specified threshold. Resident 27 was given miconazole powder, to which they were allergic, without a physician's order, leading to a rash and open area on the skin. The Director of Nursing confirmed that miconazole should not have been applied without an order and should not have been used on someone with a known allergy.
Failure to Assist with Grooming Leads to Matted Hair
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) related to grooming for Resident 20, who was moderately cognitively impaired and had impairments on one side of both upper and lower extremities. The resident required partial/moderate assistance with personal hygiene, including combing hair. Despite this need, the resident's hair was observed to be matted and tangled in clumps, which the resident reported as bothersome and affecting their self-esteem. The resident had repeatedly informed Certified Nursing Assistants (CNAs) about the issue, stating they were unable to brush their hair due to physical limitations. Staff members, including a CNA and a Licensed Practical Nurse (LPN) Unit Manager, acknowledged the unacceptable condition of the resident's hair upon observation.
Failure to Provide Podiatry Care for Resident
Penalty
Summary
The facility failed to provide necessary podiatry care and services for a resident, identified as Resident 27, who was reviewed for foot care. Resident 27 was admitted with diagnoses including hemiplegia, hemiparesis, diabetes, and an ulcer on the left heel. The resident was bed bound, required extensive assistance for ADLs, and was moderately cognitively impaired. An admission assessment noted the resident's toenails were thick and had a fungal-like appearance, and diabetic foot checks and nail care were scheduled as weekly tasks for nursing. However, observations revealed that the resident had long, uneven, thickened toenails, and the resident reported not receiving any foot care, including toenail cutting, since admission. Staff interviews revealed that any nurse could provide diabetic foot care, including nail cutting, and that part of the admission process involved assessing the resident's feet and notifying Social Services if a podiatrist referral was needed. Despite this, the Social Services Director confirmed that Resident 27 had not been seen by a podiatrist during the last two visits. The Unit Manager/LPN acknowledged that the resident should have been referred to a podiatrist and expressed discomfort in cutting the resident's nails due to their poor condition. This oversight placed the resident at risk for further skin impairment, discomfort, and a diminished quality of life.
Deficiencies in Nutritional and Fluid Management
Penalty
Summary
The facility failed to adequately address the nutritional needs of Resident 87, who experienced significant weight loss after admission. Despite a care plan aimed at preventing weight loss, the resident lost 7% of their body weight within a week and 12.2% within 30 days. Although a nurse's note acknowledged the weight loss and suggested re-weighing, no further assessment or intervention was documented until a month later. The Registered Dietician (RD) recommended specific dietary changes, including providing peanut butter and jelly sandwiches, but these recommendations were not implemented, as confirmed by the Director of Nursing. Additionally, the facility did not have an effective system to monitor and document fluid intake for Resident 37, who was on a fluid restriction due to heart failure. The care plan required a daily fluid intake limit, but there was no process to reconcile fluid intake from nursing and dietary sources to ensure adherence to the restriction. Staff recorded fluid intake but did not calculate the 24-hour total, leaving the resident's adherence to the fluid restriction unverified. This lack of documentation and monitoring was acknowledged by the Resident Care Manager.
Failure to Assess and Obtain Consent for Bedrail Use
Penalty
Summary
The facility failed to comprehensively assess the use of bedrails and obtain accurate and complete informed consent for a resident, identified as Resident 27, who was reviewed for accidents. Resident 27 was admitted with diagnoses including hemiplegia and hemiparesis due to a stroke, and an open wound on the right back wall. The resident was bed bound, required extensive assistance for Activities of Daily Living, and was moderately cognitively impaired. On observation, mobility rails were attached to the resident's bed, but the required Safety Device Data Collection, Evaluation, and Information form was not completed for the side rails, and the care plan did not include side rails. Staff D, a Unit Manager/LPN, confirmed that side rails needed to be on the care plan, have consent, and have the safety form completed.
Failure to Develop Comprehensive Dementia Care Plan
Penalty
Summary
The facility failed to develop a comprehensive dementia care plan for a resident diagnosed with non-Alzheimer's dementia, which resulted in unmet physical, mental, and psychosocial needs. The resident, who had severe cognitive impairment and displayed signs of delirium, was admitted to the facility after residing in a memory care unit. The care plan, revised on 06/21/2024, aimed to maintain the resident's current cognitive function and ability to communicate basic needs. However, it lacked specific information on how the resident's dementia manifested, such as triggers for stress or anxiety, and did not incorporate input from the resident's family. The resident's family reported that the resident enjoyed walking and experienced increased confusion and anxiety in the early evenings due to sundowning. Despite this, the facility's interdisciplinary team did not document any family input in developing a personalized dementia care plan with person-centered goals and interventions. This oversight placed the resident at risk for increased behaviors and decreased quality of life, as the care plan did not address the resident's specific needs or preferences.
Inappropriate Use of Antipsychotic Medication for a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drug use. Resident 87, who was admitted with severe cognitive impairment and a diagnosis of non-Alzheimer's dementia, was started on risperidone for dementia with behavior disturbances. However, there was no documentation to support that the resident experienced hallucinations, delusions, or aggressive behavior, which were listed as potential benefits of the medication. The care plan indicated the medication was initiated to treat target behaviors such as intrusively going into others' spaces, poor safety awareness, and placing self on the floor, but these were not adequately justified as indications for the use of antipsychotic medication. The report highlights that the facility did not consider the resident's prior routine of walking and pacing, which was a normal and enjoyed activity, especially related to sundowning. The Director of Nursing acknowledged that the diagnosis of dementia with behavioral disturbances and the identified target behaviors were not appropriate indications for the use of antipsychotic medication. This oversight placed the resident at risk of receiving unnecessary medications and experiencing adverse side effects.
Failure to Assist Residents with Meals in Dining Room
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for assistance with their Activities of Daily Living (ADLs) received the necessary help to eat their meals in the dining room. This deficiency was observed in two residents, both of whom had severe cognitive impairments and required staff assistance for eating. Resident 1, who had diagnoses including dementia and nutritional deficiency, was observed in bed during meal times instead of being assisted to the dining room as per their care plan. Despite having a care plan that emphasized the importance of dining room meals to promote intake, Resident 1 was assisted with meals in bed by a CNA, who stated that they wanted the resident to relax in bed that day. Similarly, Resident 2, who also had dementia and required total assistance for eating, was observed receiving meals in bed after being laid down for wound care. The CNA assisting Resident 2 indicated that they planned to get the resident up for dinner instead. Both residents' care plans specified that they should be in their wheelchairs and in the dining room for meals unless there was a clinical reason or refusal. The Director of Nursing confirmed that staff were expected to follow the care plans, and there was no clinical justification for the deviation observed.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer in a resident, identified as Resident 2, who was at risk for pressure ulcers. Despite having a care plan in place since 2017, which was revised in 2023, to educate caregivers on the causes of skin breakdown and the importance of repositioning, the facility did not consistently complete pressure ulcer care. Resident 2 developed an unstageable pressure ulcer on the right buttock, which required debridement. The care plan included interventions such as providing maximum assistance for turning and repositioning and checking and changing the resident after incontinence episodes. However, there was no documentation of the resident refusing care, and staff confirmed that the resident allowed care and did not resist repositioning. The facility's records showed that wound care was not documented as completed on two occasions in June 2024, due to time constraints and short staffing. The Treatment Administration Record and nursing progress notes indicated that wound care was deferred to the night shift, but there was no documentation that it was completed. The Director of Nursing confirmed the lack of documentation for wound care on these dates and could not explain why the resident acquired the pressure ulcer. This lack of consistent wound care documentation and follow-through contributed to the development of the pressure ulcer, placing the resident at risk for further complications.
Infection Control Breach During Wound Care
Penalty
Summary
Facility staff failed to adhere to proper infection control practices during wound care for a resident with an unstageable pressure injury. The resident, who was admitted with dementia and muscle weakness, developed a pressure injury on the right buttock that was not present upon admission. During an observation, a registered nurse, identified as Staff E, was seen providing wound care to this resident. Staff E donned gloves, removed the resident's brief and soiled dressing, and then changed gloves without performing hand hygiene. The nurse proceeded to cleanse the wound, apply medication, and place a new dressing. After removing the gloves, Staff E failed to perform hand hygiene before handling a pen from their pocket to write on the wound dressing. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing, revealed that the expected protocol was not followed. Both staff members confirmed that hand hygiene should be performed after removing soiled dressings and gloves, and before donning new gloves. Additionally, they stated that staff should not handle personal items, such as pens, without first washing their hands. The failure to follow these infection control practices placed residents at risk for healthcare-associated infections.
Failure to Perform Proper Hand Hygiene During Pressure Ulcer Care
Penalty
Summary
The staff failed to perform proper hand hygiene and change gloves when providing pressure ulcer care for three residents. For Resident 2, who had a stage 4 pressure ulcer on the right heel, the LPN removed the soiled dressing and then took a picture of the wound with the resident's cell phone without changing gloves or performing hand hygiene before applying a new dressing. Resident 2 had previously been hospitalized for an infection in the same wound, highlighting the importance of proper wound care practices. For Resident 3, who had a stage 3 pressure ulcer on the right heel, the LPN removed the soiled dressing and then washed the wound and applied a clean dressing without changing gloves or performing hand hygiene. Similarly, for Resident 4, who had a stage 2 pressure ulcer on the buttocks, the LPN removed the soiled dressing and then washed the wound and applied a clean dressing without changing gloves or performing hand hygiene. The Director of Nursing Services confirmed that the expected procedure was to remove gloves and perform hand hygiene before donning new gloves and applying a clean dressing.
Failure to Recognize Clinical Change of Condition
Penalty
Summary
The facility failed to recognize a clinical change of condition from the resident's baseline for a resident with medically complex conditions and mental health disorders. The resident was cognitively intact upon admission and had no signs of delirium. However, after being sent to the emergency room for a reported seizure and suspected stroke, the resident returned to the facility with signs of confusion and disorientation. Despite these changes, the facility did not adequately address the resident's fluctuating mental and physical status, leading to multiple emergency calls and erratic behavior, including calling 911 multiple times and being found in another resident's room. The resident expressed a desire to leave the facility and discharge to a motel, despite being alert but not fully oriented to person, place, and time. The Social Service Director and the Director of Nursing Services (DNS) assessed the resident and discussed the risks of discharging to a motel. Despite the resident's fluctuating mental status and the documentation of these changes in the medical record, the DNS and the Administrator allowed the resident to leave, believing the resident was within their rights to do so. The facility paid for a cab to take the resident to a motel, where the resident was later found in a distressed state by emergency responders. The facility staff, including the DNS and the Administrator, were not fully aware of the resident's documented mental status changes prior to the discharge. The DNS admitted to not having read the progress notes before the resident left, and the Administrator stated that if they had known about the fluctuating mental status, they would have summoned emergency responders. This lack of awareness and failure to recognize the clinical change of condition placed the resident at risk for unmet care needs and poor decision-making, ultimately leading to a diminished quality of life.
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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