Bridge Crest Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Vancouver, Washington.
- Location
- 5220 Northeast Hazel Dell Avenue, Vancouver, Washington 98663
- CMS Provider Number
- 505341
- Inspections on file
- 29
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Bridge Crest Post Acute during CMS and state inspections, most recent first.
A resident with chronic heel ulcers and cognitive impairment did not receive consistent wound care as ordered, with missed assessments, lack of wound documentation, and incomplete or falsely documented treatments. Staff and family observed persistent foul odor and flies, and ultimately maggots were found in the resident's wound, requiring hospitalization and antibiotic treatment. Facility leadership acknowledged multiple missed opportunities in wound care and monitoring.
The facility did not complete required background checks before hiring a nurse, and failed to conduct reference checks for multiple staff, including nursing assistants and a social service assistant. Staff were allowed to begin work without these checks, contrary to policy, placing residents at risk for abuse, neglect, and exploitation.
Two certified nursing assistants were hired and began providing care without documented verification from the nurse aide registry, as required. Personnel files lacked evidence of completed OBRA registry checks at the time of hiring, resulting in unverified staff qualifications.
A resident with complex medical and behavioral needs was transferred to a hospital and not readmitted, but did not receive a written discharge notice as required by facility policy. Staff confirmed that the required notice was not provided at the time of discharge.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist as required.
A resident with diabetes and hemiplegia developed new pressure ulcers that were not promptly reported to the provider or treated according to facility policy. Nursing staff documented the wounds and applied dressings based on nursing judgment, but did not obtain wound care orders or document treatments on the TAR for 20 days. Staff interviews revealed confusion about responsibility for notification and documentation, resulting in delayed intervention and worsening of the wounds.
A resident received an incorrect dosage of a blood thinner due to a transcription error, leading to hospitalization and a blood transfusion. The error was not caught by multiple staff members, including medical records, pharmacy, and nursing staff, resulting in the resident receiving ten times the prescribed amount on two occasions.
A resident with Chronic Myelomonocytic Leukemia experienced a delay in lab services due to missed and unnoted orders, leading to a critically elevated white blood cell count. Inconsistent staff responsibilities and communication contributed to the deficiency, resulting in the resident being sent to the emergency department.
The facility did not provide the required eight hours of RN supervision on three occasions, as revealed by staffing records and interviews. The Staffing Coordinator acknowledged the lack of 24-hour RN coverage, and the DON confirmed recruitment efforts and plans to submit a staffing exception.
The facility failed to conduct monthly Medication Regimen Reviews (MRR) for four residents, placing them at risk for medication-related issues. The residents were taking multiple medications, including antipsychotics and anticoagulants. The Director of Nursing acknowledged the oversight, noting that no MRRs had been conducted since April.
The facility failed to obtain timely consent for psychotropic medications for two residents. One resident with schizophrenia was prescribed Olanzapine and Clonazepam without proper consent, while another resident with dementia and depression received Seroquel and Sertraline without timely consent. Staff acknowledged that consents should have been completed prior to medication administration.
The facility failed to assist two residents with completing advance directives (ADs) and maintaining Durable Power of Attorney (DPOA) documentation. One resident was moderately cognitively impaired, and the other was alert and oriented, yet neither had an AD or documentation that an AD was addressed in their electronic health records. The facility's policy required assistance during admission, but this was not followed, as confirmed by the Social Services Director and Administrator.
A facility failed to ensure the confidentiality of a resident's medical information when a podiatrist left a progress note visible on a cart in the hallway. A registered nurse acknowledged the breach and turned the note over, while the administrator confirmed that such information should not be visible.
A facility failed to ensure a resident was free from physical restraints by placing their bed against the wall without obtaining consent. The resident, who was severely cognitively impaired, had their bed positioned this way as a fall risk intervention, but no consent was documented. The DON confirmed that consent should have been obtained.
A facility failed to provide a written Bed Hold Notice to a resident or their representative during a hospital transfer, as required by policy. The resident, who was moderately cognitively impaired, was transferred emergently, and there was no documentation of the notice being given. The DON confirmed the lack of documentation.
A resident with an indwelling urinary catheter did not have a comprehensive care plan documented in their electronic health record. Despite being alert and oriented, and having the catheter observed over several days, staff interviews revealed a lack of documentation and awareness of the resident's catheter care needs. The Resident Care Manager and Director of Nursing acknowledged the oversight, indicating a failure to adhere to facility policies.
A facility failed to update a resident's EHR to reflect their DNAR status as per the POLST form, leading to conflicting CPR orders. Staff relied on the EHR for CPR status, which was incorrect, as confirmed by a review of the POLST form and physician notes.
The facility failed to perform neurological assessments for a resident after unwitnessed falls and did not initiate bowel protocols for several residents who experienced extended periods without bowel movements. Despite having physician orders for bowel interventions, these were not administered, and there was a lack of documentation. Staff acknowledged the deficiencies in following the facility's policies.
A facility failed to obtain physician orders for a urinary catheter for a resident, as required by their policy. The resident was observed with a foley catheter, but their Electronic Health Record lacked the necessary physician's order. Staff interviews confirmed that such orders are expected to include details like catheter size and care instructions, but none were found for this resident.
A facility failed to address a resident's weight loss, risking inadequate nutrition. The resident's care plan included monitoring weight and notifying the provider of changes, but significant weight fluctuations were not reported. Staff involved acknowledged the procedure for weight loss notification, but no record of provider notification was found.
The facility did not update nurse staffing postings daily for four days, as required. Observations showed that postings from 09/07/2024 to 10/07/2024 were not updated, displaying outdated information on 10/07/2024 and 10/08/2024. Interviews with staff revealed that the overnight charge nurse was responsible for updating the postings, but this was not done, risking uninformed residents and visitors.
The facility failed to monitor targeted behaviors for a resident on psychotropic medications and did not conduct AIMS tests for two residents prescribed antipsychotics. Staff confirmed that monitoring and testing were expected but not documented.
The facility did not properly monitor medication refrigerator temperatures in the West Hall and TCU. Temperature logs were missing for several days in the West Hall, and no log was found in the TCU. Staff indicated that night shift was responsible for temperature checks, but the Director of Nursing confirmed the logs were not up to date.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling devices and wounds, as well as proper PPE protocols. A resident with a urinary catheter and another with a feeding tube lacked EBP signage and PPE at their room entrances. An LPN did not wear a gown during wound care for a resident with a pressure ulcer. Additionally, a podiatrist did not change PPE between rooms with different precautionary requirements, despite facility protocols.
The facility did not document the offer, education, or consent for Pneumococcal, Influenza, and COVID-19 vaccines for a resident, as required by their policy. The resident's electronic health record lacked information on immunization status, and the Infection Preventionist and LPN could not provide consent forms. The administrator confirmed the expectation for vaccination per policy.
A resident expressed concern about a loose bed rail, which was confirmed by staff to have significant movement, posing a risk of entrapment. The facility failed to conduct routine inspections, and although procedures existed for reporting issues, the bed rail remained loose.
Failure to Provide Consistent Wound Care and Monitoring Resulting in Maggot Infestation
Penalty
Summary
The facility failed to consistently assess, monitor, and provide wound care treatments as ordered for a resident with existing pressure ulcers. Upon admission, the resident had chronic ulcers on both heels, osteomyelitis, and vascular dementia, and was cognitively impaired. The initial skin assessment documented the presence of pressure wounds, but there was no evidence that wound photographs or measurements were taken during the resident's stay, despite facility policy requiring such documentation. Nursing staff did not consistently complete or document daily wound care treatments as ordered by the physician, with several days lacking signatures or indicating refusals without further follow-up. Multiple staff interviews and record reviews revealed that wound dressings were frequently soaked, malodorous, and not changed as required. Staff reported that nurses on certain shifts did not have access to the camera for wound documentation, and that wound care was sometimes signed off as completed by one nurse but not actually performed. The resident's family and therapy staff noted a persistent foul odor and the presence of flies in the resident's room. On one occasion, a nurse signed off on all treatments for a medication cart but did not perform them, expecting other nurses to complete the tasks, which did not occur. The resident's condition deteriorated, and maggots were discovered in the left heel wound during a dressing change, prompting immediate hospitalization. Hospital records confirmed the presence of maggots and noted that the wounds appeared uncared for, with necrotic tissue and excessive drainage. The resident required removal of maggots and antibiotic treatment for the infected wounds. Facility leadership acknowledged missed opportunities for wound evaluation, daily rounding, and ensuring that wound care standards were upheld during the resident's transition and stay.
Failure to Complete Background and Reference Checks Prior to Staff Hire
Penalty
Summary
The facility failed to implement its abuse prohibition policy and procedures by not ensuring that required background checks and reference checks were completed prior to the hire dates for several staff members. Specifically, one licensed nurse was hired and began working before a background check was conducted, and five staff members, including nursing assistants, a social service assistant, and a staffing coordinator, were hired without evidence of reference checks being completed beforehand. The facility's policy requires background checks to be conducted and prohibits the employment of individuals with findings of abuse, neglect, exploitation, or related disciplinary actions. Record reviews confirmed the absence of background and reference checks in the personnel files of the affected staff. Interviews with the Human Resource Director and the Administrator confirmed that staff were allowed to begin work prior to the completion of these checks, contrary to facility policy and regulatory requirements. This lapse in procedure placed residents at risk for abuse, neglect, exploitation, and misappropriation of property.
Failure to Verify Nurse Aide Registry Status Prior to Employment
Penalty
Summary
The facility failed to ensure that nursing assistants were properly screened through the nurse aide registry (OBRA) prior to providing care to residents. Specifically, two certified nursing assistants were hired without documentation in their personnel files confirming that OBRA registry checks had been completed. This was confirmed through both interview and record review, which revealed that the required registry verification was missing for both staff members at the time of their hiring. The absence of these checks meant that the facility did not verify whether the nursing assistants were qualified and eligible to provide care before they began working with residents.
Failure to Provide Written Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of discharge for one resident who was reviewed for transfer and discharge requirements. According to the facility's policy, a written notice of transfer or discharge must be given 30 days prior to the event unless there is an immediate threat to health or safety. Record review and staff interviews confirmed that no written discharge notice was provided to the resident at the time of discharge. The Social Service Director acknowledged that a written notice was not given. The resident involved was cognitively intact, able to make her own decisions, and required moderate assistance with activities of daily living. She had ongoing and active substance use, including nicotine, methamphetamines, and methadone, which led to complex and unstable medical conditions. The resident exhibited behaviors such as leaving the facility and returning in a compromised state, declining care, and inconsistent eating, resulting in medical interventions for diabetes-related events. The facility determined that her needs exceeded their capacity and arranged for her transfer to a hospital, after which she was not readmitted. The lack of written discharge notice was confirmed through interviews with facility staff and collateral contacts.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Address and Treat New Pressure Ulcers
Penalty
Summary
The facility failed to address a newly developed pressure ulcer for a resident with significant medical conditions, including diabetes with polyneuropathy and hemiplegia following a stroke. The resident required substantial assistance with activities of daily living and repositioning. On discovery of open wounds and areas of concern on the resident's right buttock and heel, nursing staff documented the findings and applied dressings per nursing judgment, but did not notify the provider, obtain wound treatment orders, or document the interventions on the Treatment Administration Record (TAR) as required by facility policy. No progress notes or physician orders for wound care or pressure reduction modalities were entered for 20 days after the wounds were first identified. Multiple staff interviews revealed confusion and lack of clarity regarding responsibility for provider notification, order acquisition, and documentation. Some staff believed it was the responsibility of the wound nurse or Resident Care Manager, while others stated it was the responsibility of the nurse who identified the wound. The delay in obtaining appropriate wound care orders and implementing pressure reduction interventions resulted in the deterioration of the resident's wounds, with the wounds becoming unstageable by the time they were properly assessed and treated.
Significant Medication Error Due to Incorrect Dosage Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the case of a resident who received an incorrect dosage of a blood thinner medication. The resident, who had been admitted with diagnoses including hemiplegia and transient ischemic attack, was prescribed Enoxaparin 30 mg/0.3 ml to be administered subcutaneously once daily. However, due to an error in transcribing the hospital discharge orders, the medication administration record incorrectly indicated a dosage of 300 mg/3 ml, leading to the resident receiving ten times the prescribed amount on two consecutive days. This error resulted in the resident developing multiple hematomas and requiring hospitalization and a blood transfusion. The error occurred due to multiple oversights in the medication administration process. The Director of Nursing Services acknowledged that the error was missed by several staff members, including medical records personnel, the pharmacy, and the nurses responsible for administering the medication. The medical records staff member who entered the orders was not familiar with the correct dosage of Lovenox and did not flag the discrepancy for further review. Additionally, a Licensed Practical Nurse admitted to activating all orders without thoroughly checking them due to being busy, and the Resident Care Manager, who was still in training, did not review the orders until after the error was discovered.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide timely laboratory services for a resident who was readmitted with Chronic Myelomonocytic Leukemia, a condition characterized by an overproduction of white blood cells. Hospital discharge orders required a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) to be completed by a specific date, but these were not noted or completed as required. Subsequent physician orders for lab draws were inconsistently followed, with some lab results missing from the resident's medical record. A critically elevated white blood cell count was eventually identified, but the necessary repeat analysis was not ordered promptly. The deficiency was further compounded by unclear processes and responsibilities among staff for implementing and overseeing lab orders. Interviews with staff revealed inconsistencies in who was responsible for entering and verifying lab orders, as well as ensuring their completion. Despite discussions in clinical meetings about missed labs, the orders were not consistently followed through, leading to a delay in identifying the resident's critically elevated white blood cell count. This delay resulted in the resident being sent to the emergency department with increased swelling and discomfort, and the resident did not return to the facility.
Failure to Provide Required RN Supervision
Penalty
Summary
The facility failed to provide at least eight hours of Registered Nurse (RN) supervision for three out of thirty days, specifically on 09/29/2024, 10/05/2024, and 10/06/2024. This deficiency was identified through interviews and record reviews, which included the Aging and Long-Term Support Administration (ALTSA) Staffing Pattern and the facility's Daily Nurse Staffing Forms. These documents revealed that there was no RN on duty for all three shifts (day, evening, and night) on the specified dates. During an interview on 10/11/2024, the Staffing Coordinator, Staff T, acknowledged that the facility did not always have 24-hour RN coverage and mentioned ongoing recruitment efforts. Additionally, the Director of Nursing Services, Staff B, confirmed attempts to recruit RNs using online hiring services and indicated plans to submit an exception for staffing.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed a monthly Medication Regimen Review (MRR) for four out of five sampled residents. This deficiency was identified during interviews and record reviews, which revealed that the facility did not conduct monthly pharmacy MRRs for the months of June, July, August, September, and October 2024. The absence of these reviews placed residents at risk for delays in necessary medication changes, adverse side effects, and receiving medications without the required pharmacist oversight. The residents involved were alert and oriented, and were taking multiple medications, including antipsychotics, antidepressants, hypnotics, anticoagulants, diuretics, opioids, antianxiety medications, and hypoglycemics. The Director of Nursing Services acknowledged the oversight, stating that the facility had not received any monthly pharmacy MRRs since April 2024. This lapse in procedure was a direct violation of the facility's policies and procedures, as well as regulatory requirements.
Failure to Obtain Timely Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed and provided consent before administering psychotropic medications. This deficiency was identified for two residents. Resident 41, who was diagnosed with schizophrenia, was prescribed Olanzapine and Clonazepam. The consent for Olanzapine was obtained 47 days after the medication was started, and there was no documented consent for Clonazepam. Staff E, a Resident Care Manager and RN, acknowledged that consents should have been completed prior to starting these medications. Similarly, Resident 3, who had diagnoses of dementia and depression, was prescribed Seroquel and Sertraline. The consent for these medications was signed 22 days after they were initiated. Staff B, the Director of Nursing Services, confirmed that it was her expectation that consents should have been obtained on the day the orders were initiated. This oversight placed residents at risk of not being fully informed of the risks and benefits before making decisions about their medications.
Failure to Address Advance Directives for Two Residents
Penalty
Summary
The facility failed to have procedures in place to assist residents with completing advance directives (ADs) and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for two residents. Resident 3, who was moderately cognitively impaired, was admitted to the facility, and their electronic health record (EHR) did not show an AD or documentation that an AD was addressed since admission. Similarly, Resident 9, who was alert and oriented, also did not have an AD or documentation that an AD was addressed in their EHR since admission. The facility's policy on advance directives, dated August 1, 2018, indicated that assistance would be provided during the admission process if a resident wished to formulate an AD. However, the facility did not adhere to this policy. Staff X, the Social Services Director, stated that ADs were addressed during the initial admission care conference and a few days later, but typically only documented if residents declined. The Administrator, Staff A, confirmed that it was her expectation to address ADs per facility policy but was unable to provide further documentation of ADs being addressed for the two residents.
Failure to Maintain Resident Medical Information Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' medical information, specifically for Resident 258. During an observation, Staff S, a podiatrist, was seen providing care to Resident 258 in their room. However, Staff S left multiple papers on a cart in the hallway, with the top paper being a Podiatric Progress Note that displayed Resident 258's medical information. This information was visible to anyone passing by in the hallway. Staff R, a registered nurse, acknowledged that resident information should not be visible and turned the progress note over to conceal it. Staff A, the administrator, also confirmed that resident medical information should not be visible to others and should be turned over to maintain confidentiality.
Failure to Obtain Consent for Bed Placement as Restraint
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints, as evidenced by the case of Resident 38. Resident 38, who was admitted to the facility and assessed as severely cognitively impaired, was found to have their bed placed against the wall with a floor mat on the side not against the wall. This setup was intended as a fall risk intervention, as Resident 38 had previously attempted to get out of bed and fallen. However, there was no consent found in the electronic health records for the bed being placed against the wall, which is considered a form of restraint. The Director of Nursing Services confirmed that consent would typically be obtained for such an arrangement.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a written Bed Hold Notice to a resident or their representative at the time of transfer to a hospital, as required by their policy. This deficiency was identified during a review of the facility's records and interviews with staff. The facility's Bed Hold Policy mandates that residents or their representatives be informed in writing about the bed hold policy upon admission, transfer, or leave of absence, and if not possible at the time of transfer, within 24 hours. However, for a resident who was moderately cognitively impaired and transferred emergently to an acute care hospital, there was no documentation of a Bed Hold Notice being provided. The Director of Nursing Services confirmed the absence of such documentation.
Failure to Develop Care Plan for Resident with Urinary Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an indwelling urinary catheter, which was necessary to address the resident's care needs. Resident 28, who was alert and oriented, was admitted and readmitted to the facility with a foley catheter. Despite this, the resident's electronic health record did not document a care plan for the catheter. Observations over several days confirmed the presence of the catheter, yet no care plan was in place. Staff interviews revealed a lack of awareness and documentation regarding the resident's catheter care needs. A Certified Nursing Assistant indicated that care needs are typically communicated through the Kardex and care plan, but the care plan for the catheter was missing. The Resident Care Manager and RN acknowledged the absence of the care plan, stating it should have been included. The Director of Nursing Services also confirmed that it was expected for care plans to address residents with foley catheters, highlighting a gap in the facility's adherence to its own policies.
Discrepancy in CPR Orders and POLST Form
Penalty
Summary
The facility failed to ensure that the physician's orders in the Electronic Health Record (EHR) accurately reflected a resident's wishes for Cardiopulmonary Resuscitation (CPR) status as documented in the Physician Orders for Life Sustaining Treatment (POLST) form. This discrepancy was identified for a resident who was alert and oriented, and whose POLST form clearly indicated a Do Not Attempt Resuscitation (DNAR) status. However, the EHR contained conflicting orders to attempt CPR, which was inconsistent with the resident's documented wishes and the physician's progress notes that confirmed a DNAR status. Staff interviews revealed that registered nurses relied on the EHR to determine a resident's CPR status. The error was discovered when a Resident Care Manager reviewed the POLST form and found it contradicted the EHR orders. The Director of Nursing Service acknowledged that the physician orders should have matched the POLST form, highlighting a failure in the facility's process to ensure that residents' advance directives were accurately reflected in their medical records.
Failure to Conduct Neurological Assessments and Initiate Bowel Protocols
Penalty
Summary
The facility failed to conduct ongoing neurological assessments for a resident after experiencing multiple unwitnessed falls. Resident 38, who was severely cognitively impaired, had several unwitnessed falls over a period of time, yet no neurological assessments were documented in the electronic health record (EHR) or fall investigations. The Director of Nursing Services confirmed that neurological assessments should be initiated and completed after such incidents, and any refusal by the resident should be documented. Additionally, the facility did not adhere to its bowel management policy for several residents. Resident 10, who was alert and oriented, went over 96 hours without a bowel movement, yet the prescribed bowel protocol was not initiated. Similarly, Resident 11 experienced significant delays between bowel movements on two occasions, with no initiation of the bowel protocol as per physician orders. The facility's records showed a lack of documentation and administration of necessary bowel interventions. Residents 28 and 41 also experienced extended periods without bowel movements, with no documentation of bowel interventions being initiated. Despite having physician orders for PRN constipation medications, these were not administered, and there was no record of refusals. Staff members acknowledged the lack of documentation and administration of bowel protocols, which should have been initiated after three days without a bowel movement.
Failure to Obtain Physician Orders for Urinary Catheter
Penalty
Summary
The facility failed to obtain physician orders for a urinary catheter for Resident 28, who was one of the two sampled residents reviewed for urinary catheter use. Resident 28 was admitted and readmitted to the facility with an indwelling catheter, as documented in the Medicare - 5 day Minimum Data Set assessment. However, a review of Resident 28's Electronic Health Record revealed the absence of a physician's order for the indwelling foley catheter, which is necessary to ensure proper catheter care and management. Observations over several days confirmed that Resident 28 had a foley catheter bag hanging on the left side of the bed frame. Interviews with facility staff, including a Licensed Practical Nurse, a Resident Care Manager and Registered Nurse, and the Director of Nursing Services, revealed that it was the facility's expectation and policy that residents with foley catheters should have physician orders detailing catheter size, care instructions, and other relevant details. The absence of such orders for Resident 28's catheter was acknowledged by the staff, indicating a lapse in following the facility's policy and procedures.
Failure to Address Resident's Weight Loss
Penalty
Summary
The facility failed to identify and address weight loss for one resident, placing them at risk for inadequate nutrition and diminished quality of life. Resident 3 was admitted to the facility and was alert and oriented according to the Admission Minimum Data Set assessment. The resident's nutrition care plan aimed to maintain adequate nutritional status through stable weight, with interventions including obtaining weights as ordered and reporting significant changes to the physician and responsible party. However, the electronic health record showed fluctuating weights for the resident, with significant weight loss not being reported to the provider. Staff I, a Resident Care Manager and LPN, stated that they would notify the dietician and provider if a resident was losing weight, but Staff B, the Director of Nursing Services and RN, could not find any provider notification of the resident's weight loss in the EHR.
Failure to Update Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that nursing hours were accurately posted daily for four out of thirty days reviewed. This deficiency was identified through observation, interview, and record review. Specifically, the nurse staff postings from 09/07/2024 to 10/07/2024 were examined, and it was found that on 10/07/2024 and 10/08/2024, the postings still displayed the date 10/04/2024 with a census of 67. Interviews with Staff T, the Staffing Coordinator, and Staff B, the Director of Nursing Services, revealed that the overnight charge nurse was responsible for updating the postings over the weekend, but this was not done. This failure placed residents, their representatives, and visitors at risk of not being fully informed about the current staffing levels and census, as the postings were not updated as required.
Failure to Monitor Psychotropic Medication Use and Conduct AIMS Tests
Penalty
Summary
The facility failed to monitor targeted behaviors for a resident who was prescribed psychotropic medications, which is necessary to evaluate the effectiveness and necessity of such medications. Resident 3, who was diagnosed with dementia and depression, was not monitored for targeted behaviors as expected by the facility's protocol. The Director of Nursing Services confirmed that residents should be monitored every shift for behaviors related to psychotropic medication use, but this was not documented in Resident 3's electronic health record. Additionally, the facility did not complete the Abnormal Involuntary Movement Scale (AIMS) test for two residents who were prescribed antipsychotic medications. Resident 3 was prescribed Seroquel and Sertraline, and Resident 41 was prescribed Olanzapine, yet there was no record of an AIMS test being conducted for either resident. Staff members acknowledged that an AIMS test should be completed upon admission and when a new antipsychotic medication is started, but this was not done, as confirmed by the Director of Nursing Services and the Resident Care Manager.
Failure to Monitor Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure proper monitoring of medication refrigerator temperatures in two sampled units, the West Hall and the Transitional Care Unit (TCU). On October 9, 2024, it was observed that the temperature log for the medication refrigerator in the West Hall medication room was missing entries for October 3, 4, and 5, 2024. Additionally, on October 10, 2024, the medication refrigerator in the TCU medication room was found without a temperature monitoring log, and Staff K, an LPN, was unable to locate it. Staff K mentioned that the night shift was responsible for checking the refrigerator temperatures. On October 11, 2024, Staff B, the Director of Nursing Services, confirmed that it was expected for refrigerator temperatures to be checked twice daily, but acknowledged that the temperature log for the West Hall medication room was not up to date.
Failure to Implement Enhanced Barrier Precautions and Proper PPE Use
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents who required them due to their medical conditions. Resident 28, who had an indwelling urinary catheter, was observed multiple times without EBP signage or personal protective equipment (PPE) at the entrance of their room. Similarly, Resident 13, who had a feeding tube, also lacked EBP signage and PPE at their room entrance during several observations. Staff C, the Infection Preventionist, acknowledged that EBP had not been implemented in the facility, despite the residents' needs. Resident 107, who was being treated for a Stage 3 pressure ulcer, also did not have EBP signage or PPE at their room entrance. During wound care, Staff U, an LPN, failed to wear a gown, which is a requirement under EBP for wound care. Staff U later admitted to forgetting to wear a gown during the procedure. The Director of Nursing Services expected that residents requiring EBP, such as Residents 28 and 13, would be placed on precautions, but this was not the case. Additionally, the facility failed to ensure proper donning and doffing of PPE by staff. Staff S, a podiatrist, was observed wearing the same gown and respirator while moving between rooms with different precautionary requirements, without changing PPE as indicated by the signage. Staff C and the Administrator confirmed that staff should follow the signage instructions for PPE use, but Staff S did not adhere to these protocols, potentially compromising infection control measures.
Failure to Document Vaccine Education and Consent
Penalty
Summary
The facility failed to ensure that residents were offered, educated, and provided with the risks and benefits of Pneumococcal, Influenza, and COVID-19 vaccines, as evidenced by the case of one resident. The facility's policy, revised in February 2022, required that the risks and benefits of vaccines be reviewed with residents or their representatives, and that vaccine declinations and reasons be recorded in the resident's medical record. However, for Resident 15, who was alert and oriented upon admission, there was no documentation in the electronic health record regarding their immunization status or any offer or education about the vaccines. Staff C, the Infection Preventionist and LPN, acknowledged the absence of consent forms for Resident 15, despite the expectation that such documentation should exist. The facility administrator also confirmed the expectation that residents be vaccinated according to the facility's policies.
Failure to Inspect and Maintain Bed Rails
Penalty
Summary
The facility failed to conduct routine inspections of beds and bed rails, leading to a deficiency involving a resident's bed. Resident 106, who was alert and oriented, expressed concern about the looseness of their bed rail, which they initially felt made them feel safe. Upon inspection, the bed rail was found to have six to eight inches of movement, indicating it was loose. Staff L, a Resident Care Manager and LPN, confirmed the looseness of the bed rail. Staff B, the Director of Nursing Services and RN, mentioned that nurses were aware of the procedure to report bed rail issues through the TELLS system, and some nurses knew how to tighten them. Staff Q, the Maintenance Director, also confirmed the looseness and noted that the gap exceeded the entrapment zone, posing a risk of entrapment and injury.
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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