Brookfield Health And Rehab Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Battle Ground, Washington.
- Location
- 510 North Parkway, Battle Ground, Washington 98604
- CMS Provider Number
- 505331
- Inspections on file
- 29
- Latest survey
- June 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Brookfield Health And Rehab Of Cascadia during CMS and state inspections, most recent first.
A resident with liver and kidney disease ingested another resident's 10mg Zyprexa after a nurse left the medication unattended on the cart. The resident became unresponsive, required ICU care, and was placed on a ventilator. Staff interviews confirmed that medications were supposed to be secured and not left unattended, but this protocol was not followed in this incident.
A resident with significant medical conditions ingested a 10 mg dose of Zyprexa that was not prescribed, became unresponsive, and required hospitalization with ventilator support. The facility did not report this medication error to the State Survey Agency as required, and key staff were either advised not to report or were unaware of the incident.
Three residents with moderate cognitive impairment or mobility issues were found with bed rails or beds placed against the wall without required assessments, physician orders, or informed consent. Staff confirmed that these steps were not completed, despite facility policy requiring them for the use of restraints and bedrails.
Three medication carts were found unlocked and unattended in two hallways, with drawers accessible and no staff present. Nursing staff confirmed that carts are required to be locked when not in use, but failed to do so during the survey.
A resident who was alert and oriented was admitted without a privacy curtain in her room, and multiple observations confirmed the curtain was missing. The resident expressed ongoing concerns about her privacy, especially when using a bed pan, and reported that her requests for a curtain had not been addressed. Staff were unaware of the missing curtain and acknowledged that one should have been installed.
A resident who was alert and oriented did not have a privacy curtain installed in her room since admission, despite requesting one. She was unable to close the door herself during personal care, and staff were unaware of the missing curtain until notified during the survey.
A resident with severe cognitive impairment experienced a fall despite fall risk precautions being in place. The facility's incident investigation lacked a root cause analysis and did not determine if further interventions were needed. The CNO acknowledged that the investigation should have addressed the root cause and ruled out abuse or neglect, but this was not done.
A resident with moderate cognitive impairment had a care plan stating the bed should be against the wall with a full side rail, but repeated observations showed the bed was not against the wall and only a quarter rail was present. The care plan was not updated to reflect these changes, and staff confirmed the care plan did not match the resident's current needs.
The facility did not consistently follow physician orders for two residents: one resident was not weighed weekly as ordered, with missed and incorrect documentation, and another resident's IV bags and tubing were not labeled with the required date, time, and nurse initials during antibiotic administration, as confirmed by staff and observations.
A resident's bed was found positioned against a wall with a baseboard heater, with linens touching the heater and a plastic tub nearby, despite clear markings and signage requiring a 12-inch clearance due to fire risk. Staff interviews revealed a lack of awareness and adherence to safety protocols, and the bed's placement blocked access to the heater's controls.
A resident with COPD and acute respiratory failure was observed receiving supplemental oxygen at various flow rates, but the facility failed to document oxygen use, SPO2 measurements without oxygen, and timely tubing changes in the EHR. Staff interviews confirmed that required documentation and weekly tubing changes were not completed according to physician orders and facility protocol.
Staff did not properly don PPE when entering the room of a resident on contact precautions for conjunctivitis. Despite clear signage and physician orders, two staff members entered the room and assisted the resident without gloves or gowns, believing PPE was only needed for personal care. This misunderstanding was shared by another LPN, while the Chief Nursing Officer stated that PPE should be worn at the door for all entries.
A resident who was alert and oriented did not receive a pneumococcal vaccine despite having provided consent and having a physician's order in place. The vaccine was not documented as administered, and staff confirmed it was missed because it was not entered on the MAR as required.
The facility failed to ensure residents were free from significant medication errors, as multiple residents did not receive medications and treatments as ordered, including missed doses, late administration, and incomplete wound care, pain monitoring, and behavioral assessments. Staff confirmed that blank spaces on the MAR and TAR indicated missed or incomplete tasks.
A resident with multiple health conditions required two-person assistance for bed mobility, as per their care plan. However, only one staff member assisted, leading to the resident falling and fracturing their femur. The incident required medical intervention, and the staff member involved was no longer employed at the facility.
A resident with multiple health conditions fell from their bed and was taken to the ER. The family was not notified until over five hours later, contrary to the facility's policy. The delay was due to an LPN's failure to inform the necessary parties promptly.
The facility failed to provide timely and complete SNF ABN and NOMNC notifications to three residents, risking inadequate information for financial decisions. Notices were either issued on the last covered day, incomplete, or missing, with staff acknowledging errors and confusion in documentation processes.
A resident with severe cognitive impairment was repeatedly observed with unkempt facial hair and a dirty beard, despite being assisted with showers. Staff acknowledged the resident was supposed to be shaved on shower days and did not often refuse care, indicating a failure in providing necessary grooming assistance.
The facility failed to ensure accurate documentation and communication of residents' code status, leading to discrepancies between POLST forms and physician orders. For several residents, the POLST indicated a DNR status, but room stickers suggested a Full Code status, causing confusion among staff about the appropriate response in emergencies.
The facility failed to follow physician orders for labeling IV and TF bags and tubing for a resident, and did not implement the bowel protocol for two residents experiencing constipation. Staff acknowledged the oversight in labeling and the lapse in following the prescribed bowel management orders.
Resident Harm from Unattended Medication Error
Penalty
Summary
A significant medication error occurred when a resident with liver cirrhosis and stage 3 kidney disease ingested a 10mg Zyprexa pill that was not prescribed to them. The medication, intended for another resident, was left unattended in a cup on top of the medication cart by a licensed nurse who had stepped away. The resident took the medication while at the cart for their own bedtime medications. Shortly after, the resident became unresponsive, began mumbling incoherently, and was transferred to the emergency room, where they required intensive care and mechanical ventilation for several days. Interviews with staff revealed that standard procedures required medications to be kept locked in the cart and not left unattended, and resident identification was to be verified before administration. However, in this incident, the medication was left accessible, and the nurse provided inconsistent accounts of the event. The facility's medication error report identified the root cause as the medication cup being left on the cart. The incident was not immediately communicated to the facility's CEO, and the resident's family was notified only after the resident was found unresponsive.
Failure to Report Serious Medication Error Resulting in Hospitalization
Penalty
Summary
The facility failed to report a significant medication error to the State Survey Agency as required. A resident with liver cirrhosis and stage 3 kidney disease, who was unable to participate in their assessment, ingested a 10 mg tablet of Zyprexa that was not prescribed to them while receiving medications at the medication cart. The resident subsequently became unresponsive and began to mumble incoherently, prompting the nurse to notify the physician, who ordered a transfer to the emergency room. The resident was hospitalized and required ventilator support in the intensive care unit for three days. The facility's incident log confirmed the event and documented that the state hotline was not notified. During interviews, the Interim DNS stated that regional staff advised the incident did not require reporting, so it was not reported. A newly appointed Interim DNS later stated that the medication error should have been reported, and the CEO was unaware of the incident. The failure to report the serious medication error delayed appropriate oversight and investigation.
Failure to Assess and Document Use of Bed Rails and Bed Placement as Restraints
Penalty
Summary
The facility failed to ensure that bed placement and the use of bed side rails were properly assessed, physician ordered, and accompanied by informed consent for three residents who were reviewed for physical restraints. Specifically, for one resident with moderate cognitive impairment, a quarter rail was observed on the bed during multiple observations, but there was no evaluation assessment, consent, or physician's order documented in the electronic health record. For another resident with hemiplegia and hemiparesis following a stroke, the bed was consistently observed with one side against the wall, yet there was no related assessment, consent, or physician's order. A third resident, also moderately cognitively impaired, was found with the bed against the wall and was unaware of the reason; again, no evaluation, consent, or physician's order was found in the record. Staff interviews confirmed that the expected process was not followed, as both the Resident Care Manager (LPN) and the Chief Nursing Officer (RN) acknowledged that evaluation assessments, consents, physician orders, and care plans should have been in place for the use of bed rails or beds placed against the wall. The facility's own policy requires these steps for the use of restraints and bedrails, including assessment, care planning, physician order, and informed consent, none of which were documented for the affected residents.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that three out of four medication carts on the 200 Hall and 300 Hall were left unlocked and unattended, allowing drawers to be opened without staff supervision. At the time of observation, no staff were present in the hallway, and the carts contained medications, including controlled substances. Staff members, including a Registered Nurse and an LPN, acknowledged that medication carts are supposed to be locked when unattended, confirming that the carts should not have been left unsecured. These findings were based on direct observation and staff interviews during the survey.
Failure to Provide Privacy Curtain for Resident
Penalty
Summary
A resident who was alert and oriented was admitted to the facility and, upon admission, did not have a privacy curtain installed in her room. Observations on multiple occasions confirmed the absence of a privacy curtain. The resident reported that she had been without a privacy curtain since admission and was unable to close the door herself when using a bed pan, resulting in concerns about her privacy for over two weeks. She stated that she had requested the installation of a privacy curtain, but it had not been addressed. Staff interviews revealed that both the Maintenance Manager and the Chief Nursing Officer were unaware of the missing privacy curtain and confirmed that a privacy curtain should have been installed for every resident prior to admission.
Failure to Provide Privacy Curtain for Resident
Penalty
Summary
The facility failed to maintain personal privacy for a resident by not having a privacy curtain installed in the resident's room. The resident, who was alert and oriented, reported that there had not been a privacy curtain since admission and that she was unable to close the door herself when using a bed pan, despite having requested the curtain be installed. Observations on multiple occasions confirmed the absence of a privacy curtain in the room. Both the Maintenance Manager and the Chief Nursing Officer were unaware of the missing curtain prior to being informed during the survey.
Failure to Conduct Thorough Post-Fall Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation following an incident involving a resident who was found fallen in their room, face down and with their head positioned between the bedside table and bed. The resident was identified as being severely cognitively impaired, and fall risk precautions such as a low bed and floor mat were in place, with the call light within reach at the time of the incident. Documentation of the incident investigation did not include a root cause analysis or indicate whether additional interventions were necessary. The Chief Nursing Officer confirmed that the investigation should have addressed the root cause of the fall and ruled out abuse or neglect, but this was not completed as required.
Failure to Update Care Plan to Reflect Current Bed Placement and Side Rail Use
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to accurately reflect current care needs. The resident, who was moderately cognitively impaired, had a care plan indicating the bed should be placed against the wall for increased living space and that a full side rail should be used for ease of mobility and transfers. However, multiple observations over several days showed that the resident's bed was not against the wall and only a quarter rail was present on the middle right side of the bed. The care plan did not document the use of a quarter rail, nor did it reflect the actual bed placement. Staff interviews confirmed that the care plan was outdated and did not match the resident's current environment or equipment in use. The Resident Care Manager and LPN acknowledged that the care plan was not updated to reflect the use of a quarter rail or the change in bed placement, and the Chief Nursing Officer stated that it was her expectation that care plans should be updated to reflect current care needs. This discrepancy was identified through observation, interview, and record review.
Failure to Follow Physician Orders for Weights and IV Labeling
Penalty
Summary
The facility failed to follow physician orders and care plans for two residents regarding weight monitoring and intravenous (IV) medication administration. For one resident with severe cognitive impairment, the care plan required weekly weights every Wednesday as ordered by the physician. However, electronic health records showed inconsistent documentation, including missed weights, incorrect entries, and a lack of follow-up when weights were recorded as incorrect. Staff interviews confirmed that weights were typically done monthly unless otherwise directed, and that incorrect weights should have been rechecked by the next day, which was not consistently done. For another resident with moderate cognitive impairment receiving IV antibiotics via a PICC line, physician orders and the care plan required that IV bags and tubing be labeled with the date, time, and nurse's initials, and that administration sets be changed every 24 hours. Observations on multiple occasions found empty IV bags and tubing hanging without the required labeling. Staff confirmed that labeling was expected per orders, but the required information was not present on the used IV sets and bags.
Bed and Linens Placed Against Baseboard Heater Creates Fire Hazard
Penalty
Summary
A deficiency was identified when a resident's bed was observed positioned against a wall with a baseboard heater, with bed linens hanging down and touching the heater. A plastic tub was also found under the bed near the heater. The area around the heater was marked with red tape indicating a 12-inch clearance zone, and a warning sign was posted stating that no items should be within 12 inches of the baseboard heater due to fire risk. The heater was off at the time of observation. The resident, who was moderately cognitively impaired, stated that the bed was not supposed to be against the wall and acknowledged the fire hazard, but noted the heater had not been on while the bed was in that position. Staff interviews revealed a lack of awareness and adherence to safety protocols regarding the required clearance around baseboard heaters. A housekeeper indicated that the bed blocked access to the heater's temperature control, and a LPN confirmed that regulations required beds to be a certain distance from heaters. Upon inspection, the LPN moved the bed away from the heater, acknowledging it should not have been placed there. The Chief Nursing Officer also confirmed that nothing should be within a 12-inch radius of the heater and that the bed placement was inappropriate.
Failure to Document and Manage Supplemental Oxygen Therapy
Penalty
Summary
The facility failed to ensure accurate documentation and proper management of supplemental oxygen therapy for a resident with chronic obstructive pulmonary disease and acute respiratory failure with hypoxia. Observations revealed that the resident was receiving oxygen via nasal cannula at varying flow rates, but the oxygen tubing was undated on multiple occasions, both in the resident's room and on a portable tank attached to the resident's wheelchair. Additionally, there was no documentation in the electronic medication or treatment administration records of the resident's supplemental oxygen use on the observed dates. The resident's electronic health record also lacked documentation of oxygen saturation (SPO2) measurements without oxygen and did not indicate that the oxygen tubing had been changed as required. Interviews with facility staff confirmed that the physician's order required supplemental oxygen to be administered if the resident's SPO2 was below 90, and that oxygen tubing should be changed weekly with corresponding documentation. Staff were unable to locate documentation of the resident's oxygen use, SPO2 assessments without oxygen, or evidence that the tubing had been changed according to protocol. The Chief Nursing Officer acknowledged that documentation of SPO2 assessment and effectiveness of oxygen therapy was not completed, and that the standard for changing oxygen tubing was not met.
Failure to Don PPE for Resident on Contact Precautions
Penalty
Summary
Staff failed to properly don personal protective equipment (PPE) when entering the room of a resident who was on contact precautions for conjunctivitis. The resident, who was severely cognitively impaired, had physician orders for contact isolation and was being treated with Ofloxacin Ophthalmic Solution for a bacterial eye infection. A sign was posted on the resident's door instructing staff to gown and glove at the door before entry. Despite these instructions, two staff members, a CNA and a Staffing Coordinator/CNA, entered the resident's room and assisted the resident in bed without wearing gloves or gowns. Upon interview, both staff members indicated they believed PPE was only required when performing personal care or handling urine, not for all room entry. Another staff member, an LPN, echoed this misunderstanding, stating PPE was only necessary when treating the specific problem. However, the Chief Nursing Officer clarified that staff were expected to don gloves and gowns at the door prior to entering the room for any resident on contact precautions. This discrepancy in understanding and practice led to the failure to implement proper infection prevention and control measures.
Failure to Administer Pneumococcal Vaccine After Consent and Order
Penalty
Summary
The facility failed to ensure that a pneumococcal vaccine was administered to one of five sampled residents reviewed for immunizations. The resident was admitted to the facility and was found to be alert and oriented, with documentation indicating that the pneumococcal vaccination was not up to date. The resident signed an acknowledgement form indicating receipt of the vaccine information sheet and consented to receive any needed vaccines. A physician's order was present, authorizing the administration of the pneumococcal vaccine if indicated. The electronic health record showed the vaccine status as pending, with consent confirmed by the infection preventionist. Despite the presence of consent and a physician's order, there was no documentation in the resident's record that the pneumococcal vaccine was administered. The infection preventionist confirmed that the vaccine had not been given and that it was not entered on the Medication Administration Record as required. The Chief Nursing Officer stated that the expectation was for vaccinations to be administered after obtaining orders and consents, but this process was not followed in this instance.
Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of medications at incorrect times and the omission of prescribed medications and treatments for all five sampled residents. For example, one resident with multiple sclerosis, sepsis, and osteomyelitis did not receive several medications, such as Tramadol, Vancomycin, and Ciprofloxacin, at the times ordered by the provider. Additionally, this resident missed multiple wound care treatments, skin inspections, hygiene care, weight monitoring, and other essential interventions as documented in the Medication Administration Record (MAR) and Treatment Administration Record (TAR). Another resident with an intracranial injury and paraplegia experienced omissions in the administration of catheter care, wound care, and education regarding anticoagulant therapy. Similarly, a resident with Parkinson's disease and a catatonic disorder did not receive several prescribed treatments, including hand splint application, edema monitoring, pain assessments, and specialty mattress checks. These omissions were consistently documented as blank spaces on the MAR and TAR, indicating that the tasks were incomplete or not performed. Further review revealed that residents with complex medical needs, such as those with multiple sclerosis, respiratory failure, hemiplegia, sepsis, and cellulitis, also experienced missed medication doses and treatments. These included failures to administer pain medications, perform wound care, monitor vital signs, and provide behavioral and psychotropic medication monitoring. Staff interviews confirmed that blank spaces on the MAR and TAR signified missed tasks or medications, and that the facility's policy allowed for a specific window of time for medication administration, which was not adhered to in these cases.
Failure to Provide Adequate Bed Mobility Assistance
Penalty
Summary
The facility failed to ensure that residents were free from avoidable accidents during bed mobility assistance, resulting in harm to a resident. The resident, who had a history of asthma, diabetes mellitus type 2, hypertension, and chronic heart failure, required maximum assistance for bed mobility as per their care plan. The care plan specifically indicated the need for two-person assistance for repositioning. However, on the night of the incident, only one staff member provided assistance, leading to the resident falling from the bed and sustaining a fractured femur. The incident occurred during personal care at approximately 2:00 AM, and the resulting injury required medical intervention. A hospital orthopedic surgery consult confirmed the femur fracture and discussed the limited options for treatment, focusing on comfort care due to the significant risks associated with surgery. The staff member involved in the incident was no longer employed at the facility following the failure to adhere to the care plan, which resulted in the resident's injury.
Failure to Notify Resident's Family of Significant Change
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative following a significant change in the resident's condition. Specifically, a resident with a history of asthma, diabetes mellitus type 2, hypertension, and chronic heart failure was involved in an incident where they fell from their bed and were subsequently transported to the emergency room. Despite the facility's policy requiring immediate notification of a resident's representative in such cases, the family was not informed until over five hours after the incident occurred. The incident took place at approximately 2:30 AM, and the family was not notified until 7:45 AM. The delay in communication was attributed to Staff C, an LPN, who was responsible for the resident's care at the time of the incident. The Director of Nursing Services confirmed that neither the administrator nor the family was informed in a timely manner, which was a breach of the facility's policy on resident change of condition.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to provide timely and complete notifications regarding Medicare coverage and potential liability for services not covered, specifically the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC). For three residents, the facility did not issue these notices at least two calendar days before the end of Medicare services, as required. Resident 33 received both the SNF ABN and NOMNC on the last covered day of services, and the SNF ABN was incomplete, lacking details on what Medicare may not pay for, the reason, estimated cost, and the resident's chosen option. Similarly, Resident 49's SNF ABN was undated and incomplete, and the NOMNC lacked a documented date. Resident 214 was not provided with a NOMNC at all. Staff G, the Social Service Director, acknowledged the errors, stating that the notices were not properly filled out or dated, and there was confusion about whether to keep original documents after scanning them into the Electronic Health Record. The Chief Executive Officer expected that SNF ABNs and NOMNCs be filled out completely, signed, and dated with at least two days' notice before non-coverage. The lack of proper documentation and timely notification placed residents at risk of not having adequate information to make informed financial decisions regarding their continued stay in the facility.
Failure to Provide Grooming Assistance for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide grooming assistance for a resident, identified as Resident 44, who was severely cognitively impaired. The resident was admitted to the facility and had an annual Minimum Data Set assessment indicating severe cognitive impairment. On multiple occasions, Resident 44 was observed with unkempt facial hair and a brown-colored substance on his face, despite being assisted out of the shower by a certified nursing assistant (CNA). The resident's son expressed concern about the resident's consistently dirty beard. Staff members, including a Resident Care Manager and a CNA, acknowledged that Resident 44 was supposed to be shaved on shower days and noted that the resident did not often refuse care. These observations and interviews indicate a failure to ensure proper grooming assistance, as required by the facility's care standards.
Discrepancies in Code Status Documentation and Communication
Penalty
Summary
The facility failed to ensure that policies and procedures were in place to accurately reflect residents' choices regarding their code status, leading to discrepancies in the documentation and communication of these preferences. For four residents, there were inconsistencies between the Physician Order for Life Sustaining Treatment (POLST) forms and the physician orders in the electronic health records (EHR). Specifically, Resident 10's POLST indicated a Do Not Resuscitate (DNR) status, while the physician order in the EHR showed a Full Code status. This discrepancy was not addressed by the staff, as evidenced by the heart sticker outside Resident 10's room, which incorrectly indicated a Full Code status. Similar issues were observed with Residents 8, 11, and 36, whose POLST forms indicated a DNR status, but the stickers outside their rooms suggested otherwise. Staff members, including the Chief Nursing Officer and other nursing staff, were unaware of these discrepancies and relied on the stickers to determine the residents' code status. This lack of accurate communication and documentation placed residents at risk for receiving care that was not aligned with their documented wishes.
Failure to Follow Physician Orders for IV/TF Labeling and Bowel Protocol
Penalty
Summary
The facility failed to adhere to physician's orders and care plans for labeling intravenous (IV) and tube feeding (TF) bags and tubing for a resident. The resident, who was moderately cognitively impaired, was receiving vancomycin IV and Jevity enteral nutrition. Despite physician orders requiring the labeling of IV and TF bags and tubing with date, time, and initials, observations on multiple occasions revealed that these items were not labeled. Staff members acknowledged the oversight, confirming that the labeling was necessary to ensure compliance with physician orders and care plans. Additionally, the facility did not follow the bowel protocol for two residents experiencing constipation. One resident did not have a bowel movement for five days, and the electronic medication administration record (EMAR) showed that PRN bowel medications were not administered as per physician orders. The orders included a sequence of administering Miralax, milk of magnesia (MOM), Dulcolax suppository, and Fleet enema if necessary, but this protocol was not initiated. Staff confirmed the protocol was not followed. For the second resident, the bowel management orders required MOM to be given if no bowel movement occurred for two days, followed by a Dulcolax suppository if there were no results within 24 hours. However, the Dulcolax suppository was administered four days after the MOM, not within the required 24-hour period. This failure to implement the bowel protocol as ordered by the physician was acknowledged by the staff, indicating a lapse in following the prescribed treatment plan.
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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