Canterbury House
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, Washington.
- Location
- 502 29th Street Southeast, Auburn, Washington 98002
- CMS Provider Number
- 505344
- Inspections on file
- 31
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Canterbury House during CMS and state inspections, most recent first.
The facility failed to implement its abuse and neglect policies, leading to inadequate investigations and reporting of incidents involving several residents. A resident's allegation of sexual abuse was not promptly reported to the police, and incidents of crawling out of bed were not properly assessed or logged. Additionally, staff failed to follow care plans, and investigations into verbal abuse and inappropriate care were incomplete, placing residents at risk for further harm.
The facility failed to ensure residents were free from unnecessary psychotropic medications due to inadequate documentation and monitoring of behaviors, and lack of non-pharmacological interventions. Residents were prescribed psychotropic medications without proper documentation of behaviors or effectiveness of interventions, and medications were extended without documented rationale. Staff interviews revealed a lack of adherence to facility policies regarding behavior monitoring and medication administration.
The facility failed to obtain informed consent for psychotropic medications and devices for three residents. A resident with severe decision-making impairments received an antipsychotic and increased antidepressant dosage without consent from their collateral contact (CC). Additionally, several devices were used without consent. Another resident under hospice care and a resident who could communicate also received medications without documented consent. The Director of Nursing confirmed that consent should have been obtained and documented.
A resident with severe cognitive impairment and multiple diagnoses, including pressure ulcers, experienced a significant injury of unknown origin when a large hematoma on their right calf was not promptly assessed or treated by the facility. Despite an order for an immediate ultrasound, the facility delayed action, leading to the resident requiring surgical intervention and a blood transfusion. The facility failed to follow its policies for skin assessment and notification, and did not report the injury to the state agency or investigate potential abuse or neglect in a timely manner.
A facility failed to complete and incorporate a PASRR Level II evaluation into the care plan for a resident with complex medical diagnoses, including a psychotic disorder. Despite a notification indicating a significant change in behavioral health, no Level II referral or recommendations were documented. The Divisional Director of Social Services confirmed the oversight.
The facility failed to ensure accurate PASRR assessments for several residents, leading to missed mental health indicators and necessary evaluations. A resident's PASRR did not reflect PTSD and bipolar disorder diagnoses, while another's did not require a Level II Evaluation despite severe conditions. Incomplete PASRRs for other residents also missed significant mental health diagnoses, preventing necessary assessments.
The facility failed to develop and implement comprehensive care plans for several residents, leading to potential risks for unmet care needs. A resident's care plan lacked specific goals, another's did not address mobility needs, and others were outdated or missing crucial interventions. Observations showed care plans were not consistently followed, with staff unaware of directives, resulting in inadequate care.
The facility failed to update care plans for several residents, including one whose PICC line was discontinued and another requiring oxygen therapy without specified details. Additionally, care conferences lacked participation from the Interdisciplinary Team (IDT), with residents not receiving prior notice or having overdue conferences. Staff interviews confirmed these deficiencies.
The facility failed to provide adequate ADL assistance, affecting residents' personal hygiene and daily routines. A resident requiring substantial help was left in bed without assistance, while another was not offered the use of a new wheelchair. Inconsistent documentation and failure to honor bathing preferences were noted for several residents, leading to extended periods without proper hygiene care.
The facility failed to provide Restorative Nursing Programs (RNP) as ordered for several residents, leading to deficiencies in maintaining or improving their range of motion (ROM) and mobility. A resident with complex diagnoses received RNP inconsistently, another with severe cognitive impairment did not have their RNP initiated, and two others did not receive their scheduled RNPs due to staff workload issues. These failures were noted in staff interviews and documentation reviews.
The facility failed to provide adequate nursing staff, resulting in delayed call light responses and unmet resident needs. A CNA was found asleep on duty, and residents reported waiting up to three hours for assistance, particularly during night shifts. Grievances highlighted prolonged wait times, and the DON confirmed that call lights should be answered within 15 to 30 minutes.
The facility failed to ensure timely documentation and follow-up on pharmacists' monthly Medication Regimen Reviews (MRRs) for several residents with complex medical conditions. Recommendations for medication adjustments were not acknowledged or acted upon, leading to potential risks for adverse effects. Interviews revealed that the facility's process for handling MRRs was not consistently followed.
Two residents were not free from unnecessary psychotropic medications, with one resident not undergoing a Gradual Dose Reduction (GDR) for over a year and another receiving increased antipsychotic dosages without documented rationale. Despite monthly reviews and care plans, there was insufficient documentation of behaviors or non-pharmacological interventions, leading to a deficiency in medication management.
A facility experienced a 26.92% medication error rate during a medication pass. An LPN doubled a beta-blocker dose and crushed uncrushable medications for a resident, while an RN failed to observe another resident during administration, leading to omitted doses of vitamin D and B. The DON confirmed expectations for proper medication administration and observation.
The facility failed to secure and properly manage medications, with unlocked carts, expired medications, and improper storage noted. Medications were left unsecured at a resident's bedside and in a shower room. Staff interviews confirmed these practices were against policy, posing risks to residents.
The facility failed to adequately explain arbitration agreements to residents and their representatives, leading to confusion and lack of understanding. Four residents, all alert and oriented, did not recall signing or being informed about the agreements. Staff interviews revealed a need for improved communication to ensure residents understood the legal implications of the agreements.
The facility failed to maintain an effective infection control program during a COVID-19 outbreak, with staff not adhering to PPE protocols, neglecting hand hygiene, and failing to maintain a sanitary environment. Observations included improper mask usage, lack of face shields, and inadequate handwashing during resident care, increasing infection risks.
The facility failed to ensure two residents had Advance Directives (AD) in place, as required by policy. One resident, severely cognitively impaired, did not have an AD discussed or offered upon admission, nor reviewed during care conferences. Another resident, with clear comprehension and complex conditions, also lacked an AD, with no review conducted during care conferences. Staff interviews confirmed the oversight in providing and reviewing ADs, risking residents' treatment preferences not being honored.
The facility failed to implement its grievance policy for three residents, leading to unresolved grievances. A resident reported a distressing incident with another resident, but it was not documented or addressed. Two other residents experienced missing clothing items, which were not logged as grievances, resulting in unresolved issues and dissatisfaction.
The facility failed to provide written transfer notices to three residents and did not notify the LTCO for two residents during hospital transfers. A resident with no memory impairment and another who was severely cognitively impaired were transferred without written notifications. Staff interviews revealed confusion about responsibility for these notifications, and the Social Service Director did not report one resident's transfer to the LTCO.
The facility failed to provide written notice of its bed-hold policy to residents and their representatives during hospital transfers, affecting three residents. One resident was transferred without receiving the required information, and staff confirmed the oversight. Another resident, severely cognitively impaired, was not informed about the bed-hold policy, and their representative was not given the option to return to the same room. A third resident was also transferred without the necessary documentation, as confirmed by staff.
The facility failed to clarify and follow physician's orders for three residents, leading to potential risks. A resident received a fiber supplement without a specified dosage, another was given opioid medication without checking respiratory rate, and a third received blood pressure medication despite a low heart rate. Additionally, the administration of a calorie-dense supplement was inconsistent with prescribed dosages.
A facility failed to meet the activity needs of a resident with depression and moderate memory impairment. Despite a care plan indicating a preference for activities like painting and puzzles, the resident did not consistently receive these activities or the daily activity sheet. Staff interviews revealed inconsistencies in activity delivery, with the resident not being on the schedule for activities on certain days.
The facility failed to ensure resident safety by improperly using and monitoring air mattresses, placing a blanket under a resident's mattress, and leaving sharps and chemicals unsecured. A resident with memory impairment had a blanket under their mattress, potentially acting as a restraint. Three residents were on air mattresses without proper assessments or monitoring, and unsecured sharps and chemicals were found in accessible areas.
The facility failed to provide proper oxygen administration and equipment maintenance for several residents, leading to discrepancies in oxygen levels and unclean equipment. A resident with respiratory failure had oxygen set higher than ordered without physician approval, and another with COPD received more oxygen than prescribed, risking carbon dioxide retention. Observations revealed dusty filters and undated tubing, with staff interviews confirming non-compliance with facility policies.
A resident with chronic pain syndrome and pressure wounds did not receive timely pain management, as staff failed to administer PRN pain medication promptly and did not implement nonpharmacological interventions. The resident's representative had to request medication based on physical signs of pain, and there was no care plan for managing the resident's chronic pain.
Two residents in an LTC facility experienced significant medication errors. One resident received both immediate and extended release antipsychotic medications due to a failure to discontinue the former. Another resident was nearly given double the dose of a beta-blocker and missed a calcium channel blocker due to an LPN's error. These incidents were identified through staff review and interviews, highlighting a failure to follow medication administration guidelines.
A resident with complex medical conditions did not receive timely lab services as ordered. Despite orders being marked as completed, no test results were found. Staff interviews revealed a lack of documentation and a system to audit lab results, highlighting a deficiency in the facility's process for obtaining necessary lab tests.
The facility failed to ensure sanitary conditions in food storage and distribution, with dented cans found in storage, uncovered food served during a respiratory outbreak, and mold in the ice machine. Staff acknowledged these issues, highlighting lapses in adherence to sanitary protocols.
The facility failed to maintain complete and accurate Task Care Records for three residents over several months, as required by professional standards. Interviews revealed that the DON and Resident Care Manager were aware of the documentation gaps, yet the records remained incomplete, risking unmet care needs.
A resident with severe cognitive impairment and multiple diagnoses was found with a large hematoma on the right calf, which was not reported to the state agency as required by the facility's policy. The hematoma was discovered by the resident's representative and reported to the nurse and later to the DON, but the injury of unknown origin was not reported to the state agency, leading to a deficiency in reporting and potential risk to residents.
The facility failed to thoroughly investigate alleged abuse/neglect incidents for two residents. One resident, who was severely cognitively impaired, developed a large hematoma, but the investigation was incomplete and delayed. Another resident, requiring maximum assistance with transfers, sustained a leg injury during a transfer, but the investigation lacked caregiver interviews and equipment evaluation. Both incidents were not properly assessed, leading to deficiencies in care.
The facility failed to follow physician orders and care plans, leading to deficiencies in care for several residents. A resident did not receive a prescribed high protein diet, while another experienced delays in receiving anxiety and depression medications. Pain management documentation was inadequate for a third resident, and insulin administration was inconsistent for another. Additionally, the facility did not adhere to its weight monitoring policy, resulting in unaddressed significant weight changes.
The facility failed to provide adequate care for three residents with pressure ulcers, leading to a lack of proper care plans, delayed implementation of wound care recommendations, and missed dressing changes. These deficiencies resulted in the worsening of pressure ulcers and inadequate documentation and care planning, placing residents at risk for further skin deterioration and pain.
A resident with severe impairments and medically complex conditions experienced significant weight loss due to the facility's failure to consistently monitor weights, identify significant changes, and implement RD recommendations. The resident's nutritional needs were not adequately addressed, leading to continued weight loss and decreased quality of life.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement its abuse and neglect policies and procedures, resulting in multiple deficiencies related to the identification, investigation, protection, and reporting of abuse and neglect incidents. The facility did not thoroughly investigate incidents and allegations of abuse, sexual abuse, and neglect for several residents. For instance, Resident 2 reported an allegation of sexual abuse, but the facility delayed notifying the police and did not conduct a thorough investigation, failing to rule out abuse or neglect. Additionally, the facility did not ensure that staff followed care plans requiring two staff members for certain care tasks, which was not documented or investigated properly. Resident 1, who had a history of crawling on the floor, was found crawling out of bed on multiple occasions without proper assessment for injury or notification to the provider and responsible party. The facility did not log these incidents as falls or investigate them as potential neglect. Furthermore, the facility failed to use bed and chair alarms as ordered, which were intended to prevent such incidents. This lack of adherence to care plans and failure to investigate and report incidents placed residents at risk for further harm. Other residents, such as Resident 4 and Resident 5, reported verbal abuse and inappropriate behavior by staff, but the facility's investigations were incomplete, lacking documentation and follow-up. Staff D, who was involved in these incidents, returned to the residents' rooms despite being instructed not to, and the facility did not adequately monitor or document the psychological impact on the residents. Additionally, Resident 6 reported inappropriate care involving the use of multiple briefs, but the investigation did not rule out abuse or neglect, and other residents expressed concerns about care quality, which were not thoroughly addressed.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, as evidenced by the lack of documentation and monitoring of target behaviors, and the absence of non-pharmacological interventions before administering medications. The facility's policy required the interdisciplinary team to evaluate and implement interventions for residents on psychotropic medications, including environmental and behavioral interventions prior to initiating such medications. However, the facility did not adhere to these guidelines, resulting in residents being at risk for unnecessary medications and adverse side effects. Resident 1, who had severe impairments in decision-making and medically complex conditions, was prescribed multiple psychotropic medications without proper documentation of behaviors or non-medicinal interventions. The facility staff administered as-needed antianxiety medication without documenting the behaviors or the effectiveness of interventions before medicating. Similarly, Resident 3, who had no documented behaviors, was prescribed an antianxiety medication without a stop date, and there was no consent obtained or behavior monitoring conducted. Resident 12, who was unable to make needs known, was also administered antianxiety medication without a stop date or behavior monitoring. The facility's failure extended to Resident 14, who was prescribed an antianxiety medication repeatedly without documented rationale for extended use, despite having no documented behaviors. Resident 15, who was discharged from the facility, was prescribed an antianxiety medication without a stop date or behavior monitoring. Interviews with staff revealed that they were not monitoring behaviors or implementing interventions as expected, and there was a lack of documentation to support the continued use of psychotropic medications.
Failure to Obtain Informed Consent for Psychotropic Medications and Devices
Penalty
Summary
The facility failed to ensure that residents or their representatives were fully informed and provided consent for the use of psychotropic medications and devices. Specifically, three residents were not informed orally or in writing about the potential risks associated with psychotropic medications, and informed consent was not obtained. This deficiency was identified through interviews and record reviews, which revealed that the facility did not adhere to its policy requiring informed consent before administering such medications. Resident 1, who had severe impairments in decision-making and was rarely understood, was administered a one-time dose of an antipsychotic medication and had the frequency of an antidepressant increased without obtaining informed consent from their collateral contact (CC). The facility's records showed no documentation of consent, and the CC confirmed that no discussion about the medications occurred. Additionally, Resident 1 had several devices implemented without consent from the CC, including a fall mat, bed against the wall, and perimeter mattress. Resident 12, who was under hospice care and unable to make decisions, received an antipsychotic medication multiple times without consent from their CC. Similarly, Resident 3, who could make decisions and communicate, was administered an antianxiety medication without documented consent. Interviews with the Director of Nursing confirmed that informed consent should have been obtained and documented before administering these medications.
Failure to Timely Assess and Treat Resident's Hematoma
Penalty
Summary
The facility failed to consistently assess and monitor a change in condition and implement provider orders timely for a resident who experienced a significant injury of unknown origin. The resident, who was severely cognitively impaired and had diagnoses including pressure ulcers and paraplegia, was admitted to the facility with no new skin impairments noted. However, a large hematoma on the resident's right calf was reported by the resident's representative, but the facility delayed in assessing and treating the condition. Despite an order for an immediate ultrasound of the resident's right leg, the facility did not obtain the ultrasound, and the resident was eventually sent to the hospital for surgical intervention due to the expanding hematoma and a critically low blood count. The facility's policies required immediate assessment and documentation of skin impairments, as well as notification to the physician and resident representative, but these were not followed. Additionally, the facility did not conduct necessary pain assessments or monitor the hematoma as required. Interviews revealed that the Director of Nursing was informed of the hematoma but failed to act promptly, resulting in a delay in obtaining the ultrasound and a lack of documentation and assessment. The facility also did not report the significant injury to the state agency within the required timeframe, nor did they initiate an investigation to rule out abuse or neglect. These failures placed the resident at risk for harm and indicated a lack of adherence to facility policies and procedures.
Failure to Complete PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASRR) Level II comprehensive evaluations were obtained, implemented, and incorporated into the Care Plan for a resident reviewed for PASRR Level II. This deficiency was identified for one resident who had medically complex diagnoses, including a history of stroke, alcohol dependence, and a psychotic disorder. The resident was taking antipsychotic medication as per a physician's order. The record review revealed that the resident had a PASRR Notification of Determination form indicating a significant change in their behavioral health, meeting the requirements for Level II services. However, no Level II referral was completed, and no recommendations were documented. During an interview, the Divisional Director of Social Services confirmed the absence of a PASRR Level II evaluation for the resident, acknowledging that a referral and evaluation should have been completed following the Notification of Determination.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Pre-Admission Screening and Resident Review (PASRR) assessments for several residents, which is crucial for identifying mental health or intellectual disability needs. Resident 22's PASRR was outdated and did not reflect their diagnoses of PTSD and bipolar disorder, despite being on medications for these conditions. The PASRR only listed depression, and a new Level I PASRR was not completed until much later, missing the opportunity to update the resident's mental health indicators. Resident 57's PASRR was also inaccurate, as it did not require a Level II Evaluation despite the resident having severe memory impairment and complex diagnoses, including anxiety, bipolar disorder, and schizophrenia. The PASRR failed to reflect the significant changes in the resident's condition, which included receiving hospice services and multiple medications for mental health conditions. Similarly, Resident 13's PASRR was incomplete, failing to indicate the presence of schizophrenia, mood, or anxiety disorders, despite the resident being on multiple medications for these conditions. This oversight meant that a necessary Level II assessment was not conducted. Additionally, Residents 185 and 53 had inaccuracies in their PASRR Level 1 forms, with Resident 185's form not listing depression and Resident 53's form incorrectly marked, preventing a Level II evaluation referral.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for six of the twenty sampled residents, leading to potential risks for unmet care needs and decreased quality of life. For Resident 53, the care plan was not individualized or measurable, lacking specific goals even 30 days post-admission. Similarly, Resident 70's care plan did not address the resident's ambulation status or required mobility device, despite being assessed with a functional limitation. Staff interviews confirmed the importance of comprehensive care plans, yet these were not adequately developed. Resident 32's care plan was outdated and did not reflect the resident's current needs, such as assistance with bed mobility and pressure wound care. The care plan for Resident 43 lacked interventions for a diagnosed skin condition, and Resident 45's care plan only referred to a baseline plan without specific interventions. Resident 16, diagnosed with paraplegia and chronic pain syndrome, did not have a pain management care plan, and the care plan for contractures was missing, despite a referral for a Restorative Nursing Program. The implementation of care plans was also deficient. Resident 16's care plan directed staff to keep the resident's heels elevated to prevent pressure ulcers, but observations showed this was not consistently done. Staff interviews revealed a lack of awareness and adherence to care plan directives, as seen with Resident 32, who reported not being repositioned as required. Staff claimed the resident refused assistance, but there was no documentation of such refusals, indicating a failure in implementing and documenting care as per the care plans.
Deficiencies in Care Plan Updates and Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were updated and revised to reflect person-centered care for several residents. Resident 70's care plan was not updated to reflect the discontinuation of a PICC line, which was initially listed as an intervention. Resident 53's care plan lacked specific details regarding the use of oxygen therapy, including the reason for the therapy and whether a humidifier was required. Similarly, Resident 185's care plan did not specify a toileting schedule or the primary language for communication, despite the resident's need for substantial assistance with these activities. Staff interviews confirmed that these care plans needed to be updated to reflect the residents' current conditions. The facility also failed to ensure that residents participated in care conferences that included the Interdisciplinary Team (IDT). Resident 21, who had no memory impairment, reported being unfamiliar with care conferences and did not recall attending one. Documentation showed that care conferences for Resident 21 were conducted without the presence of the IDT, and the resident was invited on the same day the conferences occurred. Staff interviews confirmed that care conferences should include the IDT and that residents should receive prior notice of these meetings. Resident 43, who had no memory impairment and was working towards returning home, reported having a care conference upon admission but not subsequently. Staff interviews revealed that Resident 43 was overdue for a quarterly care conference due to a lack of staff to arrange these meetings. The Executive Director confirmed that care conferences should be conducted upon admission, quarterly, and as needed, and that care plans should be updated to reflect current conditions.
Deficiencies in ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for several residents, leading to deficiencies in personal hygiene and daily routines. Resident 70, who required substantial assistance due to a functional limitation, was observed lying in bed without being assisted to get up, despite expressing frustration over the lack of help. The care plan for Resident 70 lacked specific directions for daily ambulation, and staff interviews revealed a misunderstanding of responsibilities, with some staff assuming physical therapy would handle getting residents out of bed. Resident 21, who was totally dependent on staff for transfers, was not regularly assisted out of bed as per their care plan. Despite having a new wheelchair, Resident 21 reported not being offered the opportunity to use it. The facility's documentation showed inconsistencies in offering and recording bathing assistance, with several instances of blank or 'not applicable' entries, indicating a failure to adhere to the resident's preferences for showers or bed baths. Other residents, such as Resident 20, 13, 22, 43, 16, and 45, also experienced similar issues with inadequate ADL support. Resident 20 had long, unkempt nails that led to skin injuries, contrary to their care plan's goal of maintaining short nails. Residents 13, 22, 43, 16, and 45 were not consistently offered showers or bed baths according to their preferences and schedules, with some residents going extended periods without bathing assistance. Staff interviews confirmed that residents' preferences were not always honored, and documentation of refusals was lacking, contributing to the overall deficiency in care.
Failure to Implement Restorative Nursing Programs
Penalty
Summary
The facility failed to provide appropriate Restorative Nursing Programs (RNP) for several residents, leading to a deficiency in maintaining or improving their range of motion (ROM) and mobility. Resident 70, who had multiple complex diagnoses and a recent surgical procedure, was supposed to receive an RNP three times a week to maintain muscle strength and ROM. However, the program was only provided twice in six occurrences, despite the resident's expressed desire to work on mobility for discharge goals. The delay in implementing the RNP and the lack of consistent delivery were noted. Resident 16, who was severely cognitively impaired with conditions such as Alzheimer's dementia and paraplegia, was referred for an RNP that included hand splints and stretching exercises. Despite the referral, the program was not initiated, and observations showed the splints were not used. Staff interviews revealed a lack of awareness and initiation of the RNP, which was crucial to prevent further deformity of the resident's contracted hands and limbs. Resident 43, with chronic pain syndrome and nerve damage, was referred for elastic band exercises to improve ROM in their arms. However, the resident reported not receiving the RNP, and staff confirmed the program was not offered due to workload issues. Similarly, Resident 46, diagnosed with paraplegia, was scheduled for an RNP to maintain leg muscle strength but did not receive the program as documented. The lack of RNP provision and documentation of refusals were highlighted as deficiencies.
Inadequate Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple observations and interviews. On one occasion, a Certified Nursing Assistant (CNA) was found asleep at the nurse's station with call lights going unanswered, indicating a lack of staff to cover the needs of residents during the night shift. The CNA admitted to being asleep and expressed that there were not enough staff at night, which prevented them from taking all their breaks. The night shift supervisor confirmed that staff should not be sleeping on duty. Several residents reported excessive wait times for assistance, particularly during the night shift. One resident stated they waited three hours to be changed after an aide failed to return promptly. Another resident reported having to wait hours for their call light to be answered, resulting in them soiling themselves. Additional residents described waiting times ranging from 30 minutes to three hours for their call lights to be answered, with one resident expressing concern over their health condition due to prolonged wait times in a soiled brief. Grievance forms filed by residents further highlighted the issue of long call light response times. Residents and their families reported waiting over 30 minutes for assistance, and staff were reportedly educated on the importance of timely responses. The Director of Nursing stated that call lights should be answered within 15 to 30 minutes and confirmed that staff should not be sleeping while on duty. The facility's failure to provide adequate staffing and timely responses to call lights placed residents at risk for unmet care needs and decreased quality of life.
Failure to Document and Act on Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that licensed pharmacists' monthly Medication Regimen Reviews (MRRs) were properly documented in resident records and that recommendations were reviewed and acted upon in a timely manner. This deficiency was observed in the cases of five residents, including those with complex medical conditions such as dementia, depression, bipolar disorder, and psychotic disorders. For Resident 3, there was no documentation of MRRs being completed monthly since March 2024, and multiple recommendations for medication review and dose reduction were not acknowledged or acted upon by the physician. Similarly, Resident 13's records showed a lack of follow-up on recommendations regarding medications for side effects of antipsychotic drugs and thyroid medication adjustments. Resident 23's records indicated a delay in the physician's acknowledgment of a recommendation to discontinue an iron supplement, which was not addressed until nearly a month later. Resident 16, who was severely cognitively impaired, had no MRRs documented, and a recommendation to adjust the timing of blood pressure medication was not implemented or recorded. Resident 46, who had diabetes and was on insulin, had a recommendation regarding the use of sliding scale insulin without a longer-acting insulin acknowledged by the physician only after a significant delay. Interviews with the Director of Nursing (Staff B) revealed that the facility's process for handling MRRs was not being followed as expected. Staff B stated that MRRs should be reviewed and addressed by the end of the month in which they were completed, but this was not happening consistently. The lack of timely follow-up on pharmacy recommendations placed residents at risk for delays in necessary medication changes, adverse side effects, and negative outcomes.
Failure to Ensure Residents are Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications, which left them at risk for adverse side effects and other negative health outcomes. Resident 3, with complex medical diagnoses including dementia and bipolar disorder, had not undergone a Gradual Dose Reduction (GDR) for over a year, and there was no documentation from a physician indicating that a GDR was clinically contraindicated. Despite monthly reviews showing that Resident 3's mood and behaviors were managed by medications, there was no significant documentation of target behaviors or monitoring related to the antidepressant. The pharmacist had recommended a review of the psychotropic medications, but there was no documented clinical rationale or acknowledgment from the physician. Resident 23, diagnosed with conditions such as stroke and dementia, was administered routine antipsychotic medication without a GDR attempt or physician documentation of contraindication. The resident's care plan included interventions for behavior management, but behavior monitoring showed no documented behaviors except for one instance. Despite this, the antipsychotic medication dosage was increased twice within a short period, with no documented rationale for the increases. The practitioner had previously declined a GDR recommendation, citing past failures and the benefits outweighing the risks, but there was no documentation of attempted GDRs. Interviews with staff revealed expectations for documenting resident behaviors, identifying triggers, and using non-pharmacological interventions before increasing medications. However, there was a lack of documentation supporting these practices for both residents. The facility's interdisciplinary team was expected to review medication dosages and recommendations, but the records did not reflect adherence to these processes, contributing to the deficiency.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 26.92% error rate during a medication pass observation. For Resident 72, a Licensed Practical Nurse (LPN) mistakenly prepared and almost administered a double dose of an extended-release beta-blocker blood pressure medication while omitting a calcium channel blocker. Additionally, the LPN crushed medications that should not have been crushed, including an enteric-coated iron tablet, an extended-release beta-blocker, and a delayed-release anticonvulsant. The LPN was unaware of a list of medications that should not be crushed, which was later provided by the Director of Nursing (DON). For Resident 4, a Registered Nurse (RN) failed to properly observe the resident during medication administration, resulting in two pills falling, one on the floor and one on the resident's shirt. The RN mistakenly believed all medications were administered, leading to the omission of a vitamin D tablet and a vitamin B tablet. The RN acknowledged the error, attributing it to the similarity in the names and doses of the medications on the computer system. The DON confirmed the expectation that staff should administer medications as ordered and observe residents during administration.
Medication Security and Management Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper management of medications and biologicals, leading to several deficiencies. Observations revealed that medication carts were left unlocked and unattended, containing both over-the-counter and prescription medications with resident information. Staff interviews confirmed that the carts should have been locked, and medications should not have been left unsecured. Additionally, a medication room contained an opened vial of tuberculin testing solution without an open or discard date, which was acknowledged by staff as a failure to adhere to expected standards. Further deficiencies were noted with the improper storage of medications. A medication cart contained a prescription medication for a discharged resident and a bottle of topical antifungal powder stored alongside oral medications, which staff confirmed was incorrect. Another cart had expired lubricating jelly and medicated patches, with one patch opened and returned to its box. The cart was also found to be dirty, and documentation for narcotic counts was incomplete, as noted during a shift change observation. Additional issues included unsecured medications at a resident's bedside and in a shower room. A resident had two pills left unsecured in their room, which they had not taken. In the shower room, an unlocked cabinet contained prescription medicated shampoos, which staff admitted should have been secured. These findings indicate a failure to comply with professional standards for medication security and management, placing residents at risk of accessing expired or unsecured medications.
Failure to Explain Arbitration Agreements
Penalty
Summary
The facility failed to ensure that the arbitration agreement was explained in a manner that residents and their representatives could understand. This deficiency was identified for four out of five residents reviewed for arbitration agreements. The facility's policy required the admissions coordinator to review the arbitration agreement with residents upon admission, but this was not effectively implemented. Resident 37, who was alert and oriented, did not recall signing the arbitration agreement or being informed about its contents. When presented with the agreement, the resident expressed surprise at waiving their right to a court hearing and stated that they would not have agreed to it if they had understood. Similarly, Resident 48, also alert and oriented, found the admission paperwork overwhelming and did not remember signing the arbitration agreement or being informed about it. Resident 35, who was alert and oriented, did not recall any discussion about the arbitration agreement and suggested that the facility staff might have spoken to their family member instead. However, the family member also stated they were not informed about the agreement. Resident 59's representative, who signed the agreement, did not remember doing so and stated they would not have signed if they understood what it entailed. Staff interviews revealed a lack of clarity in the process, with the Admission Director acknowledging the need for better communication to ensure residents understood the agreement.
Infection Control Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to proper PPE protocols during a COVID-19 outbreak. Staff members, including medical directors, nurses, and aides, were observed not wearing masks properly, neglecting to wear required face shields, and failing to change or disinfect PPE as directed by the facility's policies. These lapses in protocol were noted despite clear signage and instructions posted outside resident rooms indicating the necessary precautions for aerosol and contact precautions. Additionally, staff did not consistently follow hand hygiene protocols, particularly during wound care and personal care activities. Instances were observed where staff did not wash their hands between glove changes or after handling soiled materials, which is critical to preventing the spread of infections. This was particularly concerning during the care of residents with COVID-19, where strict adherence to hygiene protocols is essential to prevent cross-contamination and further spread of the virus. The facility also exhibited deficiencies in maintaining a sanitary environment, as evidenced by cracked and uncleanable surfaces on linen cart covers and improper disposal of soiled linens and garbage. These issues, combined with the failure to follow PPE and hand hygiene protocols, placed residents and staff at increased risk of infection during an active COVID-19 outbreak. The facility's infection preventionist acknowledged these expectations and the importance of following established protocols to mitigate infection risks.
Failure to Ensure Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that residents had the appropriate Advance Directives (AD) in place, as required by their policy. This deficiency was identified for two residents during a review of their records and interviews. Resident 16, who was severely cognitively impaired and had diagnoses of non-Alzheimer's dementia, anxiety disorder, and depression, did not have an AD on file. The facility did not offer or discuss the formulation of an AD with Resident 16's representative upon admission, nor was it reviewed during care conferences. The representative confirmed that the facility had not discussed or offered assistance in formulating an AD. Similarly, Resident 32, who had clear comprehension and multiple medically complex conditions, also lacked an AD. The facility's records showed that the review of ADs was not completed during care conferences, as indicated by unchecked boxes on the forms. Staff interviews revealed that ADs should be provided upon admission and reviewed quarterly, but this process was not followed for Resident 32. The failure to provide and review ADs placed residents at risk of not having their medical treatment preferences honored.
Failure to Implement Grievance Policy
Penalty
Summary
The facility failed to implement its grievance policy for three residents, leading to unresolved grievances and potential impacts on their quality of life. Resident 54 reported a distressing incident where another resident entered their room in a disoriented state, but the staff did not document or address the grievance. The facility's grievance log did not reflect this incident, and staff interviews revealed a lack of awareness and action regarding the grievance. Resident 70 experienced frustration over missing clothing items, which they reported to staff without resolution. Despite the resident's repeated inquiries, the grievance was not logged, and the missing items were only partially found after a significant delay. Staff interviews indicated a lack of adherence to the grievance procedure, with staff failing to report the issue promptly. Resident 53 also reported missing clothing items, which were not resolved or logged as grievances. The resident expressed dissatisfaction with the situation, and staff interviews confirmed that the grievance process was not followed. The facility's policy required grievances to be logged and addressed within a specific timeframe, but this was not adhered to, resulting in unresolved issues for the residents.
Failure to Provide Written Transfer Notices and Notify LTCO
Penalty
Summary
The facility failed to provide required written notices to residents and their representatives at the time of transfer or discharge, as well as notify the Office of the State Long-Term Care Ombudsman (LTCO) for certain residents. Specifically, three residents did not receive written transfer notifications, and two residents were not reported to the LTCO. Resident 65, who had no memory impairment, was discharged to an acute care hospital without any record of a written transfer notification. Resident 16, who was severely cognitively impaired, was also transferred to a hospital without a written notification being provided to their representative, who confirmed not receiving such notice. Additionally, Resident 53 was sent to the hospital without documentation of a written notice before transfer. Staff interviews revealed confusion and lack of clarity regarding the responsibility for providing written transfer notifications. The Social Service Director and Director of Nursing both indicated that their departments were not responsible for these notifications, and the Executive Director did not provide further information on who was responsible. The Social Service Director also failed to notify the LTCO about Resident 53's transfer, as confirmed by their review of the notification log.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents and their representatives at the time of transfer to a hospital or within 24 hours, as required by regulations. This deficiency was identified for three residents who were reviewed for hospitalization. Resident 67 was transferred to an acute care hospital with an anticipated return, but there was no documentation indicating that the facility provided the required bed-hold information. Staff L, responsible for providing this information, confirmed that Resident 67 did not receive the bed-hold policy upon transfer. Similarly, Resident 16, who was severely cognitively impaired, was transferred to a hospital without receiving the necessary bed-hold information. The resident's representative reported that they were not informed about the bed-hold policy and did not have the option to return to the same room. Staff K and Staff L acknowledged that they failed to discuss the bed-hold policy with Resident 16 and their representative. Additionally, Resident 53 was sent to the hospital, and there was no documentation of a bed-hold form being provided. Staff D confirmed that the admissions department was responsible for this task but could not locate the necessary documentation for Resident 53.
Failure to Clarify and Follow Physician's Orders
Penalty
Summary
The facility failed to ensure physician's orders were clarified and followed for three residents, leading to potential risks for unneeded care and unmet care needs. For Resident 29, a physician's order dated 08/15/2024 for a fiber supplement lacked a specified dosage, which was acknowledged by the Director of Nursing as needing clarification. This oversight could lead to improper administration of the supplement. For Resident 4, a physician's order from 12/06/2023 required that opioid pain medication be withheld if the resident's respiratory rate was below 14 breaths per minute. However, during a medication pass on 10/03/2024, a registered nurse failed to measure the resident's respirations before administering the medication. Additionally, Resident 3, who had heart failure and difficulty swallowing, was given blood pressure medication despite orders to hold it if the heart rate was below 60 BPM. The medication was administered on two occasions when the resident's heart rate was below the specified threshold. Furthermore, the administration of a calorie-dense supplement for Resident 3 was inconsistent with the prescribed dosage, with varying amounts given over several months.
Failure to Provide Adequate Activities for Resident
Penalty
Summary
The facility failed to ensure that the activity programs met the needs of Resident 32, who was part of a sample reviewed for activities. Resident 32 had a diagnosis of depression and moderate memory impairment but could communicate their needs and be understood by others. The resident's care plan indicated a preference for activities such as painting, arts and crafts, and coloring, with a goal to participate in one-on-one activities two to three times weekly. Despite this, observations and interviews revealed that the resident did not consistently receive the activities they preferred, such as puzzles and music, and often did not receive the daily activity sheet. Interviews with staff, including Staff Y and the Activities Director, Staff X, highlighted inconsistencies in the delivery of activities to Resident 32. Staff Y, who was new to assisting with activities, admitted to not stopping at Resident 32's room with the activity cart because the resident was not on the schedule for that day. Staff X acknowledged that Resident 32 should have received one-on-one activities and that the activities schedule should be delivered daily to bed-bound residents. However, observations showed that the activity sheet was not present in Resident 32's room, and the resident expressed dissatisfaction with the lack of activities provided.
Deficiencies in Resident Safety and Equipment Monitoring
Penalty
Summary
The facility failed to ensure residents were free from accident hazards, as evidenced by several deficiencies observed during the survey. Resident 41, who had moderate memory impairment and required substantial assistance, was found with a folded blanket placed under the right side of their mattress, raising it by one to two inches. This practice was not in line with facility protocols, as confirmed by the Director of Nursing, who stated that such placement could act as a restraint. For Residents 57, 43, and 16, the facility did not properly assess or monitor the use of air mattresses. Resident 57, who was on hospice care and at risk of falls, was observed on an air mattress with a pump set incorrectly and a flashing red light indicating low air pressure. There were no physician orders or assessments for the air mattress, and similar issues were found for Residents 43 and 16, with no monitoring or documentation of air mattress settings and safety checks. Additionally, the facility failed to secure sharps and chemicals, posing potential risks to residents. Unsecured sharps were found in a hallway, and chemicals, including a hazardous spray can, were left in an unlocked shower room. Staff interviews confirmed that these items should have been secured to prevent resident access, highlighting a lapse in safety protocols.
Deficiencies in Oxygen Administration and Equipment Maintenance
Penalty
Summary
The facility failed to provide oxygen administration consistent with professional standards of practice for five residents, leading to deficiencies in care. Resident 32, who had respiratory failure and required oxygen therapy, was observed with oxygen levels set higher than the physician's order of two LPM, reaching up to 4.25 LPM without documented physician approval. Additionally, the oxygen equipment was not maintained properly, with dusty filters and tubing found on the floor or incorrectly placed on the resident's head. Resident 45, diagnosed with COPD and respiratory failure, was also administered oxygen at 3.5 LPM instead of the ordered two LPM, risking carbon dioxide retention. The oxygen concentrator for this resident was observed with a thick layer of dust and an unclean filter, indicating a lack of regular maintenance. Staff interviews confirmed the discrepancies in oxygen administration and equipment maintenance, highlighting a failure to adhere to physician orders and facility policies. Other residents, including Residents 53, 185, and 22, were found with undated oxygen tubing and unclean oxygen concentrator filters. These observations were corroborated by staff interviews, which revealed a lack of awareness and adherence to the facility's policy on cleaning and maintaining oxygen equipment. The deficiencies in oxygen administration and equipment maintenance posed risks to the residents' respiratory health and safety.
Inadequate Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate pain management for Resident 16, who was severely cognitively impaired and had diagnoses of chronic pain syndrome and pressure wounds. The resident's records indicated that they received pain medications both routinely and as needed (PRN), but there were no documented nonpharmacological interventions for pain management. Additionally, there was no care plan in place for managing the resident's chronic pain. The resident's representative reported having to request PRN pain medication for the resident, as staff did not administer it based on the resident's physical signs of pain, such as heavy breathing, restlessness, or excessive sweating. On one occasion, the resident appeared sweaty and had labored breathing, prompting the representative to request PRN pain medication from a Licensed Practical Nurse (LPN). However, the LPN delayed administering the medication, prioritizing wound care instead, and only returned with the medication 40 minutes later. Interviews with staff revealed that there was an expectation for nonpharmacological interventions to be ordered and for pain medications to be administered promptly, ideally within 15 minutes of a request or observation of pain. The Director of Nursing acknowledged the need for a pain care plan for residents with chronic pain, which was not in place for Resident 16.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors, which placed them at risk for adverse health outcomes. Resident 23, who had a history of stroke, dementia, and other conditions, was administered both an immediate release and a 24-hour extended release antipsychotic medication simultaneously. This error occurred because the immediate release medication was not discontinued when the extended release medication was prescribed. The error was identified when a registered nurse reviewed the medication cards and confirmed the discrepancy with the physician's order. The facility pharmacist also confirmed that the 24-hour extended release medication should not have been administered twice daily, indicating a need for clarification of the order. Resident 72, who had complex medical diagnoses including high blood pressure and end-stage kidney failure, experienced a medication error during a medication pass. A licensed practical nurse mistakenly prepared and almost administered double the ordered dose of a beta-blocker while omitting the calcium channel blocker. This error was caught before administration, and the nurse acknowledged the potential negative impact of incorrect blood pressure medication administration on the resident's condition. The Director of Nursing stated that it was expected for staff to administer medications as ordered. These incidents highlight the facility's failure to adhere to its medication administration guidelines, which require verification of medications three times before administration. The errors in medication administration for both residents were due to a lack of proper verification and clarification of medication orders, leading to significant medication errors that could have adversely affected the residents' health.
Failure to Obtain Timely Lab Services for Resident
Penalty
Summary
The facility failed to provide timely laboratory services for a resident with multiple complex medical diagnoses, including heart failure, high blood pressure, diabetes, lung disease, and a thyroid disorder. The resident had a STAT order for a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and Thyroid-Stimulating Hormone (TSH) level on one occasion, and a subsequent order for the same tests plus a vitamin D level on another occasion. Both orders were marked as completed in the Medication Administration Records, but no test results were found in the resident's records. Interviews with facility staff revealed that there was an expectation for lab tests to be obtained as ordered, with STAT orders typically completed the same day and routine orders on the next scheduled lab day. However, the lab confirmed that no tests were performed for the resident's orders, and there was no documentation or lab requisition slips to explain the oversight. The Director of Nursing acknowledged the lack of a system to audit the receipt of lab test results and emphasized the importance of lab tests in monitoring residents' conditions and determining necessary interventions.
Sanitation Deficiencies in Food Storage and Distribution
Penalty
Summary
The facility failed to maintain sanitary conditions in the storage and distribution of food and drinks, as observed in the kitchen and during meal service. During an inspection of the dry food storage area, several large cans of apricots, sliced apples, and diced pears were found to be significantly dented, contrary to the facility's policy that requires such cans to be discarded. Staff CC, a Food and Nutrition Service Aide, acknowledged that dented cans should not be present in storage. Additionally, during meal service, staff were observed distributing lunch trays with uncovered desserts and fruit cups, carrying them through hallways past multiple rooms, including a unit experiencing a contagious respiratory outbreak, which violated sanitary protocols. Further observations revealed unsanitary conditions in the facility's ice machine, which had mold and black, sticky debris along its opening. Staff T, the Dietary Manager, confirmed the presence of mold and stated that the ice machine should be cleaned monthly. However, the last cleaning was reported to have occurred in August 2024, indicating a lapse in the maintenance schedule. These deficiencies in food storage, distribution, and equipment cleanliness posed a risk of foodborne illness to residents.
Incomplete and Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to ensure that the medical records for three residents were complete and accurate, as required by professional standards. Specifically, the Task Care Records for Residents 16, 43, and 45 were found to be incomplete and inaccurately documented over several months. For Resident 16, the Task Care Records for August, September, and October 2024 showed multiple instances where staff did not document the care provided. Similar issues were found for Resident 43 in July, August, September, and October 2024, and for Resident 45 in June, July, August, September, and October 2024. Interviews with staff revealed that the Director of Nursing and the Resident Care Manager were aware of the missing documentation. Staff BB confirmed that the Director of Nursing had reviewed the Task Care Records and informed staff about the documentation gaps. Staff B emphasized the importance of accurate and complete documentation to ensure that residents receive the care they need. Despite these expectations, the records remained incomplete, placing residents at risk for unmet care needs and inaccurate assessments.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report a significant injury of unknown origin for a resident, identified as Resident 16, which placed the resident and all other residents at risk for repeated incidents and unidentified abuse and/or neglect. The facility's policy required immediate reporting of such injuries to the state agency, but this was not adhered to. Resident 16, who was severely cognitively impaired and diagnosed with paraplegia, non-Alzheimer's dementia, and chronic pain syndrome, was found to have a large hematoma on the right calf. The hematoma was discovered by the resident's representative on August 10, 2024, and reported to the nurse on duty the same day, and later to the Director of Nursing on August 13, 2024. Despite the report of the hematoma, the Director of Nursing acknowledged that the significant injury of unknown origin was not reported to the state agency as required. The Executive Director also admitted that the injury should have been reported within two hours but was not. The facility's policies on abuse reporting and response, as well as abuse identification, were not followed, leading to a deficiency in reporting and potentially compromising the safety and well-being of the residents.
Inadequate Investigation of Alleged Abuse/Neglect Incidents
Penalty
Summary
The facility failed to conduct thorough investigations into alleged abuse or neglect for two residents, leading to deficiencies in their care. For Resident 16, who was severely cognitively impaired and on blood thinners, an incident involving a large hematoma on the right calf was not properly investigated. The incident report was incomplete and submitted eight days past the regulatory requirement. Key assessments, such as pain, skin, and mental status, were not conducted, and potential environmental or situational factors were not explored. The investigation was prematurely concluded without determining the root cause of the hematoma, despite the resident's representative raising concerns about a possible injury during a transfer. For Resident 4, who required maximum assistance with transfers and used a wheelchair, the facility did not adequately investigate an incident where the resident's right shin was injured during a transfer. The investigation was completed 18 days after the incident, and crucial steps were missed, such as interviewing caregivers, evaluating the sit-to-stand lift's function, and assessing caregivers' ability to safely transfer the resident. The investigation failed to consider whether the lift remained a safe method for transferring the resident, and the conclusion was reached without a comprehensive assessment of the incident.
Deficiencies in Care and Medication Management
Penalty
Summary
The facility failed to ensure that residents received necessary care and services in accordance with professional standards of practice. For Resident 2, the facility did not follow physician orders for a high protein diet, as indicated in hospital transfer orders. The Registered Dietician acknowledged the oversight, and the Director of Nursing confirmed that Resident 2 was not discussed in nutrition/hydration skin committee meetings. Additionally, Resident 2's nutritional status was not assessed within the required timeframe, and care plans were not developed promptly. Resident 4 experienced a delay in the implementation of psychiatric provider recommendations for anxiety and depression medications. The recommendations were made on September 4, 2024, but the physician orders for the medications were not written until six days later. This delay affected Resident 4's eating, sleeping, and therapy progress, as reported by the resident's Collateral Contact. The Director of Nursing was unable to explain the delay in implementing the provider's recommendations. Resident 3's pain management was inadequately documented, with staff failing to record observed side effects of opioid use and actions taken to address them. Despite documentation indicating side effects for 12 days, there were no progress notes detailing the side effects or staff responses. Additionally, Resident 5 did not receive insulin as ordered, with missed doses and a lack of timely clarification of insulin orders. The facility's emergency medication kit was not utilized effectively, and staff failed to communicate medication shortages to the resident or physician. Furthermore, the facility did not adhere to its weight monitoring policy for several residents, including Residents 1, 2, and 3, leading to unaddressed significant weight changes.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services for three residents with pressure ulcers, consistent with professional standards of practice. Resident 3 was admitted with multiple skin impairments, including a stage 4 pressure ulcer, but did not have a care plan developed to manage these conditions. The facility delayed implementing wound care provider recommendations for seven days, and staff frequently documented 'not applicable' for assisting Resident 3 with bed mobility, indicating a lack of repositioning. Resident 3's collateral contact reported concerns about inadequate care, including the resident being left in soiled conditions and not being repositioned, which contributed to the worsening of the pressure ulcer. Resident 4 was admitted with a risk for skin impairments but did not have a care plan to address this risk. Despite a physician's order for a foam dressing to be applied to the tailbone, the dressing change was missed when Resident 4 was out of the facility for an appointment. A new stage 2 pressure ulcer was discovered at a subsequent medical appointment, and the facility did not have a care plan with interventions to manage this new wound. Staff B acknowledged the lack of appropriate documentation and care planning for Resident 4's condition. Resident 1 was admitted with a stage 2 pressure ulcer but did not have a care plan that identified the type and location of the wound. Weekly wound assessments were not documented after the initial assessment, and Resident 1 was not referred to a wound provider as expected. Staff B confirmed that the facility failed to conduct weekly assessments and did not have a proper care plan in place for Resident 1's pressure ulcer. These deficiencies in care and documentation placed all residents at risk for deterioration in skin condition, pain, and diminished quality of life.
Failure to Maintain Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, leading to significant weight loss and decreased quality of life. The facility did not consistently obtain timely weights and re-weights, identify significant weight changes promptly, notify interested parties, or implement the Registered Dietician's (RD) recommendations. This failure placed the resident at risk for delayed identification of interventions to prevent continued weight loss and decreased quality of life. The resident, who had severe impairments in decision-making, highly impaired vision, and behaviors of rejecting care, was admitted with medically complex conditions including fracture, dementia, and muscle weakness. The resident experienced a weight loss of five percent or more in the last month and had an unhealed stage 3 pressure ulcer (PU). Despite the facility's policy requiring weekly weights for residents with PUs, the resident's weight was not consistently monitored, and significant weight changes were not promptly addressed. The resident's weight record showed multiple instances where weights were not obtained or re-weighed within the required 24-hour period, and significant weight loss was not documented or communicated to the physician or resident representative in a timely manner. The facility's Nutrition Hydration Skin Committee (NHSC) failed to identify the resident's significant weight loss during their review meetings, and the RD's recommendations for an appetite stimulant were not implemented. The resident's collateral contact reported that staff did not provide adequate supervision and encouragement during meals, and there was confusion and lack of communication regarding the need for a feeding tube. The resident continued to lose weight, and the facility did not take appropriate actions to address the resident's nutritional needs, leading to the resident being moved to another care facility.
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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