Cashmere Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Cashmere, Washington.
- Location
- 817 Pioneer Avenue, Cashmere, Washington 98815
- CMS Provider Number
- 505151
- Inspections on file
- 29
- Latest survey
- January 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cashmere Post Acute during CMS and state inspections, most recent first.
The facility failed to ensure a designated Infection Preventionist (IP) worked at least part-time, with Staff J only dedicating 15% of their time to infection control duties. The Facility Assessment did not specify required IP hours, and Staff B, the DON, confirmed the insufficiency of time allocated for IP duties, placing residents at risk for infectious disease transmission.
The facility failed to develop baseline care plans within 48 hours for three residents, including one with vertebral fractures and another with heart failure. The plans lacked necessary PASARR recommendations and social services goals, and a readmitted resident's previous care plan was not updated promptly. Staff interviews indicated lapses in the timely creation and delivery of these care plans.
The facility failed to properly store and label potentially hazardous food in the kitchen, with numerous items found without use-by dates. Additionally, the concentration of disinfectant solution used for cleaning food preparation areas was below the required range, increasing the risk of cross-contamination. Staff E, the Dietary Department Director, acknowledged these lapses in procedure.
The facility failed to honor the rights of two residents regarding shower frequency and meal preferences. A resident with bipolar disorder was limited to one shower per week despite requesting more, and another resident with diabetes faced meal restrictions contrary to facility policy. The DON confirmed that the correct processes were not followed.
A facility breached a resident's privacy by posting a sign in their room that disclosed their schizophrenia diagnosis and personal preferences. The sign, observed by surveyors, included sensitive health information, which a registered nurse later confirmed should not be displayed in resident rooms.
The facility failed to maintain a sanitary and homelike environment in the shower room, which contained personal items and clutter, including a staff desk with electronic devices and personal drink containers. The resident bathtub area had damaged tiles and a crusty film on the faucet, compromising the comfort and safety of residents during showers. Staff acknowledged the inappropriate presence of food and drink in the shower room.
The facility failed to provide written bed-hold notices to two residents during hospital transfers, as required by policy. One resident experienced multiple hospital transfers without receiving complete or any bed-hold notices, while another resident's representative confirmed not receiving a notice. The DON acknowledged issues with the transition to electronic forms, affecting clarity and acknowledgment of bed-hold agreements.
The facility failed to ensure accurate PASARR assessments for residents with mental health conditions, leading to deficiencies in care. A resident was readmitted with mental health diagnoses, but the PASARR Level I form was incorrect, and no Level II screening was conducted. Two residents with mood disorders were not referred for Level II evaluations, and another resident was admitted without a completed PASARR Level I form. Staff acknowledged these procedural failures.
A facility failed to develop and implement a comprehensive care plan for a resident with a heart condition, as required by a physician's order. The resident refused to wear a pulmonary vest and take medication multiple times, but these refusals were not documented, nor was the physician notified. Staff interviews confirmed the resident's autonomy in decision-making, but the care plan was not updated to reflect these refusals, leaving the resident at risk for unmet care needs.
A facility failed to monitor fluid intake for a resident with a fluid restriction order, leading to consistent overages in fluid consumption. Additionally, another resident with mobility and positioning needs was not provided with necessary care, resulting in unsafe eating and mobility conditions. Staff interviews revealed a lack of awareness and procedures for both issues, placing residents at risk for health complications.
A resident with chronic pain conditions experienced inadequate pain management due to the facility's failure to implement an effective program. Despite receiving medications like oxycodone and Tylenol, the resident consistently reported high pain levels. Observations and interviews revealed a lack of clear dosing parameters and follow-up on specialist recommendations, contributing to unmanaged pain. The resident's care plan was outdated and lacked non-pharmacological interventions.
The facility had a medication error rate of 7.69% due to improper insulin administration for two residents. An LPN administered insulin without holding the needle in place for the recommended duration, as per facility policy and FDA guidelines. Both the LPN and the DON demonstrated a misunderstanding of the correct procedure, leading to potential incomplete dosage delivery.
The facility failed to remove expired medications from use and secure medication carts when unsupervised. Expired medications were found in multiple medication carts, and carts were left unlocked and unattended. Additionally, the facility did not follow CDC guidance for vaccine temperature monitoring, recording temperatures only once daily. These issues risked residents receiving expired or compromised medications and vaccines.
The facility failed to implement an effective Infection Control and Prevention Program, with staff not adhering to hand hygiene, equipment sanitation, and PPE protocols. Observations included improper handling of food, unsanitized use of mechanical lifts, and non-compliance with Enhanced Barrier Precautions and Transmission-Based Precautions, increasing the risk of infection transmission.
The facility failed to update the daily nursing staff posting, with observations showing outdated information for four out of five days. Interviews revealed confusion over responsibility for weekend updates, with the Staffing Coordinator and DON acknowledging the need for a better system. The Administrator was informed of the inconsistency and planned to assign the task to a dedicated staff member.
A resident with intact cognition and independent mobility left the facility unsupervised, and the investigation was incomplete, lacking witness statements and documentation of notifications. No interventions were formulated to prevent further elopement, and the care plan was not updated. The resident went missing again the next day and discharged against medical advice.
The facility failed to assess and implement interventions for residents with substance use disorder (SUD) and elopement risks. A resident with a PICC line and high elopement risk was allowed unsupervised access outside the facility, leading to multiple elopements. Two other residents with SUD were also at risk for elopement, but their care plans lacked necessary interventions. Staff interviews revealed a lack of training in managing SUD, contributing to inadequate care planning and delayed responses to elopement incidents.
A facility failed to inform a resident and their representative of an increase in monthly financial responsibility before charging the updated amount to the debit card on file. The Business Office Manager altered the Credit Card Authorization Form without agreement, and attempts to notify the representative were unsuccessful. Both the former and current administrators acknowledged the facility's responsibility to notify residents and representatives of billing changes.
Inadequate Infection Preventionist Time Allocation
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) who worked at least part-time and was responsible for the Infection Control and Prevention Program (IPCP). This deficiency was identified through interviews and record reviews, which revealed that the current IP, Staff J, only devoted approximately 15% of their working hours to infection control duties. The remaining time was spent on responsibilities as a Resident Care Manager. The facility's policy required the IP to be employed on-site at least part-time, with enough time allocated to assess, develop, implement, monitor, and manage the IPCP, as well as address training requirements and participate in required committees such as Quality Improvement and Performance Improvement (QAPI). The Facility Assessment (FA) dated 09/20/2024, indicated the need for an IP to develop and regularly update infection control protocols, ensure personal protective equipment availability, and manage vaccination availability. However, the FA did not specify the number of IP hours per week required to meet the needs of residents and staff. During an interview, Staff B, the Director of Nursing, confirmed that they did not perform any IP duties and acknowledged that the 15% of time Staff J devoted to IP duties was insufficient to cover the facility's needs. This lack of adequate time and resources for infection prevention placed residents at risk for the transmission of infectious diseases and unmet care needs.
Failure to Develop Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for three residents, which is a requirement to ensure continuity and resident-centered care. Resident 48 was admitted with conditions such as vertebral fractures, kidney and respiratory failure, and muscle weakness, requiring maximum assistance for ADLs. However, the baseline care plan was not documented until five days after admission, missing PASARR recommendations and behavioral health goals. Similarly, Resident 196, admitted with heart failure and adult failure to thrive, did not have a baseline care plan with PASARR recommendations or social services goals until four days post-admission. Resident 9, who was a readmission, had their previous care plan automatically pulled into their new admission record, which was not updated until five days after their current admission. This oversight was due to the previous care plan not being closed out in the electronic medical record upon their prior discharge. Staff interviews revealed that the responsibility for creating and delivering the baseline care plans was assigned to specific staff members, but the process was not completed within the required timeframe, leading to the deficiency.
Improper Food Storage and Disinfectant Use in Kitchen
Penalty
Summary
The facility failed to properly store and label potentially hazardous food (PHF) and dry goods in the kitchen, as observed during a survey. Items in the refrigerator, such as green beans, peas, chicken noodle soup, shredded American cheese, carrots, thickened cranberry juice, health shake, and whipped topping bags, were found without use-by dates. Similarly, items in Freezer #1, Freezer #2, and Freezer #3, including ground beef, diced ham, battered fish, biscuits, garlic bread, various soups, chicken breast, pork sausage patties, beef hot dogs, chili, beef steaks, ham, and cinnamon rolls, were also unlabeled and lacked open or use-by dates. Staff E, the Dietary Department Director, acknowledged that the process for labeling and dating food items was not being followed, which is contrary to the facility's policy and the Washington State Retail Food Code. Additionally, the facility failed to maintain the proper concentration of disinfectant solution used for cleaning food preparation areas, which is crucial to prevent cross-contamination. During an observation, Staff E tested a bucket of Disinfect Multi-Quat 146 solution and found it had a concentration of 100 parts per million (PPM), which is below the required range of 150 to 400 PPM. Staff E admitted there was no process for testing the solution in the disinfectant buckets, and they were changed approximately every four hours. This failure to maintain the correct concentration of disinfectant solution further increased the risk of cross-contamination in the kitchen.
Failure to Honor Resident Choices in Showers and Meals
Penalty
Summary
The facility failed to honor the residents' rights to self-determination and choice, specifically regarding the frequency of showers and meal preferences. Resident 87, who has diagnoses including bipolar disorder and personality disorder, was only scheduled for one shower per week despite expressing a desire for at least two showers weekly. The resident had communicated this preference to the staff, but the request was not accommodated. The Director of Nursing acknowledged that the process for accommodating such requests was not followed. Resident 22, who has diabetes mellitus, heart failure, and liver disease, reported limitations on the amount of food they could have at meals, which was contrary to the facility's stated process. The resident expressed dissatisfaction with the meal restrictions, noting that if they were still hungry after a meal, they could not receive additional food. The Director of Nursing confirmed that it was not the facility's process to limit food and that residents should be allowed additional meals if requested.
Violation of Resident Privacy Due to Posted Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical condition by posting a sign in the resident's room that disclosed private health information. The sign, observed on January 6, 2025, was laminated and displayed in bold black lettering above the bed of a resident diagnosed with schizophrenia. It included details about the resident's mental health condition, stating, 'I have schizophrenia, I come in and out of reality (not from drugs),' along with other personal preferences and needs. This action violated the resident's right to privacy regarding their medical condition. A registered nurse confirmed during an interview on January 9, 2025, that such signs should not be displayed in resident rooms as they contain private personal health history information.
Unsanitary and Cluttered Shower Room Environment
Penalty
Summary
The facility failed to ensure a sanitary and homelike environment in the shower room, which was observed to contain various personal items and clutter. During an observation and interview, it was noted that the shower room had a staff desk with a laptop, computer tablet, and a clipboard of resident names, along with personal items such as a large pink jug, a black shaker cup, and a pink cell phone. The shower area also contained a large pink drink tumbler and a Dutch Bro's cup with a brown and white liquid. Additionally, the resident bathtub area had a chair with torn fabric, bulging tiles, and broken tiles with sharp edges, as well as a white, crusty film on the faucet handles and spout. Staff G, a Nursing Assistant, was observed using the personal items in the shower room, and Staff B, the Director of Nursing, acknowledged that food and drink should not be present in the shower room. Staff B also stated that the desk was intended for nursing assistants to document, but they could use the nursing station instead. The presence of these items and the condition of the shower room did not provide a comfortable and homelike experience for residents during showers, as required by the facility's policy on resident rights.
Failure to Provide Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to issue a written notice of bed hold to residents or their representatives at the time of hospital transfer, as required by their policy. This deficiency was identified for two residents, Resident 27 and Resident 58, who were transferred to the hospital for evaluation due to various health issues. The facility's policy mandates providing written information about the duration of the bed hold, reserve bed payment, and policies regarding bed-hold periods before transferring a resident to the hospital. However, the records for Resident 27 showed that during multiple hospital transfers, either the bed-hold notice was incomplete or not provided at all. Similarly, for Resident 58, there was no documentation of a bed-hold notice being issued during their hospital transfer. Interviews conducted with Resident 58's representative and the Director of Nursing (DON) revealed further insights into the deficiency. Resident 58's representative confirmed that they were not provided with a bed-hold notice during the resident's hospital stay. The DON acknowledged that while bed holds were offered upon admission, the transition from paper to electronic forms had led to issues with clarity and acknowledgment of the bed-hold agreement by residents or their representatives. This oversight placed residents at risk of not being informed about their rights and potential charges associated with bed holds during hospital stays.
Deficiencies in PASARR Assessments for Residents with Mental Health Conditions
Penalty
Summary
The facility failed to ensure accurate Preadmission Screening and Resident Review (PASARR) assessments for residents with mental health conditions, leading to deficiencies in the care provided. Resident 51 was readmitted with multiple mental health diagnoses, including bipolar disorder and adjustment disorder, but the PASARR Level I form incorrectly indicated no serious mental illness, and no Level II screening was conducted. Staff D acknowledged the oversight, noting that a new PASARR Level I was not completed upon the resident's return from the hospital. Resident 55, admitted with major depressive disorder and experiencing delusions, was identified in the PASARR Level I assessment as having a mood disorder. However, a Level II evaluation was not conducted, contrary to the requirements. Similarly, Resident 84, with diagnoses of schizophrenia and major depressive disorder, was also not referred for a Level II evaluation despite being identified with a schizophrenic and mood disorder in the PASARR Level I assessment. Staff D admitted to not following the correct process for these residents. Additionally, Resident 9 was admitted without a completed PASARR Level I form, as required. Staff E and Staff F were unable to locate the form in the medical record, indicating a lapse in the admission process. The facility's administrator, Staff A, confirmed the necessity for timely and accurate PASARR screenings upon admission, highlighting the procedural failures in the facility's handling of PASARR assessments.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for Resident 27, who had complex medical diagnoses including a heart condition that could lead to fluid in the lungs. Despite a physician's order from November 2024 directing staff to assist the resident with wearing a pulmonary vest and documenting any refusals, the facility did not create a care plan addressing the use of the pulmonary vest or the resident's refusal of care. The resident's medical record showed numerous refusals of the pulmonary vest and medication, yet there was no documentation of these refusals, no risk and benefits assessment, and no notification to the physician. Interviews with staff revealed that Resident 27 had worn the pulmonary vest initially but had since stopped, and staff did not document the refusals or update the care plan accordingly. The Director of Nursing acknowledged that refusals should be part of the care plan to meet the resident's needs. The lack of a comprehensive care plan and failure to document refusals left the resident at risk for unmet care needs and other negative health outcomes.
Deficiencies in Fluid Monitoring and Positioning Care
Penalty
Summary
The facility failed to develop and implement a process for monitoring daily fluid intake for a resident with a physician's order for fluid restriction. Resident 196, who was admitted with diagnoses including biventricular heart failure and generalized edema, had a physician's order for a 2000 mL fluid restriction per day. However, observations and interviews revealed that the nursing staff did not accurately monitor or record the resident's fluid intake. The medication administration record showed consistent overages in fluid intake, with daily totals significantly exceeding the prescribed limits. Staff interviews indicated a lack of awareness and proper procedures for tracking fluid intake, leading to the resident receiving more fluids than allowed. Additionally, the facility failed to provide necessary care and services for Resident 4, who required assistance with positioning during meals and wheelchair use. Resident 4, diagnosed with conditions such as osteoporosis and spastic hemiplegia, was observed in a hunched position in their wheelchair, which affected their ability to eat and move safely. The care plan lacked interventions for proper positioning, and staff interviews confirmed that no assessments or instructions were provided for Resident 4's positioning needs. Observations showed that Resident 4 struggled with eating and mobility due to their positioning, leading to concerns about their safety and well-being. The deficiencies in monitoring fluid intake and providing appropriate positioning care placed both residents at risk for health complications and poor clinical outcomes. The facility's failure to implement effective processes and provide necessary care highlights significant gaps in the quality of care provided to these residents.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to develop and implement an effective pain management program for a resident, identified as Resident 51, who was reviewed for pain management. The resident was admitted with multiple diagnoses, including neck pain, chronic pain syndrome, lumbar stenosis with neurogenic claudication, and osteoarthritis of the knee. Despite receiving scheduled pain medication, PRN medications, and non-medication interventions, the resident consistently reported high pain levels, indicating that their pain was not adequately managed. Observations and interviews revealed that Resident 51 experienced significant pain in their knees, hip, and back, and expressed feelings of not being believed about their pain. The resident was receiving oxycodone and Tylenol for pain management, but continued to rate their pain at a high level on the pain scale. The facility's pain assessments indicated that the resident's pain appeared to be fairly well controlled, despite the resident's verbal and non-verbal expressions of pain. Additionally, the resident had not been evaluated by relevant specialists for over two years, and there was a lack of follow-up on recommended treatments such as steroid injections. Interviews with facility staff highlighted inconsistencies in the administration of pain medication, with no clear parameters for dosing based on pain levels. Staff members acknowledged the need for a process to ensure appropriate medication administration and conversion of PRN medications to scheduled medications. The resident's care plan had not been updated for over two years and did not include non-pharmacological interventions for pain management. The lack of clear guidelines and follow-up on specialist recommendations contributed to the deficiency in providing effective pain management for the resident.
Medication Administration Errors in Insulin Delivery
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 7.69% during a survey. This was identified through observations of medication administration for two residents, Resident 8 and Resident 345, out of 26 opportunities. Resident 8, who had diabetes and a history of stroke, was observed receiving 12 units of insulin, but the needle was only held in place for two seconds instead of the recommended six to ten seconds. This improper technique could lead to incomplete dosage delivery. Similarly, Resident 345, who also had diabetes, was administered seven units of insulin with the needle held for only three seconds, contrary to the facility's policy and FDA guidelines. The observations revealed that Staff C, an LPN, did not adhere to the correct procedure for insulin administration, as confirmed by their statement that holding the needle for a second or two was sufficient. This was further corroborated by the Director of Nursing, who also indicated a misunderstanding of the correct procedure. The facility's failure to ensure proper insulin administration practices contributed to the medication errors, potentially affecting the therapeutic outcomes for the residents involved.
Expired Medications and Unsecured Carts Found in Facility
Penalty
Summary
The facility failed to ensure expired medications were removed from use and that medication carts were secured when unsupervised. During observations, expired medications were found in the South and North Hall medication carts, including Nystatin powder and cream, Ketoconazole cream, Ciclopirox cream, GI Cocktail, Nitroglycerin, Flonase Spray, Albuterol inhalers, wound gel, Ondansetron, and Chlorhexidine Gluconate. Additionally, the East Hall medication cart was left unlocked and unattended by a registered nurse on two occasions, and the wound treatment cart, which contained vaccines and other medications, was also left unsecured. The wound treatment cart lacked a locking mechanism, and staff were observed walking away from it while it contained medications. The facility also failed to adhere to CDC guidance for temperature monitoring of vaccines stored in the medication refrigerator. The refrigerator, which contained RSV and influenza vaccines, had its temperature recorded only once a day, contrary to CDC recommendations of using a digital data logger or recording temperatures at least twice daily. The Director of Nursing was unaware of the requirement for more frequent temperature monitoring. These deficiencies placed residents at risk of receiving expired or compromised medications and vaccines, as well as unauthorized access to potentially harmful medications.
Inadequate Infection Control and Prevention Program
Penalty
Summary
The facility failed to implement an effective Infection Control and Prevention Program (IPCP), as evidenced by multiple observations of staff not adhering to established infection prevention measures. Staff Q was observed during dining service handling food and soiled items without performing hand hygiene, which is a critical step in preventing the spread of infection. This lack of hand hygiene was contrary to CDC guidelines, which emphasize the importance of cleaning hands before and after patient contact and after contact with potentially contaminated surfaces. Additionally, the facility did not ensure proper cleaning of equipment, as observed with the use of mechanical lifts by multiple staff members (Staff W, Y, S, V, T, U, AA, and BB). These lifts were used for resident transfers without being sanitized between uses, increasing the risk of cross-contamination. The mechanical lifts were stored in a soiled utility room, which was not an appropriate storage area for clean equipment, as it contained soiled items and standing water, further compromising infection control practices. The facility also failed to adhere to Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP). Staff members were observed not wearing the required personal protective equipment (PPE) such as gowns and gloves during high-contact resident care and while in isolation rooms. This non-compliance with PPE protocols was observed during wound care, catheter management, and other resident interactions, which are critical moments for preventing the spread of multidrug-resistant organisms and other infections. Furthermore, food service practices were inadequate, with meal carts containing uncovered food items being left unattended, increasing the risk of foodborne illnesses.
Failure to Update Daily Nursing Staff Posting
Penalty
Summary
The facility failed to ensure that the nursing staff posting was updated daily to reflect the actual nursing staff hours worked during four out of five days of the survey period. Observations on multiple days showed that the nursing staff posting, located across from the nurses' station, was outdated and did not display the current day's staffing information. Specifically, on January 6th, 7th, 8th, and 9th, the posting was dated January 3rd, and on January 10th, it was dated January 9th, failing to show the actual nursing staff hours for those days. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for updating the nursing staff postings, particularly over the weekends. Staff H, the Staffing Coordinator, mentioned that the postings were prepared in advance and left for the nursing staff to display over the weekend, but acknowledged the need to revisit this process. Staff B, the Director of Nursing, admitted the necessity for a better system, and Staff A, the Administrator, was made aware of the inconsistency and planned to assign the task to a dedicated staff member. This deficiency prevented residents, family members, and visitors from knowing the facility's actual number of available nursing staff.
Failure to Investigate Resident Elopement
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a missing resident, identified as Resident 1, who was reviewed for elopement. Resident 1, who had an intact cognition and was independent in transfers and walking, left the facility unsupervised and without staff knowledge. The investigation into the incident was incomplete, lacking witness statements, a timeline of events, and documentation of notifications to the provider, local law enforcement, or the resident's representative. Additionally, there were no interventions formulated to prevent further elopement, and the resident's care plan was not updated to reflect the risk or actual elopement. Staff interviews revealed that key personnel were out of town during the incident, and those present did not conduct interviews with staff or other residents to determine how Resident 1 left unnoticed. Notifications to the resident's representative and law enforcement were made but not documented. A verbal agreement was made with Resident 1 not to leave the facility again without notifying staff, but this was not documented in the care plan. The following day, Resident 1 went missing again and was later found at a bus stop, after which they discharged from the facility against medical advice. The second elopement was not treated as such, and no investigation was conducted.
Failure to Address Elopement Risks and SUD in Residents
Penalty
Summary
The facility failed to ensure that residents with substance use disorder (SUD) received appropriate assessments and interventions, particularly concerning the risk of elopement. Three residents were identified as having SUD and were at risk for elopement, yet their care plans did not reflect necessary interventions or increased supervision. Resident 1, who had a history of drug use and was previously homeless, was assessed as high risk for elopement but was allowed to leave the facility unsupervised, even with a PICC line in place. The care plan for Resident 1 lacked coping strategies and did not address the elopement risk or the potential misuse of the PICC line. Resident 2, who was assessed as a moderate risk for elopement, was observed attempting to leave the facility without proper supervision or intervention. Their care plan also failed to include coping strategies or specific interventions for their alcohol/drug dependency and elopement risk. Similarly, Resident 3, also assessed as a moderate risk for elopement, had no care plan addressing their SUD or elopement risk. The facility's policies on elopement and SUD were not effectively implemented, as evidenced by the lack of staff training and the absence of appropriate care planning. Interviews with staff revealed a lack of training and awareness regarding the management of residents with SUD. Staff E, responsible for formulating care plans, admitted to not assessing residents for SUD due to a lack of training. The facility's response to Resident 1's elopement incidents was delayed, with notifications to law enforcement and the resident's representative occurring hours after the resident was last seen. The facility's failure to implement timely and effective interventions for residents with SUD and elopement risks placed these residents at risk for preventable accidents.
Failure to Notify Resident of Increased Financial Responsibility
Penalty
Summary
The facility failed to inform a resident and their representative of an increase in their monthly financial responsibility before charging the updated amount to the debit card on file. The resident, who was admitted with diagnoses including a left hip fracture, osteoporosis, and severe obesity, had intact cognition and required assistance for mobility and personal care. The admission agreement stipulated that residents would be notified of any rate changes at least 30 days in advance. However, the facility received notification from a State Agency about the change in the resident's care cost participation amount, but did not inform the resident or their representative before charging the increased amount. The Business Office Manager admitted to altering the Credit Card Authorization Form using correcting tape to reflect the new amount without obtaining agreement from the resident or their representative. Attempts to notify the representative via phone were unsuccessful, and no written notification was provided. The former and current administrators acknowledged the facility's responsibility to notify residents and representatives of billing changes and stated that a new authorization form should have been obtained. The failure to properly notify and obtain agreement for the increased charge was identified as a deficiency.
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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