Cedar River Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Renton, Washington.
- Location
- 17420 106th Pl Se, Renton, Washington 98055
- CMS Provider Number
- 505532
- Inspections on file
- 14
- Latest survey
- April 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cedar River Healthcare Center during CMS and state inspections, most recent first.
The facility did not ensure that the QAA committee included all required members or that meetings were held as scheduled, with repeated absences of the Medical Director, DON, and Infection Preventionist, and missing documentation for some months, in violation of facility policy and regulatory requirements.
Staff failed to secure medical records and appointment information, leaving documents with resident names and medical details visible at nurse's stations and in public areas. In one case, a family member received another resident's insurance information via email. The DON confirmed staff were expected to keep all PHI confidential and out of public view, but these expectations were not met.
A resident who required maximal assistance with eating due to shoulder fractures was left unattended for 11 minutes after being given only a few bites of food, as a CNA prioritized delivering other trays. The DON and Administrator acknowledged the need for improved meal assistance practices to ensure a dignified dining experience, in line with facility policy.
Two residents were admitted from the hospital with incomplete or inaccurate PASRR documentation, including missing or incorrectly recorded diagnoses of anxiety and depression. Despite the presence of SMI indicators, required Level II evaluations were not performed prior to admission, resulting in the residents not being properly assessed for mental health needs.
Staff did not develop or update care plans to address all identified needs for four residents, including pain management after knee surgery, bilateral shoulder fractures, gout, and GERD. Care plans lacked necessary details for specific conditions and interventions, despite medical records and resident reports indicating these needs.
Staff did not follow physician orders for a resident with heart conditions, failing to notify the physician after a significant weight gain and administering blood pressure medication despite a low pulse. The facility's own policies for medication administration and weight monitoring were not followed.
Two residents assessed as needing assistance with ADLs did not receive scheduled showers or proper nail care. One resident missed multiple scheduled showers and had overgrown fingernails, while another, dependent on staff and requiring diabetic nail care, had long, cracked toenails despite documentation indicating care was provided. Staff interviews confirmed these lapses in care.
Staff did not promptly remove fall interventions that were determined to be unbeneficial for a resident with multiple complex conditions, leaving floor mats in place after they were discontinued. Additionally, a resident with a neurological disorder and fall risk was found using a low air loss mattress that extended beyond the bedframe, with staff confirming the need for adjustment to ensure safety.
A resident with multiple medical conditions experienced significant weight loss over several days, but staff did not notify the provider or dietitian as required by facility policy and physician orders. Documentation and staff interviews confirmed that the necessary notifications and interventions were delayed, and snacks were not provided until several days after being recommended in a nutritional assessment.
A resident with a history of stroke and swallowing difficulties did not consistently receive the full volume of tube feeding nutrition as ordered, with staff documentation showing repeated shortfalls and observations confirming leftover nutrition in the feeding bag at the end of scheduled periods. The MAR lacked a section for daily totals or remaining amounts, and staff were unclear about monitoring practices, leading to incomplete delivery of prescribed artificial nutrition.
A resident with multiple medical conditions and a history of refusing care, including daily weights and other treatments, was not referred to or assisted by social services despite a care plan assigning them this responsibility. Nursing staff attempted to address the refusals, but social services staff were unaware of the ongoing issues and did not participate in problem-solving, resulting in a failure to provide required medically-related social services.
A resident with a POLST form requesting CPR experienced an unexpected death due to staff's failure to initiate CPR, miscommunication about the resident's code status, and the misplacement of the POLST form. The staff mistakenly believed the resident was a DNR, leading to a delay in CPR initiation until emergency services arrived.
A resident was left in the same room with their deceased roommate for 19.5 hours, compromising their dignity and mental well-being. Despite being cognitively intact and having a history of depression and anxiety, the resident was not moved, nor was the deceased, due to a lack of process for such situations. Staff acknowledged the oversight and the discomfort it would cause.
The facility failed to ensure nursing staff and nurse aides had the necessary competencies to provide adequate care, affecting all 11 staff members reviewed. Despite the facility's assessment indicating that staff competencies should be evaluated, training records lacked documentation verifying staff competency according to their licensure or certification. Interviews revealed the absence of a system to verify staff competency, placing residents at risk.
A resident with a Physician Order for full resuscitation did not receive CPR when their heart stopped, leading to their death. The Director of Nursing confirmed that staff neglected to follow the order and the incident was not reported to the state agency as required, placing other residents at risk.
A facility failed to investigate and document an incident where a resident did not receive CPR despite a Physician's Order. The DON did not conduct a thorough investigation or report the incident to the state agency, and staff involved were not interviewed. This failure to follow protocol placed other residents at risk.
A resident at high risk for pressure ulcers due to a stroke and hemiplegia developed a Deep Tissue Injury (DTI) on the left heel. The care plan lacked specific interventions for the resident's condition, and inconsistencies in staff assistance with bed mobility were noted. The facility's investigation identified risk factors but did not incorporate them into the care plan, leading to the preventable injury.
Failure to Maintain Required QAA Committee Membership and Meeting Frequency
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee with the required members and did not consistently hold meetings as outlined in their policy. According to the facility's December 2024 QAPI Committee policy, the committee was to meet monthly and include the Administrator, Director of Nursing Services, Medical Director, and an infection control representative. However, review of meeting sign-in sheets revealed repeated absences of key members, including the Medical Director, Director of Nursing, and Infection Preventionist, across multiple meetings. Additionally, there was no documentation of QAPI meetings for certain months, specifically December 2024 and March 2025. During an interview, the newly hired Administrator confirmed that QAPI meetings were expected to be held monthly and that all required committee members should attend. The Administrator was unable to account for the missing meetings and acknowledged the absence of key participants in several documented meetings. This lack of compliance with both facility policy and regulatory requirements resulted in the deficiency cited by surveyors.
Failure to Protect Resident Health Information Privacy
Penalty
Summary
Facility staff failed to maintain the privacy and confidentiality of residents' medical information as required by facility policy and state regulations. Multiple observations revealed that appointment arrangement forms and medical information for several residents were left in plain view on nurse's station counters and in upright document stands, making them easily readable to anyone passing by. These documents included residents' names and details about their medical appointments, such as visits to oncology, hematology, orthopedic, urology, pulmonary, sleep, and radiology clinics, as well as information about blood draws. Additionally, a list of resident weights was left out in a public area, and the names of the residents could be matched to their weights using signage outside their rooms. In one instance, a family member of a resident reported receiving an email from the facility that contained insurance information for another resident, rather than for their own family member. The email included the other resident's name, admission status, co-pay amount, and supplemental insurance company. This error was acknowledged by the facility, and a corrected email was sent the following day. Interviews with facility staff, including the Director of Nursing, confirmed that the expectation was for all staff to maintain the privacy and confidentiality of resident information at all times. Staff were instructed to ensure that computer screens were not visible to others, carts were locked, and that report sheets and other information were not left visible in public areas. Despite these expectations, the observed actions and inactions led to the exposure of protected health information for multiple residents.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
Staff failed to provide care and services in a manner that maintained and promoted dignity for a resident who required substantial to maximal assistance with eating due to bilateral shoulder fractures. During observation and interview, a CNA assisted the resident with only four large bites of oatmeal before leaving the room to deliver other food trays, leaving the resident unattended for 11 minutes before returning to continue assistance. The resident expressed that they needed to be fed because they could not move their arms and noted that staff seemed very busy with other residents. The CNA confirmed that their practice was to give the resident a few bites and then return after distributing other trays. The Director of Nursing acknowledged that care staff needed help with tray services and had requested leadership assistance. The Administrator stated that their expectation was for staff to only place a tray in front of a resident when they were ready to assist with the entire meal, in order to promote dignity. The facility's policy required that residents be supported and provided with a dignified dining experience.
Failure to Complete Accurate PASRR Assessments Prior to Admission
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were completed accurately and as required for two residents reviewed for PASRR screening. For one resident, the Level I PASRR received from the hospital did not include a diagnosis of anxiety, which was later identified and corrected by facility staff. However, although the corrected Level I PASRR included an indicator for Serious Mental Illness (SMI), a referral for a Level II evaluation was not made as required. For the second resident, the Level I PASRR completed at the hospital marked the resident as having no SMI indicators, but also identified depression as an SMI indicator in a subsection. Despite this, the form concluded that a Level II evaluation was not required, and the resident was admitted without the necessary Level II PASRR evaluation. Staff interviews confirmed that the expectation was for Level I PASRRs to be accurate and for Level II evaluations to be obtained when indicated. In both cases, the residents were admitted from the hospital with incomplete or inaccurate PASRR documentation, and the required follow-up for Level II evaluation was not performed, despite the presence of SMI indicators such as anxiety and depression. This failure resulted in the residents not being properly evaluated for mental health needs prior to admission.
Failure to Develop Comprehensive Care Plans for Multiple Residents
Penalty
Summary
Facility staff failed to develop and implement comprehensive care plans (CPs) that addressed all identified care needs for four residents. For one resident with a history of spinal cord dysfunction, spinal stenosis, and a recent total knee replacement, the CPs did not include the resident's right knee pain or the need to keep the knee straight for healing, despite the resident reporting ongoing pain and limited mobility due to the surgery. Staff interviews confirmed that the knee pain and related interventions were omitted from the CP, which should have included these details for appropriate pain management and therapy. Another resident with fractures in both shoulders had a CP that only addressed the right shoulder fracture, even though medical records and care conference notes documented fractures in both shoulders. The resident required slings on both arms and needed staff to exercise caution during transfers and showers. Staff confirmed that the left shoulder fracture and necessary precautions were not included in the CP, despite the resident experiencing pain in both shoulders and requiring similar interventions for each. Additionally, two other residents with complex medical conditions did not have CPs developed for specific diagnoses being actively treated. One resident receiving medication for gout did not have a CP addressing gout management, including signs, symptoms, and interventions for acute episodes. Another resident with GERD and a physician's order for a proton-pump inhibitor lacked a CP for GERD and related medication use. Staff interviews confirmed that CPs for these conditions were missing, contrary to facility policy requiring CPs for each diagnosis or condition under treatment.
Failure to Follow Physician Orders for Medication and Weight Monitoring
Penalty
Summary
Facility staff failed to follow physician's orders for a resident with complex medical conditions, including heart disease, heart failure, and high blood pressure. The physician's orders required daily weight monitoring with notification to the physician if the resident gained more than two pounds in a day or five pounds in a week. On one occasion, the resident's weight increased by 4.2 pounds in a single day, but there was no documentation that the physician was notified as required by the order. The facility's policy also required monitoring for undesirable weight changes, which was not followed in this instance. Additionally, the resident had an order for a blood pressure medication that was to be held if their pulse was less than 60 beats per minute. Despite the resident's pulse being recorded at 57 beats per minute on one occasion, the nurse administered the medication instead of holding it as directed. The Resident Care Manager confirmed that the physician was not notified of the weight gain and that the medication should have been held when the resident's pulse was below the specified threshold.
Failure to Provide Required ADL Assistance and Nail Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents who were assessed as needing help. One resident, who had a compression fracture in the spine and required moderate assistance with bathing, was scheduled for showers twice weekly according to the care plan and facility policy. However, observations and interviews revealed that this resident repeatedly requested showers and was told by staff that it would be done the following day, resulting in no showers being provided over an eight-day period. The resident's fingernails were also observed to be overgrown, and staff confirmed that nail care should have been provided on shower days. Another resident, who was dependent on staff for dressing and repositioning and had diabetes, was assessed to require weekly diabetic nail care by a licensed nurse. Despite documentation indicating that nail care was provided, observations showed the resident's toenails were long, cracked, and curling, and the resident reported that requests for nail care were not fulfilled. Staff confirmed the importance of nail care and acknowledged that the resident's toenails had not been properly trimmed.
Failure to Timely Remove Unbeneficial Fall Interventions and Ensure Proper Mattress Fit
Penalty
Summary
Facility staff failed to remove fall interventions in a timely manner when they were assessed as unbeneficial for a resident with multiple complex medical diagnoses, including cancer, heart failure, kidney disease, muscle weakness, and Parkinson's disease. Despite documentation that floor mats were not an appropriate intervention and should be discontinued, observations showed that the mats remained at both sides of the resident's bed several days after the decision. The DON confirmed that staff did not implement the change as expected, resulting in the continued presence of the floor mats. Additionally, the facility did not ensure that a resident's mattress fit the bedframe properly. A resident with a progressive neurological disorder, wasting condition, and a history of falls was observed lying on a low air loss mattress that extended beyond the bedframe by one to four inches. Staff confirmed that the mattress overhang required correction and that extender bars were needed to secure the mattress for safety, as the mattress should be properly fitted to the bedframe.
Failure to Timely Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure timely evaluation and intervention for a resident experiencing significant weight loss. According to facility policy, any weight change of five percent or more required immediate written notification to the dietitian, and physician orders required staff to monitor the resident's weight daily and notify the provider of more than two pounds of weight loss in one day or five pounds compared to the previous week. Despite these requirements, documentation showed that the resident experienced a weight loss of over six percent between 4/16/2025 and 4/21/2025, but there was no evidence that the provider or dietitian were notified as required. Progress notes did not reflect timely communication or intervention, and snacks were not implemented until five days after the nutritional risk assessment recommended them. The resident involved had diagnoses including congestive heart failure, dementia, gastric ulcer, and unilateral weakness, and required supervision or assistance with eating. Staff interviews confirmed that the required notifications were not made, with some staff unaware of the need to report weight loss, and others unsure of the reporting requirements. The lack of timely notification and intervention was contrary to both physician orders and facility policy, resulting in a delay in addressing the resident's nutritional needs.
Failure to Provide Ordered Volume of Tube Feeding Nutrition
Penalty
Summary
Facility staff failed to ensure that a resident who required tube feeding received the full volume of artificial nutrition as ordered by the physician. The resident, admitted for care after a stroke and with swallowing difficulties, had a physician order for 1440 CC of liquid nutrition to be administered via feeding tube over an 18-hour period each day. Review of the Medication Administration Record (MAR) revealed that on multiple days, the resident received less than the ordered amount, with discrepancies ranging from 105 CC to 241 CC below the prescribed volume. The MAR did not provide a place to document the daily total of nutrition provided or the amount remaining at the end of each feeding cycle. Observations confirmed that the feeding pump was not always running as scheduled, and significant amounts of liquid nutrition remained in the bag at the end of the feeding period. Staff interviews indicated a lack of clarity regarding documentation of daily totals and remaining nutrition, and staff were not certain if this information was being monitored. The facility's policy required documentation of the amount and type of feeding provided, but this was not consistently done, resulting in the resident not receiving the full prescribed nutrition.
Failure to Involve Social Services in Addressing Resident's Refusals of Care
Penalty
Summary
The facility failed to ensure that medically-related social services were provided for a resident who was reviewed for nutrition and demonstrated a pattern of refusing care. The resident, who had intact memory and diagnoses including respiratory failure, reduced mobility, and pressure injuries, was dependent on staff for transfers and was on a diuretic requiring daily weights. Despite a care plan that identified social services staff as responsible for addressing refusals of care, the social services department was not informed of the resident's frequent refusals to be weighed, nor were they involved in problem-solving these refusals. Documentation showed the resident refused daily weights on 18 out of 41 occasions, as well as other treatments such as constipation management and weekly skin assessments. Staff interviews revealed that while nursing staff attempted to discuss risks and benefits with the resident and involved the resident's spouse in signing a Risks vs. Benefits form, the social services staff were unaware of the extent of the refusals and had not been engaged to address the resident's behavioral health needs. The social services coordinator expressed that they could have intervened if they had been informed. This lack of involvement from social services in managing the resident's ongoing refusals of care constituted a failure to provide necessary medically-related social services as required.
Failure to Perform CPR Due to Miscommunication and Policy Non-Compliance
Penalty
Summary
The facility failed to ensure that staff performed Cardiopulmonary Resuscitation (CPR) for a resident who was reviewed for unexpected death. The deficiency occurred when staff did not follow the facility's policy for CPR, which included the ability to accurately assess signs of irreversible death, verify the Physician's Order (PO) for CPR status, and access the resident's POLST form. The staff also failed to initiate CPR, communicate effectively with the 911 operator, and provide accurate resident records to Emergency Medical Services (EMS) personnel. Resident 1, who was admitted to the facility with a diagnosis of sepsis and pneumonia after a COVID-19 infection, had a POLST form indicating a desire for CPR and full medical treatment. On the day of the incident, Resident 1 became weak and short of breath while walking with a Certified Nursing Assistant (CNA). The resident was brought back to their room, and oxygen was started. However, when the resident's condition worsened, the staff failed to initiate CPR, mistakenly believing the resident was a Do Not Resuscitate (DNR) case. The confusion was exacerbated by the misplacement of Resident 1's POLST form, which was not in the binder at the nurse's station. Instead, Resident 2's POLST form, indicating DNR, was mistakenly provided to the Fire Department personnel. This error led to a delay in CPR initiation, and the resident was pronounced dead upon the arrival of emergency services. Interviews with staff revealed a lack of clarity and communication regarding the resident's code status, contributing to the failure to provide timely CPR.
Failure to Maintain Resident Dignity After Roommate's Death
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident, referred to as Resident 2, by not providing a comfortable environment following the death of their roommate, Resident 1. Resident 2, who was cognitively intact but had a history of depression and anxiety, was left in the same room with the deceased Resident 1 for 19.5 hours. This situation arose because the staff did not have a process in place to address such incidents, resulting in Resident 2 being exposed to a potentially distressing environment that could harm their mental well-being, safety, and dignity. Interviews with staff members revealed that the body of Resident 1 remained in the room with Resident 2 from 10:00 PM until 5:30 PM the following day. Staff C, a registered nurse, acknowledged the incident and admitted that no efforts were made to move either resident to a different room. Staff B, the Director of Nursing, confirmed the duration the body remained in the room and recognized that the situation was not conducive to maintaining a homelike environment or the mental well-being of Resident 2. Both staff members acknowledged that a reasonable person would feel uncomfortable and possibly scared in such a situation.
Lack of Competency Verification for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff and nurse aides possessed the necessary competencies and skills to provide adequate care and ensure the safety and well-being of residents. This deficiency was identified for all 11 staff members reviewed, including Certified Nursing Assistants and Licensed Nurses. The facility's assessment indicated that staff competencies should be evaluated through skills validation, testing, and face-to-face encounters, covering areas such as Person-Centered Care, Activities of Daily Living, Disaster Planning, Infection Control, and Medication Administration. However, the training records reviewed did not contain documentation verifying that staff were competent to perform their specific job duties according to their licensure or certification. During interviews, the Staff Development Nurse and the Director of Nursing acknowledged the absence of a system to verify the competency of nursing staff upon hire or on an annual basis. The Director of Nursing confirmed that the facility did not evaluate nursing staff competencies to ensure care was provided according to professional standards, although it was recognized that such evaluations should occur. This lack of a competency verification system placed residents at risk for accidents, injuries, infections, and a diminished quality of life and care.
Failure to Report and Act on CPR Directive
Penalty
Summary
The facility failed to report an alleged neglect incident involving a resident who did not receive CPR despite having a Physician Order (PO) for full resuscitation. The incident involved Resident 1, who was admitted on a specific date and later died when their heart stopped beating and they stopped breathing. The nurse's progress note indicated that no CPR was initiated, contrary to the PO that specified 'Attempt Resuscitation/CPR' and 'Full Treatment.' This failure to act according to the PO was identified as neglect, especially since the resident's death was unexpected. During an interview, the Director of Nursing (Staff B) acknowledged that the staff neglected to follow the PO for full code and did not start CPR when Resident 1 stopped breathing and had no pulse. Furthermore, the facility did not report this incident to the state agency as required by state law. This oversight placed other residents with similar POs at serious risk of harm, including death, as the facility did not identify and report the alleged neglect after the catastrophic change in Resident 1's condition.
Failure to Investigate and Document Incident of Serious Bodily Injury
Penalty
Summary
The facility failed to timely initiate, document, and complete a thorough investigation regarding an incident involving a serious bodily injury to a resident. The incident involved a resident who had a medical event requiring CPR, but CPR was not administered despite a Physician's Order to do so. The Registered Nurse in charge of the resident at the time of the incident reported the event to the Director of Nursing (DON) but did not initiate an investigation. The facility's policy required that all reports of resident abuse and neglect be promptly reported to state agencies and thoroughly investigated, which was not adhered to in this case. Interviews with staff members revealed that no comprehensive investigation was conducted. The Licensed Practical Nurse and Certified Nursing Assistant who were present during the incident were not interviewed about the event. The DON provided an incomplete incident summary that lacked necessary interviews and documentation to rule out abuse or neglect. The DON acknowledged that a thorough investigation was not conducted and that the incident was not reported to the state agency, as required by the facility's policy.
Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide appropriate care to prevent pressure ulcers for a resident who was admitted with no pressure ulcers but was at high risk due to a recent stroke and left side hemiplegia. The resident required maximum assistance with mobility and was unable to communicate needs effectively. Despite being assessed as high risk, the care plan did not include specific interventions related to the resident's condition, such as the number of staff required for safe repositioning to prevent friction and shear. The facility's policy required identification of risk factors and implementation of resident-specific interventions, but these were not adequately addressed in the care plan. The resident developed a Deep Tissue Injury (DTI) on the left heel, which was not anticipated or prevented due to the lack of specific guidance on the care plan. The facility's investigation identified multiple risk factors, including impaired mobility and the use of blood thinners, but these were not incorporated into the care plan to prevent the injury. Interviews with staff revealed inconsistencies in the provision of care, with documentation showing varying numbers of staff assisting with bed mobility. The Director of Nursing acknowledged that two staff members were needed to prevent friction and shear, but this was not documented in the care plan. The facility's investigation did not determine if the heel was dragged on the bed surface, and the Director of Nursing admitted that the DTI might have been preventable with proper assistance.
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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