Cheney Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cheney, Washington.
- Location
- 2219 North 6th Street, Cheney, Washington 99004
- CMS Provider Number
- 505346
- Inspections on file
- 35
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Cheney Care Center during CMS and state inspections, most recent first.
The facility did not consistently implement enhanced barrier precautions for three residents with conditions such as MRSA and urinary catheters, as required. Observations showed missing PPE signage and supplies, and staff interviews revealed a lack of awareness and inconsistent use of gowns and gloves during care. Additionally, infection prevention policies had not been reviewed annually, and staff were unclear about responsibility for policy updates.
The facility did not provide required education on the risks, benefits, and side effects of the COVID-19 vaccine to staff, nor did it maintain documentation of staff vaccination status. Interviews revealed that a nursing assistant had not received COVID-19 vaccine education, and Infection Prevention staff confirmed that only influenza and Hepatitis vaccine information was given. Human Resources discussed COVID-19 vaccinations only with new hires, and ongoing staff were not included, resulting in incomplete compliance with the facility's vaccination policy.
Two residents were administered psychotropic medications without documented informed consent prior to receiving the drugs. One resident with cognitive impairment received mirtazapine without a consent form on file, while another resident began taking escitalopram and mirtazapine before signing a consent form and later received Wellbutrin without any documented consent. Staff confirmed that consents should have been obtained before medication administration.
The facility did not provide required written notification to the State Long-Term Care Ombudsman when three residents were either transferred to the hospital or discharged home. Documentation and staff interviews confirmed that notifications were not sent due to lack of awareness and confusion about responsibility, resulting in noncompliance with notification requirements.
The facility did not ensure accurate and timely completion of PASRR screenings and referrals for three residents with mental health diagnoses. One resident was not referred for a Level II evaluation despite documented depression and anxiety, another was not reassessed after exceeding a short-stay exemption, and a third had inconsistent PASRR documentation following changes in psychotropic medication. Staff interviews confirmed these PASRR process failures.
A nurse prepared an antibiotic for a resident, handed it to them, and left the room without observing the medication being taken, contrary to facility policy requiring direct observation. The nurse later admitted this was not standard practice and did not verify the medication was consumed.
A resident with a history of stroke and diabetes, dependent on staff for ADLs, was not consistently provided with bathing, shaving, and nail care. Multiple observations showed the resident with greasy hair, facial stubble, and long, dirty fingernails, and documentation revealed missed scheduled showers without evidence of refusal. The care plan lacked specific interventions for grooming and nail care, and staff interviews confirmed inconsistencies in providing these services.
A resident with dementia and a history of falls did not receive consistent fall prevention interventions, including timely fall risk assessment, regular 15-minute checks, and use of hip protectors. Multiple unwitnessed falls occurred, some resulting in serious injuries, and staff were unclear about required interventions and documentation. Incident reports lacked thorough investigation, and care plan updates and communication were inconsistent.
A resident with ESRD on dialysis did not have their fluid restriction communicated or implemented due to a lack of coordination between facility staff and the dialysis center. The care plan and provider orders did not include the recommended fluid restriction, and staff were unaware of the need to monitor or limit the resident's fluid intake, resulting in inconsistent documentation and monitoring.
A resident with end-stage kidney disease, diabetes, and hypertension did not receive prescribed morning doses of hydralazine and calcium acetate on multiple dialysis days. Medications were not sent with the resident, and staff did not notify the provider or adjust orders, resulting in missed doses. Interviews confirmed a lack of communication and alternative arrangements for medication administration.
The facility did not consistently monitor or document medication refrigerator temperatures in the medication storage room, with multiple missed entries over several months. Although recorded temperatures were within safe limits, the lack of consistent checks placed stored medications, including tuberculin solution, at risk. Staff confirmed that daily monitoring was not reliably performed.
The facility did not provide food that was palatable, visually appealing, or at safe and appetizing temperatures during observed meals. Multiple residents expressed dissatisfaction with the taste and appearance of the food, and meal observations confirmed a lack of color variety and improper food temperatures. The dietary manager acknowledged ongoing complaints about the food's quality and appearance.
Surveyors observed that two resident snack refrigerators contained hard-boiled eggs and a bottle of honey mustard dressing that were not labeled with a name or date. The Dietary Manager confirmed that daily checks for labeling and expiration were supposed to occur, but these items were found unlabeled and undated.
A resident with significant care needs developed boils and a blister that were identified by staff but not properly assessed, documented, or reported to the physician as required by facility policy. Multiple staff members assumed others had completed necessary actions, resulting in no treatment being initiated and no incident report being filed. The resident's condition worsened, leading to hospitalization for scrotal cellulitis and MRSA abscesses.
A resident with MRSA required daily dressing changes under Contact Precautions, but a RN performed wound care without wearing a gown and without proper signage or PPE cart outside the room. The only contact precaution sign was inside the room and not easily visible, leading to a lapse in infection control protocol.
The facility failed to provide bed-hold notices to residents or their representatives upon hospital transfer, affecting four residents. Despite having a process for initial notification during admission, the facility lacked a clear procedure for subsequent notifications, relying on verbal communication. This deficiency was identified through interviews and record reviews.
The facility failed to complete required PASARR evaluations for three residents, leading to a deficiency in care. A resident with a history of stroke, anxiety, and depression did not receive a Level II review despite indicators of serious mental illness. Another resident with a history of stroke, Parkinson's Disease, and a suicide attempt also lacked a Level II review for intellectual disability. A third resident was admitted without a PASARR. The process was disrupted due to staffing changes.
A resident with a history of stroke and Parkinson's Disease was not re-admitted to the facility after hospitalization due to aggressive behavior. The resident was transferred to the hospital after an incident involving the Director of Nursing, and the facility informed EMS they would not take the resident back, contrary to their policy.
The facility failed to meet the behavioral health needs of two residents, leading to a deficiency in care. One resident, with a history of stroke, anxiety, and depression, did not receive a PASARR Level II assessment or adequate mental health counseling. Another resident, with a history of stroke, Parkinson's Disease, and depression, also lacked a PASARR Level II assessment and person-centered interventions. Staff interviews revealed a lack of consistent communication and documentation regarding resident behaviors and interventions.
The facility failed to manage and document residents' personal belongings, resulting in missing items and incomplete records for six residents. The facility's policy required inventorying belongings upon admission and updating the list throughout the stay, but this was not followed. Interviews revealed staff confusion about updating procedures, leading to risks of loss and diminished quality of life.
A facility failed to report and investigate a resident-to-resident altercation and an elopement involving a resident with severe cognitive impairment. The altercation was not reported to the SA, and no thorough investigation was conducted. Similarly, the elopement was logged but not reported to the SA Hotline, and the investigation was incomplete. The DON acknowledged these failures, admitting the facility did not follow its policies.
A facility failed to provide adequate discharge planning and communication for a resident, resulting in an incomplete Transfer/Discharge Report and lack of necessary medical information for the receiving community provider. The resident, who had experienced a stroke and UTI, was discharged without a comprehensive care plan, leading to a readmission to the hospital with sepsis and other complications. Facility staff acknowledged the failure to ensure a safe discharge process.
A facility failed to implement urology recommendations for a resident with a history of UTIs and kidney stones. Despite receiving specific dietary and hydration guidelines to prevent kidney stones, the facility's care plan did not include these measures. The resident's nutrition care plan lacked instructions to limit sodium and high oxalate foods or to include citrus fruits, and the recommended water intake was not ensured. A No Added Salt diet was only introduced six months later, and the DON acknowledged the oversight.
A resident with severe cognitive impairment and complex medical conditions was not provided with adequate fluids, as recommended by medical professionals. Despite orders to encourage fluid intake, documentation showed the resident received less than 1,000 cc of fluids on most days over two months. This deficiency was noted when the resident was hospitalized with a UTI, highlighting the facility's failure to monitor and ensure proper hydration.
The facility failed to maintain current oxygen orders and clean equipment for residents requiring respiratory care. A resident with dementia had an incomplete oxygen order, and another with quadriplegia used oxygen without a current order. Observations showed dusty filters and undated tubing, indicating poor maintenance. Staff interviews revealed inconsistencies in following policies for oxygen management, risking respiratory complications and infection.
The facility failed to serve meals at appropriate temperatures, risking decreased quality of life for residents. During lunch service, a cook did not recheck soup temperature after additional heating. A surveyor later found food temperatures significantly below required standards, violating health guidelines.
A resident was prescribed Trazodone and Seroquel for depression and hallucinations, respectively, but the informed consent forms were signed several days after the medications were first administered. The facility's records lacked documentation of prior education on the medications' risks and benefits. Interviews with staff confirmed that informed consents should be obtained before administering the first dose.
A resident with Alzheimer's disease was observed in an unclean wheelchair with food smeared on it over several days. Despite the facility's cleaning protocol, the wheelchair remained unclean, as confirmed by staff interviews.
A resident, who was cognitively intact and required assistance with daily activities, was discharged to a hospital due to suicidal thoughts. The facility failed to complete a discharge summary with a recapitulation of the resident's stay, as required. Despite expressing suicidal thoughts and being assessed for depression, the discharge summary only noted the hospital transfer without detailing the care and services provided.
The facility failed to follow its bowel management protocol for three residents, leading to a deficiency in care. Despite having no bowel movements for several days, the necessary medications were not administered, nor was there documentation of them being offered or refused. Staff interviews confirmed the protocol was not adhered to, and the Director of Nursing acknowledged the importance of following the medical order.
A facility failed to conduct a nutritional assessment for a resident at risk for compromised nutritional status upon admission. Despite policies requiring a comprehensive assessment within seven days, the assessment was missed, as acknowledged by the Dietetic Technician. The resident, with conditions such as malnutrition and diabetes, was not evaluated by the Dietetic Technician or Registered Dietitian, posing potential health risks.
The facility failed to accurately reconcile controlled medications in one medication cart. A bottle of narcotic pain pills was found with a taped cap marked with the number 56, which staff used instead of counting pills during shift changes. The DON confirmed the count matched the narcotic log and acknowledged the need for pill counts at every shift change.
A facility did not follow a pharmacist's recommendation to adjust the timing of Melatonin administration for a resident. The medication was given at bedtime instead of 60 to 90 minutes before, as suggested. Staff interviews confirmed the resident's usual bedtime, and the DON acknowledged the oversight.
The facility failed to ensure dietary staff had current Food Worker Cards, with two staff members lacking proper qualifications. Additionally, inadequate staffing in the dining room led to delayed assistance for residents, resulting in meals being served at unappetizing temperatures and affecting residents' dining experiences.
The facility failed to properly label, date, and monitor food items in the snack/nourishment refrigerators, posing a potential risk of foodborne illness. Observations revealed undated and expired food items, incomplete temperature logs, and inconsistencies in staff responsibilities for monitoring. Staff interviews highlighted a lack of awareness and adherence to procedures for ensuring food safety.
The facility failed to ensure proper infection control during meal service and medication administration. Staff did not perform hand hygiene or wear gloves when handling food, and a resident's nails were not maintained in a sanitary manner. Additionally, a nurse administered insulin without cleaning the injection site, contrary to infection prevention protocols.
Failure to Implement Enhanced Barrier Precautions and Annual Policy Review
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP), including the use of personal protective equipment (PPE) such as gowns and gloves, for three out of four sampled residents who required these measures. Observations revealed that residents with conditions such as MRSA colonization, urinary catheters, and wounds did not have appropriate signage or PPE available at their room entrances, and staff were not consistently using gowns and gloves during high-contact care activities. For example, one resident with MRSA and a history of osteomyelitis and gangrene had no EBP signage or PPE at their room, and a used bandage with bloody drainage was found on the floor. Another resident with a urinary catheter did not have EBP signage or PPE receptacles at their room, and the resident reported not recalling staff wearing gowns during care. A third resident with a urinary catheter also lacked EBP signage and PPE bins, and reported staff only wore gloves, not gowns, during catheter care. Interviews with staff revealed gaps in communication and awareness regarding which residents required EBP. The Infection Prevention nurse was unaware of a resident's new catheter placement because it occurred on a day they were not present, and stated that nurses were expected to implement EBP in their absence. The nurse also missed identifying a resident as an MRSA carrier. Despite claims of a system to identify residents needing EBP, these lapses resulted in inconsistent implementation of required precautions. Additionally, the facility's infection prevention policies, including those related to EBP, had not been reviewed annually as required. All reviewed policies had a last review date from over a year prior, and staff were unclear about who was responsible for ensuring the policies were kept current. This lack of timely policy review contributed to the risk of outdated procedures being followed.
Failure to Educate and Document Staff COVID-19 Vaccination Status
Penalty
Summary
The facility failed to implement and document procedures to ensure staff were educated on the risks, benefits, and potential side effects of the COVID-19 vaccine, and did not maintain records of staff vaccination status. According to the facility's COVID-19 vaccination policy, staff documentation should include education on the vaccine, offering the vaccine or information on obtaining it, documentation of any exemptions, and the vaccination status of staff. However, interviews revealed that a nursing assistant employed for four years did not recall receiving education or information about the COVID-19 vaccine. The Infection Prevention staff confirmed that only influenza and Hepatitis vaccine information was provided to staff, and that COVID-19 vaccination status was not tracked. Further interviews indicated that Human Resources discussed COVID-19 vaccinations only with new employees, excluding long-term staff. The Infection Prevention staff also incorrectly cited HIPAA as a reason for not tracking staff COVID-19 vaccination status. The Director of Nursing was initially unaware of the facility's program for staff COVID-19 vaccinations and later confirmed that ongoing staff were not included in vaccination discussions. These actions and omissions resulted in a lack of education and documentation regarding COVID-19 vaccination for staff, as required by facility policy.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were fully informed and provided consent prior to the administration of psychotropic medications. For one resident with Parkinson's disease, malnutrition, and anxiety, who was severely cognitively impaired and had a family member designated as decision-maker, mirtazapine was prescribed and administered to stimulate appetite. However, there was no documentation that consent describing the risks and benefits of the medication was obtained at the time it was prescribed. For another resident diagnosed with depression and receiving psychotropic medications, escitalopram and mirtazapine were prescribed and an informed consent form was signed two days after the medications were started. Additionally, Wellbutrin was later prescribed and administered without any documentation of informed consent, either verbal or written, prior to the resident receiving the medication. Staff interviews confirmed that informed consent should have been obtained before administration of these medications.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide written notification to the Office of the State Long-Term Care Ombudsman regarding the transfer or discharge of three residents who were either hospitalized or discharged. For one resident, documentation showed they were admitted from the hospital and later transferred back to the hospital due to respiratory distress, but there was no record of Ombudsman notification. Another resident, who had a history of hip fracture and dementia and was severely cognitively impaired, was transferred to the hospital after a fall and subsequent hip pain, yet no Ombudsman notification was documented. A third resident was discharged home after meeting rehabilitation goals, but again, no notification was sent to the Ombudsman. Interviews with facility staff revealed a lack of awareness and confusion regarding the responsibility for notifying the Ombudsman about resident transfers and discharges. Staff confirmed that notifications were not sent in these cases, and there was no documentation to indicate that the required notifications had been made for any of the three residents reviewed.
Failure to Complete and Follow Up on PASRR Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure proper completion and follow-up of Pre-admission Screening and Resident Review (PASRR) processes for three residents with mental health diagnoses. For one resident with depression and anxiety, a Level I PASRR screening was completed prior to admission but incorrectly documented that there was no serious mental illness, and no Level II evaluation was initiated. Another resident, who was initially exempt from a Level II evaluation due to an expected short stay, remained in the facility beyond the exemption period without a subsequent referral for a Level II assessment, and there was no documentation from facility management or the social worker regarding this oversight. A third resident with a history of depression and changes in psychotropic medication had a Level I PASRR completed after medication adjustments, which indicated serious mental illness indicators in one section but contradicted this in another section, resulting in no Level II evaluation being conducted. Interviews with facility staff confirmed that the required PASRR processes were not followed, including the need for timely and accurate assessments and referrals for Level II evaluations when indicated.
Medication Administration Not Observed by Nurse
Penalty
Summary
A licensed nurse failed to administer medication according to professional standards and facility policy for one resident. During a medication pass, the nurse prepared an antibiotic (Fosfomycin Tromethamine) by mixing it with water and, after observing the resident take other medications, handed the antibiotic mixture to the resident with instructions to drink it. The nurse then left the room without observing the resident consume the medication, contrary to the facility's policy, which requires nurses to observe residents taking their medications. The resident later confirmed that they had taken the medication, and the empty cup was observed, but the nurse did not return to verify this. In an interview, the nurse acknowledged that it was not standard practice to leave medication with a resident unsupervised and admitted there was no way to guarantee the medication was taken. This incident was identified during a survey and was found to be inconsistent with both professional standards and the facility's own medication administration policy.
Failure to Consistently Provide Bathing and Personal Hygiene/Grooming
Penalty
Summary
A deficiency was identified when a resident with a history of stroke and diabetes, who required staff assistance for activities of daily living (ADLs) such as bathing, shaving, and nail care, was not consistently provided with these services. Observations over several days revealed the resident had greasy hair, facial stubble, and long fingernails with black debris, indicating a lack of regular bathing and grooming. The resident reported that scheduled baths were often missed, and although staff would inform them of being on the bath schedule, the care was frequently not provided. Documentation showed that out of seven scheduled showers, only four were given, with an 11-day gap between some showers and no record of the resident refusing care during that period. Further review of the resident's care plan revealed that while it included interventions for bathing, toileting, oral care, and dressing, it lacked specific instructions or interventions for personal hygiene and grooming needs such as nail care and shaving. Staff interviews confirmed that nail care and shaving were typically performed during morning care or bathing, but for diabetic residents, nail trimming was done by nurses. However, the records did not specify which personal hygiene tasks were refused or completed, and repeated observations showed the resident remained unshaved and with long fingernails over several days.
Failure to Consistently Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to consistently implement and document care-planned supervision interventions and did not fully evaluate the effectiveness of fall prevention measures for a resident with a history of dementia, falls, and a recent femur fracture. Upon admission, the required comprehensive fall risk assessment was not completed in a timely manner, and individualized fall risk was not assessed. The resident experienced multiple unwitnessed falls, including incidents in the activity area and in their room, some resulting in significant injuries such as a hip fracture and a broken wrist. Documentation revealed that interventions such as 15-minute checks and the use of hip protectors were not consistently carried out or documented, and staff were often unclear about the specific interventions required for the resident. Observations and interviews indicated that staff did not always follow the care plan interventions, such as ensuring the resident wore hip protectors while in bed and performing 15-minute checks as ordered. There were repeated omissions in the documentation of these checks, and staff interviews confirmed that if checks were not documented, they were likely not performed. Additionally, staff were sometimes unaware of the location or use of hip protectors, and there was confusion regarding the frequency and nature of required supervision. The resident was able to move their fall mat and alarm, and staff acknowledged that the resident did not reliably use the call light, further increasing the risk of falls. Incident reports for several falls lacked thorough investigation, staff statements, or documentation of the circumstances leading to the falls. The care plan was not always updated promptly after incidents, and there was no evidence that the effectiveness of interventions was systematically evaluated following each fall. Staff interviews revealed uncertainty about the process for updating care plans and communicating changes, and there were lapses in ensuring that all staff were aware of and implementing the required interventions. These failures placed the resident at continued risk for accidents and injury.
Failure to Communicate and Implement Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to ensure consistent communication with the dialysis center regarding fluid restrictions for a resident with end-stage renal disease (ESRD) who was dependent on dialysis. The facility's hemodialysis policy required coordination and collaboration with the dialysis center to implement the dialysis care plan, but this was not followed. The resident, who was cognitively intact and independent in most activities of daily living, was observed with multiple fluid items in their room and expressed uncertainty about their fluid restriction and who was responsible for monitoring it. Review of the resident's care plan and provider orders revealed no mention of oral fluid restrictions or interventions to monitor fluid intake, despite the dialysis center's Registered Dietician stating the resident was supposed to be on a 1200 ml daily fluid restriction. Documentation of fluid intake was inconsistent, with many omissions and no data recorded for fluids given as needed. The facility's Registered Dietician was unaware of the fluid restriction recommendation and had not communicated with the dialysis center, while nursing staff were unclear about who determined and monitored fluid restrictions for dialysis residents. Interviews with facility staff indicated a lack of clear processes for communicating dietary or fluid needs between the facility and the dialysis center. The communication sheet sent with the resident to dialysis was used for general updates, but there was no evidence of direct communication regarding the resident's fluid restriction. As a result, the resident's fluid intake was not adequately monitored or restricted according to the dialysis center's recommendations.
Failure to Administer Ordered Medications for Dialysis Resident
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for a resident receiving dialysis care. The resident, who had end-stage kidney disease, diabetes, and high blood pressure, had medication orders for hydralazine and calcium acetate to be given three times daily. On multiple occasions, the resident did not receive their morning doses of these medications on days they attended dialysis, as indicated by the medication administration record, which noted the resident was absent from the facility. There was no documentation that the provider was notified about the missed doses, and no alternative arrangements were made to administer the medications as ordered. Interviews with staff revealed that medications were not sent with the resident to dialysis, and the resident would miss the morning doses if they returned too late. Staff acknowledged that no discussions had occurred with the provider to adjust medication administration times or orders. The resident reported leaving the facility early for dialysis without breakfast and feeling hungry and tired upon return. Nursing leadership stated that they expected nurses to communicate with providers when medications were missed, but this did not occur in this case.
Failure to Consistently Monitor Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to consistently monitor and document the medication refrigerator temperatures in the medication storage room, as required to ensure safe storage of drugs and biologicals. Review of the temperature log posted on the refrigerator showed that temperature checks were not recorded on nine occasions in June, eleven occasions in July, and nine occasions in August. When temperatures were documented, they were within the safe range, but the lack of consistent monitoring meant there were multiple undocumented periods. The refrigerator contained ten boxes of unopened tuberculin solution, an injectable medication used for tuberculosis screening. Staff interviews revealed that it was the responsibility of the night shift nurse to check and record the refrigerator temperatures daily. However, the Infection Preventionist acknowledged that this monitoring was not performed consistently. The failure to document refrigerator temperatures as required was observed during a review of the medication storage room, and the issue was confirmed by staff.
Failure to Provide Palatable, Attractive, and Properly Tempered Food
Penalty
Summary
The facility failed to serve food that was palatable, visually appealing, and at safe and appetizing temperatures during two observed meals and one test tray sampling. Multiple residents reported dissatisfaction with the food, describing it as unappetizing, bland, and lacking in seasoning. Observations of meal service revealed that the food presented was mostly brown or dull in color, lacking variety and visual appeal. Specific comments from residents included complaints about the food's appearance and taste, with one resident requesting an alternative meal after seeing and tasting the food provided. Temperature measurements of the test tray items showed that hot foods were served below the required 135 degrees Fahrenheit, and cold foods were served above the recommended 41 degrees Fahrenheit. The dietary manager acknowledged receiving complaints from residents and families regarding the food's appearance and confirmed that the lack of color variety made the food less appetizing. These findings were documented in accordance with WAC 388-97-1100(1)(2).
Unlabeled and Undated Food Items in Resident Snack Refrigerators
Penalty
Summary
During observations, two resident snack refrigerators were found to contain food items, specifically hard-boiled eggs and a bottle of honey mustard dressing, that were not labeled with a name or date. One refrigerator was located in the nurses' main charting room and the other on the transitional care unit. Staff M, the Dietary Manager, confirmed in an interview that the prep cook was responsible for daily checks of these refrigerators to ensure proper labeling and monitoring of expiration dates. Staff M also acknowledged the importance of labeling and dating food items to track ownership and duration of storage. Despite these procedures, the observed food items remained unlabeled and undated at the time of the survey.
Failure to Assess, Monitor, and Notify Physician of Non-Pressure Skin Condition
Penalty
Summary
The facility failed to properly assess, monitor, and notify the physician regarding a non-pressure related skin condition for a resident with a history of stroke, anxiety, and depression, who required substantial to maximal assistance with most activities of daily living. Upon identification of boils and a blister during a skin assessment, staff documented the findings but did not initiate any treatment, complete an incident report, or notify the physician as required by facility policy. The electronic Medication Administration Record (eMAR) showed no treatments in place for the skin issues, and there was no documentation in the progress notes about physician notification or a treatment plan. Multiple staff interviews revealed that nurses and CNAs observed the resident's worsening skin condition, including boils and a popped blister, but assumed that appropriate reporting and documentation had already been completed by others. Staff failed to follow the facility's protocol for new skin issues, which included completing incident reports, notifying the physician and administration, and documenting the findings. The Infection Preventionist and other nursing staff were not aware of the full extent of the resident's skin issues until the condition had significantly worsened. The resident's condition deteriorated, resulting in increased pain, inability to sit, and the presence of blood and drainage from the affected areas. Eventually, the resident was sent to the hospital, where they were diagnosed with scrotal cellulitis and abscesses caused by MRSA. The lack of timely assessment, documentation, and physician notification contributed to the escalation of the resident's skin condition.
Failure to Follow Contact Precautions During Wound Care for MRSA-Positive Resident
Penalty
Summary
Staff failed to follow proper Contact Precautions during wound care for a resident with a history of stroke, anxiety, and depression, who had recently returned from the hospital with abscesses that tested positive for MRSA. Hospital discharge orders specified daily dressing changes and the use of Contact Precautions. During an observed dressing change, the registered nurse did not wear a gown, as required, and only donned gloves. There was no visible signage on the outside of the resident's door indicating Contact Precautions, nor was there a PPE cart available outside the room. The only sign present was inside the room and difficult to see due to poor lighting. When questioned, the nurse acknowledged that a gown should have been worn and attributed the oversight to the lack of visible signage and PPE cart. The infection preventionist confirmed that signage and PPE should have been placed outside the room and that a gown was required for the procedure. The failure to follow established infection control protocols was directly observed and confirmed through staff interviews and record review.
Failure to Provide Bed-Hold Notices to Hospitalized Residents
Penalty
Summary
The facility failed to provide a bed-hold notice to residents or their representatives at the time of discharge or within 24 hours of transfer to the hospital for four sampled residents. This deficiency was identified during interviews and record reviews. Resident 1, who had a history of stroke, anxiety, and depression, was transferred to the hospital due to increased numbness and pain but did not receive a bed-hold notice. Similarly, Resident 3, with Parkinson's Disease and a history of stroke, was transferred for evaluation after exhibiting aggressive behavior, yet no bed-hold notice was documented. Resident 6, also with a history of stroke, anxiety, and depression, was transferred due to confusion and unstable vital signs without receiving a bed-hold notice. Lastly, Resident 7, who had fractures and depression, was sent to the hospital for evaluation due to confusion and lethargy, but no bed-hold notice was provided. Interviews with facility staff revealed a lack of a clear process for providing bed-hold notices. Staff C, an LPN, indicated that the responsibility for giving bed-hold notices lay with the Resident Care Manager or Social Services Director. Staff A, the Director of Nursing, and Staff B, the Resident Care Manager, confirmed that while residents received a bed-hold notice during the admission process, a second notification should be given upon hospital transfer. However, the facility's current practice involved only verbal communication of this information, leading to the deficiency.
Failure to Complete PASARR Evaluations for Residents
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASARR) processes were completed for three residents, leading to a deficiency in care. Resident 1, who had a history of stroke, anxiety, and depression, was admitted with indicators of a serious mental illness requiring a Level II PASARR review. However, there was no documentation in the Electronic Medical Record (EMR) to show that the facility requested this review. During an observation, Resident 1 expressed feelings of anger and had previously hit a staff member, indicating a potential decline in mental health. Resident 3, admitted with a history of stroke, Parkinson's Disease, and a suicide attempt, also required a Level II PASARR review due to indicators of an intellectual disability. The facility failed to document a request for this evaluation. Resident 7, admitted with fractures, a history of stroke, and depression, did not have a PASARR completed prior to admission. The Director of Nursing acknowledged that the process for handling PASARRs was disrupted due to the departure of the Social Services Director, and the issue was not addressed until a new hire was made.
Failure to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to consider re-admission for a resident who was hospitalized, which placed the resident at risk for increased anxiety and a diminished quality of life. The resident, who had a history of stroke and Parkinson's Disease, was admitted to the facility with difficulty in making their needs known. An incident occurred where the resident was found at their doorway screaming and swinging a cane at the Director of Nursing (DNS), posing a threat to staff and other residents. The resident then exited the building, and the police and Emergency Medical System (EMS) were called to transfer the resident to the hospital. During the transfer, Staff A informed EMS that the facility could not manage the resident's aggression and would not accept them back. A discharge notice was subsequently sent to the hospital at the time of the resident's discharge. This action was contrary to the facility's policy, which stated that residents should be permitted to return to the facility upon discharge from an acute care setting, unless there is evidence that the resident's status at the time of seeking to return does not allow for re-admission.
Failure to Address Behavioral Health Needs in Residents
Penalty
Summary
The facility failed to ensure that the behavioral health needs of two residents were identified and met, leading to a deficiency in care. Resident 1, who had a history of stroke, anxiety, and depression, was not provided with a PASARR Level II assessment despite indications of a serious mental illness. The resident was on maximum doses of antidepressant and antianxiety medications, yet there were no documented non-medication interventions or person-centered care plans in place. The resident expressed feelings of hopelessness and had thoughts of self-harm, but the facility did not complete a referral for mental health counseling as requested by the provider. Resident 3, admitted with a history of stroke, Parkinson's Disease, and depression, also did not receive a PASARR Level II assessment despite indicators of an intellectual disability. The resident's care plan lacked target behaviors and person-centered interventions, and there was no documentation of an interdisciplinary team assessing the resident's response to stressors or evaluating the effectiveness of the medication regimen. The resident had a history of a suicide attempt and was on psychoactive medication, yet the facility did not provide adequate behavioral or emotional support. Interviews with staff revealed a lack of consistent communication and documentation regarding resident behaviors and interventions. The facility had been without a social worker for six months, which contributed to the lack of coordination in behavioral health services. Staff reported informal meetings to discuss residents, but there was no formal documentation of interdisciplinary team discussions or evaluations of the residents' care plans and medication effectiveness.
Failure to Manage and Document Residents' Personal Belongings
Penalty
Summary
The facility failed to ensure the proper management and documentation of residents' personal belongings, leading to missing items and incomplete records for six sampled residents. The facility's policy required staff to inventory all personal belongings upon admission, update the inventory throughout the resident's stay, and ensure all items were returned to the resident or their representative upon discharge or death. However, the facility did not adhere to this policy, resulting in missing items and incomplete inventory lists. For Resident 1, the facility did not account for personal belongings such as clothing or shoes at any point during their stay, and upon discharge, incorrect items were sent with the resident. Resident 2 reported missing satin nightshirts, and their inventory list lacked photographs of valuables. Resident 3's inventory list was undated, unsigned, and incomplete, with no photographs of valuables. Resident 4 had no inventory list maintained over their seven-year stay. Resident 5's inventory list was outdated and did not reflect their current belongings, and Resident 6's list was undated, unsigned, and lacked photographs of valuables. Interviews with staff revealed a lack of clarity and consistency in the process of updating and maintaining the Personal Belongings Inventory Lists. Staff were unsure who was responsible for updating the lists after admission, and there was no clear procedure for managing additional items brought in during a resident's stay. The facility's failure to maintain accurate and complete records of residents' personal belongings placed residents at risk for loss of personal items and diminished their quality of life.
Failure to Report and Investigate Resident Incidents
Penalty
Summary
The facility failed to implement its Abuse and Neglect Prohibition Policies and Procedures, specifically in reporting and investigating incidents involving a resident. One incident involved a resident-to-resident altercation where a resident with severe cognitive impairment and requiring assistance in mobilization was involved in a verbal and physical altercation with another resident. The facility did not report this altercation to the state agency (SA) nor did it conduct a thorough investigation to prevent recurrence and rule out abuse or neglect. The Director of Nursing confirmed the lack of reporting and investigation, stating that the facility was likely unaware of the incident. Another incident involved the elopement of the same resident, who was found outside the facility in a wheelchair without supervision. The facility logged the elopement event but failed to conduct a thorough investigation or report it to the SA Hotline as required by the facility's policies and the October 2015 Nursing Home Guidelines. The Director of Nursing acknowledged the incomplete investigation and the failure to report the elopement, admitting that the facility did not adhere to its abuse and neglect policies and procedures.
Inadequate Discharge Planning and Communication
Penalty
Summary
The facility failed to provide and document sufficient preparation or orientation for a safe discharge for one resident, which placed the resident at risk for unmet care needs and a diminished quality of life. The facility's policy required a Discharge Summary to be completed for anticipated or resident-initiated discharges, including a description of the resident's stay, diagnoses, treatment, and a final summary of the resident's status. However, when the resident was discharged to a community provider, the facility did not send the resident's medical file, leaving the receiving provider without crucial information about the resident's condition. The resident experienced a change in condition and was transferred to the hospital, where they were diagnosed with a stroke and a urinary tract infection (UTI). Upon readmission to the facility, the resident was evaluated and recommended for discharge to a community setting. However, the Transfer/Discharge Report provided to the community provider was incomplete, lacking relevant information such as behaviors, mobility status, and a post-discharge plan of care. The facility did not communicate the resident's clinical background or needs to the receiving provider, resulting in inadequate preparation for the resident's transition. The community provider and a State Agency (SA) were not adequately informed about the resident's status or discharge plan. The resident was readmitted to the hospital from the community setting with sepsis secondary to a UTI, obstructing kidney stone, and possible pneumonia. Interviews with facility staff revealed that they did not send all necessary documentation or communicate the resident's follow-up needs to the community provider, acknowledging the failure to ensure a safe and orderly discharge process.
Failure to Implement Urology Recommendations for Kidney Stone Prevention
Penalty
Summary
The facility failed to implement recommendations from a urology clinic to prevent kidney stones for a resident with a history of UTIs, kidney stones, and chronic kidney disease. The resident was readmitted to the facility and had been seen by a urology provider who removed a stent and recommended specific dietary and hydration measures to prevent kidney stones. These recommendations included drinking 8-10 cups of water daily, limiting sodium intake to less than 2,300 mg per day, consuming an appropriate amount of dietary calcium, and including citrus fruits in the diet. Despite these recommendations, the facility's nutrition care plan for the resident did not include instructions to limit high oxalate and sodium-rich foods or to include citrus fruits in the diet. Additionally, there were no specific interventions to ensure the resident drank the recommended amount of water daily. The facility only implemented a No Added Salt diet six months after the initial recommendation. The Director of Nursing acknowledged that the staff did not implement the urology clinic's recommendations, indicating a lapse in following through with the necessary care plan adjustments.
Failure to Ensure Adequate Hydration for a Resident
Penalty
Summary
The facility failed to ensure adequate hydration for a resident, leading to a deficiency in care. The resident, who had severe cognitive impairment and was independent with eating, was admitted with medically complex conditions. A urology visit recommended the resident drink 8-10 cups of water daily, equivalent to 1,920 to 2,400 cc, to maintain proper hydration. However, a nutrition assessment determined the resident required 1,800 cc of fluids daily. Despite these recommendations, the facility's Medication Administration Record (MAR) showed an order to encourage fluids, but there was no documentation that staff provided the necessary fluids. Fluid intake records revealed that for September and October, the resident's fluid intake was documented as below 1,000 cc for most days. This lack of adequate fluid intake documentation was confirmed by the Director of Nursing, who stated that fluid intake should be monitored to ensure residents meet hydration goals. The deficiency was highlighted when a collateral contact reported that insufficient hydration led to the resident's hospitalization with a urinary tract infection (UTI). The facility's failure to monitor and provide the required fluids placed the resident at risk for dehydration and related health issues.
Deficiencies in Oxygen Management and Equipment Maintenance
Penalty
Summary
The facility failed to ensure that residents had current and complete oxygen orders and that oxygen equipment was maintained in a clean manner. Resident 3, who had dementia and chronic respiratory failure, had an oxygen order that did not specify the liter flow, and observations showed inconsistent oxygen settings. The oxygen concentrator's filter was dusty, indicating a lack of maintenance. Similarly, Resident 11, with quadriplegia, had no current oxygen order during the survey period, yet was observed using oxygen. The tubing was not labeled with a change date, and the concentrator's filter was also dirty. Resident 17, diagnosed with chronic respiratory failure and COPD, used supplemental oxygen, but their care plan and provider's orders lacked instructions for maintaining or cleaning the oxygen filters. Observations revealed that the concentrator's filters were covered with thick dust. Staff interviews indicated that an outside company performed maintenance bi-monthly, but nursing staff were responsible for checking and cleaning filters as needed. However, this was not consistently done. Resident 28, with heart failure and lung disease, had a continuous oxygen order but no instructions for changing the tubing. The resident complained about the tubing's condition, and observations confirmed the tubing was hard and undated. The concentrator filter was also heavily dusted. Staff interviews revealed a lack of documentation and adherence to the facility's policy for changing oxygen tubing weekly. These deficiencies placed residents at risk for respiratory complications and infection.
Failure to Serve Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that meals were served to residents at appropriate and appetizing temperatures, which could potentially decrease the quality of life for all residents. During a lunch meal service, it was observed that periodic checks of the food temperatures on the steam table were not conducted. Staff CC, a cook, was seen heating soup in a microwave and initially checked the temperature, but did not recheck it after additional heating before serving. This indicates a lapse in ensuring that food was served at the correct temperature. Further observations revealed that 63 minutes after the initial temperature check by Staff CC, a surveyor measured the temperatures of a sample tray. The recorded temperatures were significantly below the required standards: LoMein Noodles at 120°F, Mixed Vegetables at 110°F, Orange Chicken at 80°F, Cranberry juice at 56°F, Milk at 46°F, and Tuxedo cake at 50°F. These temperatures did not meet the requirements that hot food must be 140°F or greater and cold foods must be 41°F or less when served, as per the Washington State Department of Health guidelines.
Failure to Obtain Timely Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was fully informed about the potential risks and benefits associated with the use of psychotropic medications. Resident 25, who had a diagnosis of hallucinations, was prescribed Trazodone for depression and Seroquel for hallucinations. The medications were administered starting on November 24, 2023, and November 25, 2023, respectively. However, the informed consent forms for these medications were signed by the resident on November 28, 2023, which was three to four days after the medications were first administered. The review of Resident 25's records did not show any documentation that education regarding the psychotropic medications, including the reasons for their prescription, the risks, or the expected benefits, had been provided to the resident prior to the administration of the medications. Interviews with the Resident Care Manager and the Director of Nursing confirmed that informed consents for psychotropic medications should be obtained before the first dose is given to ensure residents are aware of the side effects and risks associated with the medications.
Failure to Maintain Clean Wheelchair for Resident
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for a resident diagnosed with Alzheimer's disease, who was moderately cognitively impaired and required assistance for activities of daily living. The resident was observed multiple times in an unclean wheelchair with food smeared on the sides and foot pedals. Despite the facility's protocol for cleaning wheelchairs weekly and as needed, the resident's wheelchair remained unclean over several days. Staff interviews confirmed the expectation to keep wheelchairs clean and acknowledged the unclean state of the resident's wheelchair.
Incomplete Discharge Summary for Resident with Suicidal Thoughts
Penalty
Summary
The facility failed to complete a discharge summary, including a recapitulation of the resident's stay, for a resident who was reviewed for discharge. The resident, who was cognitively intact and required moderate to maximum assistance with activities of daily living, was admitted on 12/30/2023 and had received physical therapy for four days. A discharge assessment indicated the resident was expected to return to the facility. However, the discharge summary completed by a Physician Assistant on 03/19/2024 only documented the resident's discharge to the hospital due to suicidal thoughts, without providing a detailed recapitulation of the care and services received at the facility. The resident had expressed suicidal thoughts to staff, including a specific incident on 03/16/2024 where they mentioned looking for plastic bags to suffocate themselves. This prompted an assessment for depression and the implementation of safety interventions, including increased supervision. Despite these measures, the resident continued to express suicidal thoughts over the following days, leading to their transfer to the hospital for evaluation on 03/19/2024. The Director of Nursing confirmed that a recapitulation of stay/discharge summary is required when a resident discharges from the facility, which was not completed in this case.
Failure to Implement Bowel Management Protocol
Penalty
Summary
The facility failed to implement its bowel management protocol for three residents, leading to a deficiency in care. The facility's policy required nursing staff to administer specific laxatives on consecutive days without a bowel movement (BM), and to notify the provider if no BM occurred by the sixth day. However, for Resident 2, the bowel management protocol was not followed, as documented in their medication administration record (MAR). Despite having no BMs for several days on multiple occasions, the necessary bowel medications were not administered, nor was there documentation of the medications being offered or refused. Similarly, Resident 18's care plan required adherence to the bowel protocol, but the MAR showed that bowel medications were not administered as needed. Resident 18 experienced multiple periods of three to five days without a BM, yet the protocol was not followed, and there was no documentation of medication administration or refusal. Interviews with staff confirmed that the bowel protocol was not adhered to, and the Director of Nursing acknowledged the importance of following the protocol as it was a medical order. Resident 193 also experienced a lapse in bowel management, with only one small BM recorded over four days. The MAR indicated that the bowel protocol was not followed during this period. Staff interviews revealed that the protocol was supposed to be monitored and followed up on by different shifts, but this did not occur. The Director of Nursing confirmed that the protocol was developed by the facility's medical director and emphasized the necessity of following it to prevent medication errors and potential complications.
Failure to Conduct Nutritional Assessment for At-Risk Resident
Penalty
Summary
The facility failed to document a detailed nutritional assessment at the time of admission for a resident identified as being at risk for compromised nutritional status. This oversight was observed through a review of the facility's undated nutritional management policy, which mandates a comprehensive nutritional assessment upon admission. The policy states that the dietitian should use the data from this assessment to estimate the resident's calorie, nutrient, and fluid needs. However, for Resident 10, who was admitted with a new right above-knee amputation and other health conditions such as malnutrition, diabetes, and obesity, no such assessment was completed by the Dietetic Technician or the Registered Dietitian. Interviews with facility staff revealed that the initial dietary preferences were assessed by the admission nurse or resident care manager and communicated to the kitchen. The Dietetic Technician stated that the nutritional assessment should be completed within seven days of admission, with the Registered Dietitian reviewing it weekly. Despite these procedures, the nutritional assessment for Resident 10 was missed, as acknowledged by the Dietetic Technician. This lapse in protocol resulted in a potential risk of impaired nutrition and other health complications for the resident.
Failure to Accurately Reconcile Controlled Medications
Penalty
Summary
The facility failed to accurately reconcile controlled medications in one of the two medication carts reviewed for medication storage. During an inspection of the narcotic drawer on Cart One, a bottle of narcotic pain pills labeled for a current resident was found with the cap wrapped in clear plastic tape, marked with the number 56. Staff D, an RN, indicated that the medication was from the resident's home supply and that the number 56 was used to detect any tampering. Staff D admitted to relying on the number written on the tape rather than counting the pills during shift changes. Later, Staff B, the Director of Nursing, confirmed the presence of the tape and counted the pills, finding 56 pills, which matched the narcotic log. Staff B acknowledged that nurses should have been counting the pills at every shift change.
Failure to Address Pharmacist's Recommendations for Medication Administration
Penalty
Summary
The facility failed to address recommendations from the pharmacist regarding the administration of Melatonin for one resident. The Consultant Pharmacy Report recommended that the Melatonin be administered 60 to 90 minutes before the resident's bedtime. However, the medication administration records for April and May 2024 showed that the medication was given at bedtime, between 7:00 PM and 10:53 PM, without any documented response from the provider or nursing staff to the pharmacist's recommendation. Interviews with staff confirmed that the resident typically went to bed between six to seven o'clock, and the Director of Nursing acknowledged that the recommendation should have been followed up on.
Deficiencies in Dietary Staff Qualifications and Dining Room Assistance
Penalty
Summary
The facility failed to ensure that dietary staff had the required qualifications, specifically current Food Worker Cards, for two dietary staff members. Staff W, a dietary aide, did not have a Washington State Food Workers card prior to a specified date, and Staff X, a prep staff member, did not have a current card at all. Observations confirmed that both staff members were involved in food preparation and serving without the necessary qualifications. The dietary manager acknowledged the lack of compliance with the requirement for all kitchen staff to have a valid Food Workers card, which poses a potential risk for unsafe food handling practices. Additionally, the facility did not provide adequate staffing in the dining room during meal times, resulting in delayed assistance for residents. Resident 15 was left without assistance for 41 minutes after being brought into the dining room, and their meal was served at an unappetizing temperature. Similarly, Resident 17's meal was left unattended for 19 minutes before assistance was provided. The Director of Nursing acknowledged that insufficient staffing could lead to cold food and an unpleasant dining experience, affecting the residents' dignity and quality of life.
Improper Food Labeling and Temperature Monitoring in Refrigerators
Penalty
Summary
The facility failed to ensure proper labeling, dating, and monitoring of food items in the snack/nourishment refrigerators, which posed a potential risk of foodborne illness for all residents. During an observation, it was found that the refrigerator on the Transitional Care Unit contained an open apple and grape juice container without an opened date, a foil-covered container labeled with a name and room number but not dated, an open half-full gallon jug of Kikkoman soy sauce with a date but no year, and sugar-free coffee creamer with an expired date. Additionally, the temperature logs for March, April, and May were incomplete, with only a few readings recorded, and no temperature log was present for June. Staff O, a Nursing Assistant, was present during the observation and removed the undated and expired food from the refrigerator. Interviews with staff revealed inconsistencies in the responsibility for monitoring the snack/nourishment refrigerators. Staff O stated that whoever placed items in the refrigerator was supposed to label and date them, and the kitchen was responsible for checking expired and old food. Staff E, an LPN, mentioned that the night shift was responsible for checking the temperatures, while Staff DD, a Dietary Aide, stated that the kitchen staff was supposed to monitor the temperatures when checking or filling the refrigerators. However, Staff DD admitted that this was not done daily, and they were unaware of the missing temperature logs for June and the incomplete logs for May.
Infection Control Deficiencies in Meal Service and Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during meal service and medication administration. Observations revealed that staff did not perform hand hygiene or wear gloves when handling food and feeding residents. For instance, a nursing assistant fed a resident a sandwich and handled a straw without gloves or hand hygiene. Additionally, a dietary aide was observed handling trash and then serving food without washing hands or changing gloves. These actions were contrary to the facility's hand hygiene policy and CDC guidelines, which emphasize the importance of hand hygiene in preventing the spread of infections. Another deficiency was noted in the maintenance of a resident's personal hygiene. A resident was repeatedly observed with brown matter under their nails during meal times, and their nails were not cleaned before or after meals. This lack of personal hygiene maintenance was acknowledged by the Director of Nursing, who stated that nail care was important to prevent infection. The failure to maintain the resident's nails in a sanitary manner posed a risk of infection and diminished the quality of life for the resident. Furthermore, the facility failed to cleanse a resident's skin prior to administering an injectable medication. A registered nurse administered insulin to a resident without cleaning the injection site with alcohol, citing the resident's preference to avoid alcohol due to a burning sensation. However, the resident later stated they had no such preference, and the nurse acknowledged the importance of cleaning the site to prevent infection. The Infection Preventionist confirmed that not using an alcohol wipe could lead to an infection at the injection site.
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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