Colfax Health And Rehabilitation Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Colfax, Washington.
- Location
- 1150 West Fairview Road, Colfax, Washington 99111
- CMS Provider Number
- 505251
- Inspections on file
- 60
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Colfax Health And Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
Multiple residents with lower extremity ulcers, surgical wounds, and large abdominal wounds did not consistently receive ordered wound care or NPWT (wound vac) therapy. One resident with bilateral leg ulcers and later documented wound infection had numerous missed, refused, or undocumented dressing changes and an antibiotic dose, with no care-plan interventions addressing repeated refusals despite the resident expressing concern about irregular dressings and odor. Another resident ordered for NPWT after surgical debridement of a right leg infection arrived without a wound vac, had repeated NN, blank, held, and refused entries on the MAR, and was treated with wet-to-dry dressings while the facility awaited wound vac equipment and supplies. A third resident with an abdominal NPWT order had multiple blank and refused MAR entries while the facility ran short on supplies. Two additional residents with recent surgical procedures (a below-knee amputation and a repaired hip fracture) lacked timely, clear wound care orders and care-plan interventions; one had an 11‑day delay before any wound order and then an unclear order that was later discontinued with another 11‑day gap, and the other had no surgical wound care or monitoring orders documented during their stay.
The deficiency involves failures in pressure ulcer prevention and treatment for three residents. One resident was admitted with heel pressure injuries documented by the hospital, yet admission assessments and the MDS did not reflect these wounds, and despite a care plan noting unstageable bilateral heel injuries with directions for monitoring and offloading, there was no documented skin checks or wound care until the wounds were later assessed as unstageable blisters. A second resident admitted with multiple Stage 3 and DTI pressure injuries had wounds that enlarged over time while MARs showed repeated missed and refused dressing changes, with no care plan interventions for handling refusals and no documented risk–benefit discussions about the impact of refusing wound care. A third resident with a Stage 3 left hip ulcer had no wound care orders entered for several days after admission, and an initially ordered wound culture was not completed as scheduled, requiring a new order and delaying culture collection and results.
Multiple residents with significant care needs experienced excessively long call light response times, often waiting between 22 minutes and over two hours for assistance with toileting, medication, repositioning, and medical equipment. Staff and resident interviews, as well as call light logs and observations, confirmed that short-staffing—exacerbated by reliance on agency staff and the reopening of a facility wing—led to unmet care needs and delays in essential services.
Multiple residents with complex care needs experienced excessively long call light wait times, often exceeding 30 minutes to over an hour, due to insufficient nursing staff. Residents reported delays in receiving assistance for toileting, repositioning, and other activities of daily living, with some having to wait in soiled conditions or attempt self-transfer. Staff and resident council interviews confirmed ongoing staffing shortages and untimely responses, and surveyor observations noted strong urine odors and unmet care needs.
Surveyors found that the facility failed to properly label and discard expired or undated food items, maintain required food temperatures, and ensure hand hygiene and kitchen cleanliness. Opened and expired foods were present in storage areas, cold and hot foods were served outside safe temperature ranges, and staff did not consistently change gloves or perform hand hygiene. Cleaning schedules and temperature logs were incomplete, and multiple areas of the kitchen and a nurse's station refrigerator were unclean.
The facility failed to ensure that the resident call light system was consistently audible and functional, with multiple instances where call lights were visibly activated but not heard in the hallway. Staff interviews confirmed that the system's sound was sometimes turned off by night shift staff, and residents reported long wait times for assistance due to inaudible call lights.
The facility repeatedly failed to document and communicate required information during resident hospital transfers, including the basis for transfer, unmet needs, attempts to meet those needs, and information provided to the receiving hospital. Bed hold offers were not documented, and the Office of the State LTC Ombudsman was not notified as required. Staff interviews confirmed gaps in documentation and awareness of notification requirements.
The facility did not consistently complete PASRR Level II evaluations or incorporate their recommendations into care plans for several residents with serious mental illness or behavioral health needs. Some residents did not receive timely referrals for evaluation, and others did not have behavioral health interventions implemented as recommended, resulting in unmet behavioral health needs.
The facility did not consistently provide or evaluate restorative nursing programs for two residents, including those with quadriplegia and dementia, as outlined in their care plans. Additionally, another resident with mobility deficits was not assessed or provided with restorative interventions. Staff interviews and documentation revealed missed sessions, lack of staff training, and incomplete implementation of restorative services, resulting in unmet care needs.
The facility did not ensure that nurses and nurse aides, including agency staff, had documented training or competency evaluations before providing care. Several staff files lacked evidence of required training, and agency staff reported not receiving orientation or skills assessments. Leadership and staff were unaware of processes to verify competencies, and residents reported concerns about care quality and response times.
Annual performance evaluations were not completed for three nursing assistants, as required. Personnel files lacked documentation of these evaluations, and interviews with management and HR staff revealed uncertainty about the process and frequency for conducting them. The Administrator confirmed that annual evaluations were expected but had not been performed.
Surveyors found that the facility did not maintain proper medication room temperatures, failed to remove expired insulin and date opened insulin vials, and did not track or count oral Ativan in an emergency kit as required. Staff acknowledged the importance of these practices, but deficiencies persisted in medication storage, labeling, and controlled substance accountability.
The facility did not consistently provide bedtime snacks to residents, with several residents reporting that snacks were unavailable in the evenings and staff confirming that refrigerators were sometimes empty and kitchen access was restricted at night. This issue was particularly concerning for diabetic residents who might require snacks outside of scheduled meal times.
The facility did not maintain complete and accurate medical records for three residents, including missing documentation of hospital encounters for two residents with multiple transfers and insufficient records of the final events and notifications surrounding a resident's death. Staff confirmed that required documentation was not entered into the electronic medical record as expected.
Staff failed to consistently implement enhanced barrier precautions and proper hand hygiene during high-contact care activities for several residents with wounds, indwelling devices, or infections. Observations showed that staff did not always don gowns and gloves or perform hand hygiene as required, and some staff were unclear about EBP protocols. PPE and signage were also not promptly provided for new admissions needing EBP, resulting in lapses in infection control.
The facility did not ensure that two nursing assistants received the required annual 12 hours of in-service training, including dementia care and abuse prevention, as shown by missing documentation in their personnel files. The administrator confirmed that the computerized training system did not automatically schedule required trainings, resulting in some staff not meeting training requirements.
Two cognitively intact residents with significant medical conditions were left sitting in their wheelchairs with hoyer slings underneath them after transfers, despite expressing discomfort and pain. Staff reported leaving the slings in place due to staffing limitations and convenience, without consulting the residents about their preferences. The DON confirmed that slings should not be left under residents due to the risk of pressure on the skin.
A resident who was cognitively intact was not informed or provided with written information about the right to formulate an advance directive, as required by facility policy. Documentation was lacking in the care plan, care conference evaluation, and nursing progress notes, and staff interviews confirmed the omission.
Two residents did not receive timely assistance with ADLs, including bathing and nail care, as required by their care plans. One resident experienced a 12-day gap between baths without documented refusals, while another was repeatedly observed with untrimmed, dirty fingernails despite no refusals on several dates. Staff confirmed that these hygiene tasks were expected to be performed regularly and documented, but records did not reflect this.
A resident with recent pelvic surgery and a suprapubic catheter did not receive prescribed wound care to the pubic area, as hospital transfer orders for dressing changes were not transcribed or implemented. The resident reported the dressing had not been changed for several weeks, and staff confirmed the omission of wound care orders and lack of documentation in the medical record.
Two residents with significant mental health needs did not receive timely behavioral health services as recommended and care planned. One resident, with a history of depression and suicide attempts, did not receive psychiatric or behavioral health interventions until weeks after a suicidal gesture that required hospital care. Another resident with depression and delusional disorder did not receive behavioral health evaluations or therapy despite care plan directives and consent. Staff confirmed delays and lack of documentation for these services.
The facility did not act promptly on pharmacy recommendations for two residents, resulting in significant delays in completing a uric acid test, reviewing an anticoagulant dosage, and performing an AIMS assessment for a resident on antipsychotic medication. Staff interviews confirmed the delays and uncertainty about required timeframes for addressing these recommendations.
Two residents did not receive prescribed medications as ordered, including an antibiotic, Aspirin, Hydralazine, and Voltaren gel, with missing documentation on the MAR and no explanations for the omissions. Staff interviews confirmed that medications were not administered or ordered in a timely manner, and required documentation was lacking.
The facility did not maintain required documentation showing that two staff members, including a RN and a department director, were educated about the risks and benefits of the COVID-19 vaccine, were offered the vaccine, or had their vaccination status recorded, as required by facility policy.
Surveyors found that hazardous chemicals were left unsecured in both a housekeeping closet and a shower room accessible to a resident with dementia. Additionally, a resident's wheelchair was observed to be persistently unclean and damaged, and another resident's room had unrepaired drywall damage. Staff interviews confirmed that these conditions were not in line with facility protocols for safety and cleanliness.
The facility did not identify or address substance use disorder risks for two residents with relevant diagnoses, as their care plans lacked interventions and no risk assessments or safety measures were documented. The administrator was unaware of the need for care plan interventions for substance use disorders.
The facility submitted inaccurate direct care staffing information to CMS for Q1 2024, reporting staffing levels below mandated requirements due to improper data input for agency staff. The Administrator acknowledged the error and indicated that the home office submitted the data, with efforts underway to resolve the issue.
A resident with a history of stroke and incontinence was left unattended for over an hour after activating their call light for assistance following a urinary incontinence episode. Despite requesting female staff, a male NA responded but did not return, leaving the resident in discomfort and distress. The resident's representative was informed, and staff later found the resident and their bedding soaked with urine, highlighting a communication breakdown among staff.
The facility failed to provide a safe environment for residents who smoked, lacking designated smoking areas and fire-safe receptacles. Observations showed cigarette butts in dry vegetation, posing a fire risk. Additionally, a resident was found smoking on the property without a timely smoking evaluation, despite being deemed unsafe to smoke independently. Staff acknowledged the lack of safe disposal means and inadequate processes for ensuring resident safety.
A resident in an LTC facility was not protected from physical and psychological abuse by another resident. Despite witnessing the incident, staff failed to initiate an investigation or provide immediate protection. The affected resident, who was cognitively intact and had a mental illness, experienced increased agitation and fear, with no psychosocial assessment conducted to address these changes.
The facility failed to maintain proper food safety and hygiene practices, with expired and undated food items found in refrigerators and freezers, and a cook serving food without a beard net. Additionally, uncovered food was placed on trays for residents, and the nourishment refrigerator was dirty with debris and standing liquid.
The facility failed to implement timely PPE measures after a resident tested positive for COVID-19, did not adhere to Enhanced Barrier Precautions for residents with catheters and wounds, and neglected proper hand hygiene practices. These deficiencies increased the risk of infection transmission among residents and staff.
The facility failed to maintain a safe, sanitary, and homelike environment, with issues such as gouged walls, chipped paint, damaged blinds, and stained carpets. Persistent odors of urine and fecal matter were noted, and toilets and sinks were scratched and stained. Staff interviews revealed a lack of routine cleaning schedules and systemic issues due to staffing shortages. The Interim Administrator acknowledged the need for improvements, citing frequent leadership changes as a contributing factor.
The facility failed to complete accurate and timely PASARRs for residents with serious mental illnesses. One resident's PASARR omitted psychotic and delusional disorders, another's missed an anxiety disorder, and a third was completed 98 days post-admission. A fourth resident, with multiple mental illness diagnoses, had an incomplete PASARR and exhibited delusions. Staff acknowledged the lack of a process to ensure PASARR accuracy and timeliness.
The facility failed to provide consistent bathing and grooming assistance to several residents, resulting in poor personal hygiene and unmet care needs. Residents requiring help with ADLs, such as bathing and shaving, did not receive care as per their care plans, with significant gaps between showers and no documentation of refusals or re-offers. Staff interviews revealed inconsistencies in following care plans and a lack of documentation for missed or refused care.
The facility failed to ensure that two nursing assistants, with pending licenses, met competency requirements before providing care. Both staff members were observed providing resident care despite not having completed the necessary certification, violating state law.
The facility failed to provide mandated dementia and behavioral health training to five staff members, including a Nursing Assistant, a Cook, an LPN, and two RNs. This deficiency was identified through interviews and a review of training records, highlighting the lack of training despite its importance for meeting residents' needs. The facility's assessment tool indicated that such training should be provided to all staff.
A facility failed to provide dignified catheter care for a resident with neurogenic bladder by not covering the urine collection bag with a privacy bag. This was observed multiple times, and the DON acknowledged it as a dignity issue.
A resident with obesity and a history of falls was not provided a bariatric commode, despite being unable to use the standard bathroom facilities in their room. The resident, who was making progress in physical therapy, expressed that a commode would improve their quality of life. Staff acknowledged the need for a bariatric commode, but no documentation was provided to confirm its order.
The facility failed to inform two residents about their right to formulate an advance directive, as required by regulations. Despite the DON stating that advance directives were offered upon admission and during the initial care conference, the records for these residents did not reflect that this information was provided. This deficiency was identified during a review of the residents' records, which showed a lack of documentation for informing them about their rights.
The facility failed to report and investigate abuse allegations involving two residents. One resident reported being slapped by another, which was observed by staff but not documented or reported. Another resident was involved in multiple altercations, including pushing and threatening other residents, but these incidents were not reported to the State Agency. The facility's procedures for reporting abuse were not followed, placing residents at risk.
The facility failed to investigate abuse allegations involving two residents. One resident reported being slapped by another, with no documentation or investigation initiated. Another resident exhibited aggressive behavior, including making threats, but these incidents were not logged or investigated. Staff interviews revealed a lack of adherence to abuse prevention procedures.
A resident with dementia and a high fall risk was repeatedly left alone in their room while in a wheelchair, contrary to their care plan. Despite instructions to transfer the resident to bed or a visible area, staff left the resident alone, leading to multiple observations of the resident leaning over in their wheelchair. Interviews confirmed staff awareness of the care plan, yet it was not followed.
A medication cart review revealed that medications were prepared but not administered timely due to residents' unavailability, leading to improper storage in the cart drawer. Staff R, a Medication Technician, followed instructions from the DON to label and store the medications, despite guidelines against such practices, increasing the risk of medication errors.
A facility failed to follow its bowel management protocol for a resident with multiple sclerosis and hemiplegia, leading to unaddressed constipation. Despite having a policy to administer laxatives after 72 hours without a bowel movement, the resident experienced several multi-day periods without a BM, and the necessary medications were not given. Staff interviews revealed a lack of adherence to the protocol, with some staff unaware of the resident's constipation issues.
The facility failed to monitor weights accurately for a resident with nutritional risks, leading to unrecognized weight changes. Another resident experienced significant weight loss due to unimplemented dietary recommendations and unreported health changes, including COVID-19, which the physician was not informed about.
The facility failed to maintain current oxygen orders and clean equipment for four residents, leading to potential respiratory complications. A resident with COPD had incomplete oxygen orders and unclean equipment. Another resident used oxygen without a physician's order, and their equipment was not maintained. A third resident's oxygen equipment was dusty despite orders for weekly cleaning. Lastly, a resident with acute respiratory failure had no documented oxygen orders, causing confusion in their care plan.
A resident with a history of stroke, sacral ulcer, and quadriplegia experienced unmanaged pain due to the facility's failure to provide adequate pain management. Despite having orders for pain medications and a care plan including repositioning, the resident frequently reported severe pain levels. Observations and interviews revealed inconsistent documentation and lack of communication with the physician, leading to inadequate pain relief.
A resident, independent in most ADLs but with mental health issues, expressed a desire to live elsewhere. The facility failed to assist with discharge planning, as there was no documentation of inquiries for alternate living arrangements or contact with the State Social Worker. Additionally, no Level 2 PASRR was completed to assess the need for specialized mental health services, placing the resident at risk for decreased quality of life.
The facility failed to dispose of expired medications and secure narcotics properly. Expired vaccines and Tuberculin were found in the medication storage room, and narcotics were not locked. An insulin pen on the medication cart was undated, with staff unaware of its opening date. These issues were confirmed by the DON and an RN, highlighting lapses in medication management.
Failure to Provide, Document, and Order Appropriate Wound Care and NPWT Supplies
Penalty
Summary
The deficiency involves multiple failures to provide ordered wound care, to timely obtain and document wound care supplies, and to enter and clarify wound care orders for residents with non-pressure skin conditions and surgical wounds. One resident was admitted with multiple lower extremity ulcers and scheduled wound care, including Unna boots and compression wraps, later modified to various dressing regimens and oral antibiotics for infected bilateral lower extremity wounds. Medication administration records (MARs) for several months showed numerous entries marked as refused, held, or left blank for ordered dressing changes and one antibiotic dose, with at least one dressing change held without a corresponding provider order or indication that the provider was aware. The resident’s care plan included actual wounds and later an infection of bilateral lower extremity wounds, but contained no focus or interventions addressing the resident’s repeated refusals of wound care or any documented risk–benefit discussion, even though the resident reported concern that dressings were not done regularly and that their legs were starting to smell bad. Another resident was discharged from the hospital with an open surgical wound on the right lower leg requiring NPWT (wound vac) with specific frequency and settings. The facility care plan noted cellulitis and infection of the right lower extremity but did not address the wound vac order or refusals of wound care. MARs over several months showed repeated NN (other/progress note), blank, held, and refused entries for NPWT dressing changes. Progress notes documented that the resident did not arrive from the hospital with a wound vac and instead had wet-to-dry dressings, that the wound vac canister was found full with the dressing dripping with fluid, and that staff were using wet-to-dry dressings while awaiting wound vac supplies. A third resident with a large abdominal wound and an order for NPWT three times weekly had multiple blank, NA, and refused entries on the MAR, and the Resident Care Manager stated that supplies were running out because staff were not notifying them when supplies were low and that it took about seven days to obtain new supplies. Additional deficiencies involved failures to enter and clarify wound care orders for surgical wounds. One resident underwent a left below-knee amputation and was admitted with a surgical wound and sutures; the admit assessment documented that the resident removed the dressing due to itching, with some bleeding and redressing by staff, but no wound care focus or interventions were added to the care plan. No wound care orders were entered for this surgical site until 11 days after admission, and the initial order lacked a specified wound site and solution strength, with MAR entries coded NN and progress notes indicating the order was unclear and needed clarification. The order was discontinued, leaving an 11-day gap before a new, more detailed order was entered. Another resident admitted after right hip fracture repair had a surgical wound and required surgical wound care per the admission MDS, but no surgical wound care or monitoring orders appeared on the MARs during their stay, and the Resident Care Manager reported that the resident came from the hospital with unclear instructions and they were not sure if wound care was performed.
Failure to Prevent and Manage Pressure Ulcers and Address Refusals of Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer prevention and treatment for three residents. For one resident, preadmission hospital notes documented a right heel pressure injury, but the facility’s admission skin assessment recorded no issues with the feet, and the admission MDS indicated no pressure ulcers, only risk for development. Despite a care plan dated the same day as admission identifying actual unstageable bilateral heel pressure injuries and directing staff to assess, measure, and monitor the wounds and to offload the heels in bed, there was no documented monitoring or wound care for the heels until mid-December. Skin checks were not documented, and wound assessments for the bilateral heels were not entered into the record until late December, at which time the heels were described as unstageable with blistered, discolored wound bases. Nursing leadership acknowledged being informed of the heel pressure injuries only shortly before the resident left the facility and could not explain the lack of skin checks, monitoring, or wound care orders prior to that time. For a second resident with multiple pressure injuries on admission, the facility failed to consistently provide ordered wound care and did not address ongoing refusals of care. The admission MDS showed two Stage 3 pressure ulcers and two unstageable DTI wounds with pressure injury care being performed. A skin assessment documented four pressure injuries to both scapulae, the left gluteus, and the left lateral calf, and a later wound assessment showed all four wounds had significantly increased in size. Review of MARs over three consecutive months showed numerous blank boxes where daily or scheduled dressing changes were ordered, along with multiple documented refusals. The care plan identified the actual pressure ulcers and DTIs but contained no interventions for how to address the resident’s frequent refusals of wound care. The medical record did not contain any documented risk-versus-benefit discussions regarding the likelihood of wound worsening related to refusal of care. Nursing staff confirmed that the resident frequently refused wound care, that they did not monitor the MAR to ensure wound care was consistently provided, and that blank MAR boxes indicated wound care was not performed. For a third resident admitted with a left hip Stage 3 pressure injury, the facility did not enter wound care orders in a timely manner and did not complete a wound culture as initially ordered. The admission skin assessment documented a left hip pressure injury with specific measurements and depth, and the MDS indicated the resident had one Stage 3 pressure ulcer and was receiving pressure ulcer wound care. However, the MAR showed that an order for wound care to the left hip wound, which was present on admission, was not entered until eight days after admission. Later, an order for a left hip wound culture to be completed over a specified multi-day period was entered, but only one MAR box was signed to indicate the resident was out of the facility, and the remaining boxes were left blank, indicating the culture was not obtained as ordered. A second wound culture order was then entered several days later, and the culture was finally collected and resulted, showing mixed bacteria and leading to antibiotic treatment. Nursing leadership stated that clear wound care instructions were not present on the hospital discharge orders and acknowledged that wound care orders were delayed and that the original wound culture order was not completed, causing a delay in results.
Failure to Provide Sufficient Nursing Staff Resulting in Excessive Call Light Wait Times
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by repeated excessively long call light response times for seven out of eight sampled residents. Call light activation logs revealed that residents frequently waited between 22 minutes and over two hours for assistance with essential care needs such as toileting, repositioning, medication administration, and help with medical equipment. These delays were documented across multiple days and shifts, affecting residents with significant medical conditions and dependencies, including recent surgeries, infections, wounds, amputations, and severe mobility impairments. Residents directly reported their experiences of prolonged waits, with some stating they had to remain in soiled briefs, wait for pain or nausea medication, or attempt to manage medical equipment themselves due to staff unavailability. Observations further confirmed unmet care needs, such as a resident's urinal being left full and a strong urine odor in the room. Staff interviews corroborated these findings, with nursing assistants, nurses, and the staffing coordinator acknowledging frequent short-staffing, reliance on agency staff, and challenges in maintaining adequate coverage, especially after reopening a previously closed wing. The facility's own assessment and staffing review processes were based on state minimum standards and resident acuity, but these measures were not sufficient to ensure timely care. Staff described being pulled from their assigned roles to cover shortages, leading to further strain and missed breaks. Agency staff were often used to fill gaps, but their reliability and adherence to facility expectations were inconsistent, with some agency staff being sent home for not responding to resident needs. The Director of Nursing confirmed ongoing difficulties in scheduling and meeting the facility's expectation that call lights be answered within 20 minutes.
Failure to Provide Sufficient Nursing Staff Resulting in Excessive Call Light Wait Times
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available each day to meet the needs of residents, as evidenced by repeated excessively long call light wait times for multiple residents. Review of call light activation logs for seven sampled residents revealed numerous instances where residents waited between 30 minutes to over an hour and a half for staff response. These delays occurred across various times of day and affected residents with significant care needs, including those with cerebral palsy, recent fractures, quadriplegia, stroke, muscle weakness, and incontinence. Care plans for these residents required timely assistance for activities of daily living, fall prevention, and incontinence care, but the documented wait times indicate these needs were not consistently met. Interviews with residents confirmed the pattern of delayed responses, with several residents stating they often waited over an hour for assistance, particularly for toileting and repositioning. Some residents reported having to self-transfer or remain soiled for extended periods due to the lack of timely staff response. The Resident Council also reported frequent and prolonged call light wait times, sometimes up to an hour and a half, and noted that staff would sometimes place call lights out of residents' reach. Staff interviews corroborated these concerns, with nursing staff acknowledging that excessively long wait times were not safe and could lead to negative outcomes such as falls or unmet care needs. Observations by surveyors further substantiated the deficiency, including the presence of strong urine odors in resident areas and direct observation of a resident left in soiled incontinence products for an extended period. Facility leadership acknowledged that staffing was determined based on state minimums and acuity, but also recognized that the current resident population required more staff due to increased care needs. Despite daily reviews of staffing levels, the facility did not consistently provide enough staff to ensure timely care and response to resident needs, as required by regulation.
Deficient Food Storage, Temperature Control, and Sanitation Practices
Penalty
Summary
The facility failed to store, label, and monitor food in accordance with professional standards for food service safety. During a kitchen tour, surveyors observed multiple opened food items in dry storage, the refrigerator, and freezer that were not labeled with open or expiration dates, as well as expired food items such as cereals and baking soda. Molded grapes and partially used celery without dates were also found. Staff confirmed that all food items should be labeled with open and use-by dates. Additionally, cold and hot food items were found to be outside of required temperature ranges during tray line service, with cottage cheese and hot dogs not meeting the necessary standards for safe serving temperatures. Staff acknowledged the importance of serving food at proper temperatures to prevent foodborne illness. Hand hygiene and kitchen cleanliness were also deficient. Staff were observed handling food and kitchen equipment without changing gloves or performing hand hygiene after touching potentially contaminated surfaces. The kitchen and storage areas were found to be unclean, with food debris on floors, dirty equipment, and unclean refrigerators, including one at the nurse's station. Cleaning schedules were incomplete or missing, and temperature logs for refrigerators showed multiple omissions. Staff interviews confirmed the need for regular cleaning and temperature monitoring, but these practices were not consistently followed.
Failure to Maintain Audible and Functional Call Light System
Penalty
Summary
Surveyors observed that the facility failed to maintain a functional and audible resident call light system in multiple resident rooms and bathrooms. On several occasions, call lights were visibly activated above resident rooms but were not audible in the hallway, preventing staff from being alerted to resident needs. These observations occurred over several days and at various times, indicating a persistent issue. Interviews with staff, including the Maintenance Director and nursing staff, confirmed that the call light system's sound had been turned off by night shift staff to avoid disturbing residents, and that staff were sometimes unsure how to ensure resident safety when the call lights were not functioning properly or audible. Residents reported experiencing excessively long wait times for call light responses, sometimes waiting over an hour. The Resident Council and individual residents confirmed that call lights were often inaudible during the night shift. Staff interviews revealed uncertainty about the system's security and the ability to restrict access to call light volume controls. Despite attempts to address the issue, further observations showed that the call light system continued to be inaudible at times, and staff acknowledged the ongoing problem.
Failure to Document and Notify Required Information During Resident Hospital Transfers
Penalty
Summary
The facility failed to complete required documentation and notifications related to resident hospital transfers for three of four sampled residents. Specifically, the facility did not document the basis for hospital transfers, the specific resident needs that could not be met, the facility's attempts to meet those needs, or the services available at the receiving facility. Additionally, there was no documentation of what information was communicated to the receiving provider, nor evidence that a bed hold was offered to residents upon transfer, as required by policy. For one resident with medically complex conditions and moderate cognitive impairment, there were three hospital transfers for wound assessment, a hand injury, and abdominal pain, but no documentation was found regarding information provided to the hospital or bed hold offers for two of the transfers. Another resident, cognitively intact and admitted with fractures, was transferred to the hospital four times for pain management, a fall, blood-tinged urine, and bladder pain, with no documentation of information communicated to the receiving facility. A third resident, also admitted with fractures, was transferred to the hospital for chest pain shortly after admission, again with no documentation of information provided to the hospital or a bed hold offer. Interviews with staff revealed a lack of awareness and adherence to documentation requirements, including notification to the Office of the State LTC Ombudsman for transfers and discharges. Staff acknowledged that documentation was often incomplete or missing, and that the Ombudsman was only notified in cases of discharge against medical advice, not for all required transfers or discharges.
Failure to Complete and Implement PASRR Level II Evaluations and Recommendations
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) processes were completed correctly for several residents, including the completion of Level II evaluations when indicated and the incorporation of Level II recommendations into care plans. For four out of six sampled residents, there were deficiencies in either referring for a PASRR Level II evaluation, obtaining the evaluation summary, or implementing the recommended behavioral health interventions. The facility's policy required that PASRR findings be reviewed and used to develop individualized care plans, but this was not consistently done. One resident with major depressive disorder and suicidal ideation was admitted without the PASRR Level II Initial Psychiatric Evaluation Summary in their record, and there was no evidence of behavioral health provider notes or assessments. The resident expressed willingness to receive behavioral health services but had not been seen by a provider. Staff interviews confirmed that referrals had been made but not followed up, and the administrator acknowledged that without the Level II summary, necessary interventions could not be incorporated into the care plan. Other residents with documented mental health diagnoses or behaviors indicating serious mental illness did not have timely PASRR Level II referrals or had care plans that failed to include the recommendations from completed Level II evaluations. For example, one resident with a history of suicide attempts and recent self-harm did not have the PASRR Level II recommendations integrated into their care plan, and behavioral health services were delayed. Staff acknowledged being behind on PASRR referrals and that multiple residents were awaiting evaluation. The administrator confirmed expectations for staff to review PASRRs for accuracy, refer for Level II evaluations when indicated, and implement recommendations into care plans, but these steps were not consistently followed.
Failure to Provide and Evaluate Restorative Nursing Programs
Penalty
Summary
The facility failed to provide care-planned restorative interventions and conduct periodic evaluations of current restorative programs for two out of three sampled residents reviewed for restorative services. For one resident with quadriplegia who was bed bound and required total assistance with activities of daily living, the care plan included a splinting and range of motion (ROM) program to prevent contractures. However, documentation showed that the passive ROM and splinting programs were not consistently offered on multiple dates, and the resident reported that staff did not have time to do exercises with them. Additionally, there was confusion among staff regarding responsibility for applying the splint, and therapy had indicated that it was the nursing assistants' responsibility to carry out the program. Another resident with dementia and muscle weakness, who required assistance with ambulation, was not consistently offered their care-planned ambulation program on several dates. Observations confirmed that the resident was not offered ambulation to or from meal service, despite documentation indicating refusals. Staff interviews revealed challenges in completing restorative programs due to staffing shortages and noted that refusals were documented, but the restorative program was not being well followed. A third resident, who had chronic obstructive lung disease, neuralgia, and depression, and required total assistance for most activities of daily living, did not have any restorative interventions included in their care plan to help achieve goals related to improving mobility and self-care. Staff interviews indicated that this resident would benefit from a restorative program, but such a program was not in place due to lack of staff. The facility's failure to provide and assess restorative services as care-planned placed residents at risk for a decline in mobility and decreased quality of life.
Failure to Evaluate and Document Staff Competencies
Penalty
Summary
The facility failed to develop and implement a system to evaluate staff competencies in skills and techniques necessary to provide individualized care for residents. Review of personnel files for three sampled staff members—a nursing assistant, a registered nurse (agency staff), and an LPN—showed no documentation of training or competency evaluations. The facility assessment indicated that staff competencies were to be reviewed annually and tracked via a computerized system, but records for these staff were missing. Agency staff reported not receiving training, orientation, or skills evaluations, and were only given a brief tour of the building. Interviews with facility leadership and staff revealed a lack of awareness and process for ensuring agency staff had adequate training and competencies, with the administrator and staffing coordinator acknowledging that these steps had not been completed or documented. Resident Council feedback indicated concerns about agency staff not providing adequate care, with reports of staff congregating at the nurses' station and residents experiencing long call light wait times. The facility utilized temporary contracted staff as needed, but there was no evidence that these staff received the required training or competency assessments. The absence of documentation and lack of a clear process for evaluating both permanent and agency staff placed residents at risk of receiving care from inadequately trained or under-qualified personnel.
Failure to Complete Annual Performance Evaluations for Nursing Assistants
Penalty
Summary
The facility failed to complete annual performance evaluations for three of five sampled nursing assistants, as required. Personnel files for these nursing assistants showed no documentation of performance evaluations since their respective hire dates. Interviews with the Resident Care Manager and Human Resources staff revealed uncertainty regarding the frequency and responsibility for conducting staff performance evaluations. The Administrator confirmed that annual evaluations were expected but had not been completed for the identified staff.
Medication Storage, Expired Insulin, and Controlled Substance Accountability Deficiencies
Penalty
Summary
The facility failed to maintain proper medication management practices in several key areas. Observations revealed that the medication storage room consistently exceeded recommended temperature limits, with recorded temperatures ranging from 80 to 82 degrees over multiple days. Staff acknowledged the importance of maintaining appropriate temperatures to prevent medication degradation, but the issue persisted without resolution. Additionally, expired insulin pens and undated insulin vials were found on a medication cart, with one pen opened beyond the recommended 28-day use period and another lacking an open date. Staff confirmed the necessity of discarding expired insulin to ensure medication effectiveness. Further deficiencies were identified in the handling of controlled substances. An emergency kit containing injectable and oral Ativan was stored in the medication room, but staff interviews revealed that the Ativan was not being tracked or counted as required for narcotics. While the kit was verified as sealed with a pharmacy zip tie, staff admitted that the contents were not regularly accounted for, contrary to policy and best practices for controlled substance management. These lapses in medication storage, labeling, and accountability were directly observed and confirmed through staff interviews.
Failure to Provide Bedtime Snacks and Ensure Snack Availability
Penalty
Summary
The facility failed to ensure that bedtime snacks were consistently offered to residents, as required by their needs and preferences. Multiple residents reported during interviews and a Resident Council meeting that snacks were not available in the evenings, with one resident specifically stating that requests for snacks around 10:00 PM were denied due to an empty refrigerator. Another resident noted that while the dietary manager typically prepared snacks, these were unavailable during the manager's absence, and common snack items such as applesauce, peaches, and mixed fruit were not provided in the evenings. Staff interviews confirmed that snacks sometimes ran out and that nursing staff did not have access to the kitchen at night, which was a concern especially for diabetic residents who might require snacks outside of scheduled meal times. The Director of Nursing acknowledged that refrigerators were intended to be stocked for nighttime use but confirmed that access and availability remained an issue.
Incomplete and Disorganized Medical Records for Residents
Penalty
Summary
The facility failed to ensure that resident medical records were complete, accurate, readily accessible, and systematically organized for three of four sampled residents reviewed for transfer and discharge. For two residents with multiple hospital transfers, there was no documentation in their medical records regarding the details of the hospital encounters, including the resident's status, assessment, testing, treatment, or plan of care. Staff interviews confirmed that hospital records should be scanned into the electronic medical record to maintain completeness and accuracy, but this was not done for these residents. For another resident with severe cognitive impairment and a history of stroke, the medical record lacked documentation of the final events leading up to the resident's death, including who assessed the resident, determined the time of death, or who was notified of the passing. The only documentation present was a Record of Death form indicating the date and time of death and body release. Staff interviews confirmed the expectation that a progress note should be written to include the events regarding a resident's passing.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) and proper hand hygiene as required for residents with wounds, indwelling medical devices, or colonization with antibiotic-resistant bacteria. Observations revealed that staff did not consistently don gowns and gloves during high-contact care activities, such as repositioning, medication administration, and wound care, for multiple residents who required these precautions. For example, a nurse was observed handling a resident's urinary catheter and administering medications without donning a gown or performing hand hygiene, despite clear signage indicating the need for EBP. Another nurse administered medications to several residents consecutively without performing hand hygiene between residents. In several instances, staff either misunderstood or were unaware of the requirements for EBP. Nursing assistants entered a resident's room and repositioned the resident without wearing any PPE, despite EBP signage and the resident's need for such precautions due to stage 4 pressure ulcers and an indwelling catheter. Interviews with staff revealed gaps in knowledge regarding when to use gowns and gloves, and some staff believed PPE was only necessary when there was a risk of splashing bodily fluids. Additionally, for one resident with a recent surgical wound and an indwelling catheter, staff failed to provide gowns in the PPE cart and did not use gowns during high-contact care activities, as confirmed by both staff and the resident. The facility also failed to promptly implement EBP for newly admitted residents with indications for such precautions. One resident with a PICC line and a urinary catheter did not have EBP signage or PPE available for nine days after admission. Another resident receiving wound care did not have EBP signage or PPE available in their room, and staff did not implement EBP until after the deficiency was identified. These failures were confirmed through staff interviews and record reviews, which showed a lack of consistent adherence to infection prevention protocols as outlined in facility policy and CDC recommendations.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nursing assistants received the required minimum of 12 hours of in-service training per year, including education in dementia management, abuse prevention, and care for individuals with cognitive impairment. Review of personnel files for two nursing assistants showed no documentation of completion of these mandatory trainings. The administrator acknowledged that some staff did not have the minimum required training and explained that the computerized training system did not automatically schedule trainings when due or required. This deficiency was identified through interviews and record reviews, with specific reference to the lack of documented training for the sampled staff.
Failure to Honor Resident Choice Regarding Hoyer Sling Removal
Penalty
Summary
Facility staff failed to honor the choices of two cognitively intact residents regarding the removal of hoyer slings after transfers to their wheelchairs. Both residents, who required total assistance with transfers and had significant medical conditions such as heart failure, diabetes, stroke, hemiplegia, and chronic pain, were observed on multiple occasions sitting in their wheelchairs with the hoyer sling left underneath them. Both residents expressed discomfort and pain due to the sling being left in place, and one resident reported that staff told them the sling had to remain because there was not enough staff to remove and reapply it as needed. Interviews with nursing assistants revealed that slings were routinely left under residents for reasons of convenience and perceived safety, without consulting the residents about their preferences. One nursing assistant acknowledged the importance of removing the sling to prevent pressure ulcers, while another stated that residents were not asked about their preferences due to their compromised mobility. The Director of Nursing confirmed that slings should not be left under residents as they create pressure on the skin.
Failure to Provide Written Information on Advance Directives
Penalty
Summary
The facility failed to inform and provide written information regarding the right to formulate an advance directive for one resident who was cognitively intact and able to verbalize their needs. Upon admission and during subsequent care conferences, there was no documentation that the resident was given written information about their right to establish an advance directive, as required by facility policy. The care plan and care conference evaluation both indicated that the resident did not have an advance directive, but did not show that the resident was informed of their rights or provided with the necessary information. Interviews with staff, including the Resident Care Manager and Social Services, confirmed that information on advance directives should have been offered and documented, but a review of the resident's medical record revealed no such documentation. The resident also stated that only their CPR status was reviewed, and they were not informed or provided with written information about advance directives. The facility's policy required this information to be provided and documented, but this was not done for the resident in question.
Failure to Provide Timely ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide timely and appropriate assistance with activities of daily living (ADLs) for two residents. One resident, who was cognitively intact and required substantial assistance for bathing due to diagnoses including heart failure, diabetes, and chronic pain, did not receive bed baths as often as needed. Documentation showed a gap of 12 days between bathing events, with no refusals recorded, despite the care plan specifying that a bed bath should be offered if a shower could not be tolerated. Staff interviews confirmed that bathing was expected to occur twice weekly and that refusals were to be documented, but this was not reflected in the records. Another resident, who had severe cognitive impairment and required partial to moderate assistance with personal hygiene, was observed multiple times with long, jagged fingernails containing brown matter. Documentation indicated that nail care was not completed as required, with several referrals to nursing staff and no evidence of trimming or cleaning. While some refusals were documented on certain dates, there were additional dates where nail care was not provided and no refusals were recorded. Staff interviews confirmed that nail care was to be performed on shower days, but the resident did not refuse care on the dates in question.
Failure to Implement Surgical Wound Care Orders
Penalty
Summary
The facility failed to implement wound care orders for a resident who was admitted with pelvis fractures, muscle weakness, and recent surgical repairs, including a suprapubic catheter and surgical wounds to the hips and pubic area. Upon review, it was found that the hospital transfer orders specified surgical site wound care with dressing changes every 2-3 days for the bilateral pubis area, but these orders were not transcribed into the resident's medical record or carried out by staff. The clinical admission evaluation did not document the presence of surgical wounds or the need for wound care, and the care plan only generally referenced wound care without specific implementation of the required dressing changes. During observation and interview, the resident reported that the dressing on their pubic area had not been changed for 2-3 weeks and that the current dressing was from a previous hospital visit. The dressing was visibly soiled with dark yellow drainage. Staff interviews confirmed that the wound care orders from the hospital were not processed or implemented, and staff acknowledged the importance of monitoring wounds for signs of infection. The Director of Nursing stated that staff are expected to review and implement provider orders and update care plans accordingly, but this did not occur in this case.
Failure to Provide Timely Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for two residents who were identified as needing support for mood and behavior issues. For one resident with a history of depression, encephalopathy, and multiple suicide attempts, the facility did not implement recommended behavioral health interventions in a timely manner. Despite a PASRR Level II evaluation recommending ongoing psychiatric consultation and therapy, and provider orders for psychiatric and behavioral health evaluations, there was no documentation that these services were provided prior to a significant incident. The resident expressed ongoing depression and suicidal ideation, culminating in an event where they used a dinner knife to inflict injury and made stabbing motions toward their abdomen, requiring hospital transport. Behavioral health services were not initiated until 52 days after admission and 39 days after the suicidal gesture. Another resident with diagnoses including delusional disorder, major depressive disorder, and suicidal ideation was also not provided timely behavioral health services. The resident had a history of trauma and had recently been hospitalized for psychiatric reasons. The care plan indicated the need for weekly time to talk and a psychiatric consult, but there were no behavioral health evaluations or provider progress notes in the medical record. Although the resident signed a consent for behavioral health services, there was a delay in initiating these services, and no documentation was found to show that behavioral health interventions were provided as care planned. Staff interviews confirmed that behavioral health recommendations and care plans were not implemented in a timely manner for both residents. Staff acknowledged that behavioral health services, including medication management and therapy, were not provided as ordered or recommended, and that documentation of services offered or refused was lacking. The failure to provide timely and appropriate behavioral health care placed residents at risk for further decline in mental well-being and unmet care needs.
Delayed Response to Pharmacy Recommendations for Drug Regimen Review
Penalty
Summary
The facility failed to act in a timely manner on pharmacy recommendations identified during monthly drug regimen reviews for two residents. For one resident with diagnoses including gout, irregular heartbeat, and depression, the pharmacist recommended a uric acid level test and a reduction in Eliquis dosage. The uric acid test was not completed until 49 days after the recommendation, and the Eliquis dosage was not reviewed until 104 days after the initial recommendation. Staff interviews confirmed uncertainty regarding the required timeframe for processing pharmacy recommendations and acknowledged the delay in addressing these recommendations. For another resident with a history of stroke and receiving antipsychotic medications, the pharmacist recommended completion of an Abnormal Involuntary Movement Scale (AIMS) assessment, as it was not found in the medical record. Despite repeated recommendations in consecutive months, the AIMS assessment was not completed until 51 days after the initial recommendation. Staff confirmed that pharmacy recommendations should be addressed promptly and acknowledged that these recommendations were not processed in a timely manner for this resident.
Failure to Administer Medications as Ordered and Document Appropriately
Penalty
Summary
The facility failed to ensure that residents received their medications as ordered, resulting in significant medication errors for two residents. One resident with diagnoses including obstructive uropathy and coronary artery disease did not receive prescribed Ciprofloxacin for a urinary tract infection and Aspirin for amaurosis fugax as ordered. The Medication Administration Record (MAR) was left blank for both medications, and there was no documentation explaining the omissions. Staff interviews revealed that the antibiotic was not available in the facility's medication cart and was not delivered in time, despite the pharmacy having the capability to provide the medication promptly. The omission of Aspirin was attributed to the form of the medication, but there was no documentation of provider clarification in the resident's record. Another resident with high blood pressure and chronic pain did not receive Hydralazine as needed when their systolic blood pressure exceeded the ordered threshold, and there was no documentation on the MAR to explain the omission. Additionally, Voltaren gel for pain management was marked as unavailable on multiple days. Staff interviews confirmed that nurses were responsible for ordering medications and acknowledged that the medications should have been administered as ordered. The lack of medication administration and documentation directly led to the identified deficiencies.
Failure to Document COVID-19 Vaccine Education and Status for Staff
Penalty
Summary
The facility failed to ensure that documentation was maintained showing that staff were educated about the risks and benefits of the COVID-19 vaccine, that the vaccine was offered to them, and that their vaccination status was recorded. Specifically, for two sampled staff members, the Director of Maintenance and a Registered Nurse, there was no documentation in their employee files regarding COVID-19 vaccination education, offer, or status. The facility's policy required that such education and documentation be provided and maintained for all staff and residents. During the survey, the Administrator was unable to produce records confirming that these two staff members had received education about the COVID-19 vaccine or had been offered the vaccine. A review of employee files and a search for a possible tracking spreadsheet did not yield the required documentation. The Administrator confirmed that one staff member had never received the vaccine and was unable to confirm the vaccination status of the other staff member at the time of the survey.
Unsafe Environment Due to Unsecured Chemicals, Unclean Equipment, and Room Disrepair
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for residents, as evidenced by unsecured hazardous chemicals, unclean and damaged equipment, and unrepaired room damage. Surveyors observed that a housekeeping storage closet containing harmful chemicals was left unlocked and accessible, despite staff acknowledging it should always be locked. Additionally, a shower room accessible to a resident with dementia and moderate cognitive impairment was found unlocked, with a metal box containing disinfectant chemicals left unsecured. Staff confirmed that these chemicals should have been locked away to prevent resident access. Further deficiencies included a resident's wheelchair that was persistently unclean, with thick dirt and debris, and a torn armrest exposing uncleanable padding. Multiple observations over several days confirmed the wheelchair remained in this condition, and staff interviews revealed uncertainty about cleaning frequency and repair reporting. Another resident's room was found with large gouges in the drywall next to their pillow, which had not been repaired since the resident moved in. Staff stated that such damage should be reported and repaired, but maintenance was unaware of the issue due to a lack of work orders.
Failure to Address Substance Use Disorder Risks in Resident Care Plans
Penalty
Summary
The facility failed to identify, evaluate, and analyze risks related to substance use disorder for two of three sampled residents. Both residents were admitted with diagnoses that included psychoactive substance use disorder or substance abuse, but their care plans did not include any interventions addressing these conditions. There was no evidence in the medical records that the facility recognized these residents as having substance use disorders, nor was there documentation of any risk assessment or implementation of safety interventions to mitigate associated hazards. Additionally, during an interview, the facility administrator stated they were unaware that residents required a care plan focus and interventions for substance use disorders. This lack of awareness and action resulted in the absence of necessary safety measures for residents with known substance use disorders, as required by regulatory standards.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to ensure the accuracy of direct care staffing information submitted to the Centers for Medicare and Medicaid Services (CMS) for Quarter 1 of 2024. This deficiency was identified through interviews and record reviews, revealing that the facility's Payroll Based Journal (PBJ) submission for the period from January 1, 2024, to March 31, 2024, reported staffing levels lower than the mandated requirements. The inaccuracy was attributed to improper data input for agency staff, as acknowledged by the facility's Administrator during an interview. The Administrator noted that the home office was responsible for submitting the data and was collaborating with IT staff to address the issue.
Failure to Maintain Resident Dignity and Timely Care
Penalty
Summary
The facility failed to maintain the dignity of a resident who was admitted with a history of stroke and left-sided weakness, and who was at risk for skin problems due to incontinence and a yeast infection. On the morning of September 24, 2024, the resident activated their call light at 5:06 AM to request assistance after a urinary incontinence episode. Despite the resident's request for female staff assistance, a male nursing assistant responded and promised to find a female nursing assistant but never returned. The call light remained on for over an hour, and the resident was left in a state of discomfort and distress due to their condition. The resident's representative was informed of the situation and confirmed that the resident had been left unattended for an extended period. When staff finally attended to the resident at approximately 7:30 AM, they found the resident and their bedding soaked with urine. The incident was reported to have caused the resident significant frustration and anger due to the prolonged wait for assistance. The facility's investigation revealed a lack of communication among staff, which contributed to the delay in providing necessary care.
Failure to Ensure Safe Smoking Practices
Penalty
Summary
The facility failed to ensure a safe environment for residents who smoked, as evidenced by the lack of designated smoking areas, fire-safe receptacles for cigarette disposal, and proper storage of smoking supplies. Four residents who were assessed to smoke independently did not have a designated safe location to smoke, and there was no system in place to ensure smoking supplies were stored safely. Observations revealed cigarette butts scattered around the facility, including in dry vegetation, which posed a significant fire hazard, especially during a period of extreme heat and high fire risk. Additionally, the facility did not conduct timely smoking evaluations for residents, as demonstrated by the case of a resident who was cognitively intact but required assistance for transfers and supervision when using a wheelchair. This resident was found smoking on the property despite being deemed unsafe to smoke independently. The resident had been advised of the facility's non-smoking policy and was informed that they needed to be evaluated for independent smoking safety, but no smoking evaluation was completed until months later. Interviews with staff revealed a lack of means for safe cigarette disposal and inadequate processes to ensure resident safety regarding smoking. Staff acknowledged that a smoking evaluation and safety plan should have been completed earlier for the resident who was identified as a smoker, but this was not done, leading to a situation where the resident retained cigarettes and a lighter in their possession without proper oversight.
Failure to Protect Resident from Abuse and Conduct Timely Investigation
Penalty
Summary
The facility failed to protect a resident, identified as Resident 28, from physical and psychological abuse by another resident, Resident 14. Resident 28, who was cognitively intact and diagnosed with mental illness with delusions of grandeur, reported being slapped on the buttocks by Resident 14. This incident was witnessed by Staff J, who reported it to the staffing coordinator, Staff N. However, no immediate investigation or protective measures were taken following the incident, and Resident 28 continued to experience psychological distress, including changes in behavior, agitation, and fear. The facility's policy on abuse prevention and investigation, dated 10/31/2017, was not followed. The policy required that residents involved in abuse incidents be separated and supervised to prevent further contact, and that an investigation be initiated immediately. Despite these guidelines, no investigation was conducted, and no physical or psychosocial assessments were completed for Resident 28. The Director of Nursing, Staff B, acknowledged the failure to initiate the abuse protocols and noted that the abuse was not reported or investigated in a timely manner. Resident 28's behavior became increasingly manic and agitated following the incident, as documented in progress notes. The resident was observed pacing, making rude comments, and demanding changes in the environment, such as turning down televisions. Despite these documented changes, there was no assessment to determine if these behaviors were related to the abuse. Resident 28 expressed feeling unsafe and preyed upon in the facility, indicating a significant impact on their psychological well-being.
Food Safety and Hygiene Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen and resident nourishment areas. Observations revealed expired and undated food items in the refrigerators and freezers, including tortillas, macaroni salad, salsa, and strawberry yogurt. Additionally, there were open packages of berries and celery that were not dated, and an open undated package of cooked eggs. The resident nourishment refrigerator contained multiple open food packages without labels or dates, and the refrigerator and freezer were found to be dirty with debris and standing liquid. The seals on the doors were also dirty with debris and spilled food/liquid. During a lunch tray-line service, a cook was observed serving food without wearing a beard net, despite having a full beard approximately two inches long. The dietary manager and the cook stated they were informed by a former dietician that a beard net was not necessary for short beards. Additionally, uncovered cottage cheese and pudding cups were placed on lunch trays for delivery to resident rooms. The dietary manager acknowledged the responsibility for cleaning the resident's nourishment refrigerator and discarding expired food, stating that the refrigerator should not have spilled food or debris as it is unsanitary. The manager also confirmed that opened food should be stored in a container with a lid, labeled with the item name, the date it was opened, and the use-by date.
Infection Control Deficiencies in PPE and Hygiene Practices
Penalty
Summary
The facility failed to implement timely personal protective equipment (PPE) measures in accordance with CDC and local health department guidelines after a resident tested positive for COVID-19. Despite being informed of the positive test, the facility did not place the resident in isolation, failed to notify the health department promptly, and did not ensure staff wore surgical masks as recommended. Observations showed that staff continued to work without the necessary PPE, and the resident was not isolated until later, increasing the risk of COVID-19 transmission among residents and staff. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) for residents with urinary catheters and open wounds. Staff were observed providing care without wearing gowns, and there was a lack of signage and accessible PPE near the rooms of affected residents. This oversight was noted during care for residents with catheters and wounds, where staff failed to use the required protective measures, potentially increasing the risk of infection. The facility also failed to maintain sanitary conditions for a resident's urinary catheter, which was observed lying on the floor and at the same level as the bladder, posing a risk for urinary tract infections. Furthermore, hand hygiene practices were not followed during personal care, as staff did not perform hand hygiene between glove changes, which could contribute to the spread of infections. These deficiencies highlight significant lapses in infection control practices within the facility.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment, as evidenced by multiple deficiencies observed during the survey period. Resident rooms and hallways were found with gouged walls, chipped paint, holes, and damaged blinds. The windows were dirty, and the screens were clogged with dirt and debris. The carpets in the hallways were heavily stained, and the facility had persistent odors of urine and fecal matter. Toilets and sinks in several resident rooms were scratched and stained, and the nursing station counter had sharp edges due to broken laminate. Staff interviews revealed systemic issues contributing to the deficiencies. A nurse indicated that cleaning wheelchairs was not part of the routine, and there was no established schedule for this task. A housekeeper mentioned that the facility had canceled a contract with carpet cleaners two years prior, leading to the lack of deep cleaning. The housekeeper also noted that the blinds had not been replaced despite being broken and sagging. The Maintenance Director acknowledged the absence of a systematic schedule for maintenance repairs and cited staffing shortages as a significant challenge. The Interim Administrator, who had just started on the day of the survey, acknowledged the facility's need for improvements but did not identify any critical issues like electrical or plumbing problems. The facility had experienced frequent changes in leadership, with five administrators in a year, which may have contributed to the lack of consistent oversight and maintenance. The report highlights the facility's failure to provide a clean and homelike environment, placing residents at risk for unsanitary living conditions and diminished quality of life.
Deficiencies in PASARR Completion for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) was completed accurately and timely for four residents with serious mental illnesses or intellectual disabilities. Resident 35's PASARR, completed prior to admission, failed to indicate the presence of a psychotic disorder and delusional disorder, despite the resident's documented diagnoses of depression and psychotic disorder. Similarly, Resident 40's PASARR did not reflect the resident's anxiety disorder, even though it was documented in the admission assessment. Both residents' PASARRs were not corrected to address these omissions. Resident 14 was admitted without a PASARR being completed prior to admission, and it was only conducted ninety-eight days later after a mock survey identified the oversight. Resident 28, who had multiple serious mental illness diagnoses, including schizoaffective disorder and schizophrenia, was admitted with a PASARR indicating no need for a Level II review, despite exhibiting behaviors such as delusions and refusing medication. An additional PASARR was initiated but not completed. Staff E, responsible for social services, acknowledged the lack of a process to ensure PASARRs were completed correctly and timely, and admitted to being in the learning process regarding identifying and meeting the psychosocial needs of residents with mental illnesses.
Inconsistent ADL Assistance Leads to Poor Hygiene
Penalty
Summary
The facility failed to consistently provide adequate bathing and grooming assistance to 13 out of 16 sampled residents, leading to poor personal hygiene and unmet care needs. Residents who required assistance with activities of daily living (ADLs) such as bathing and shaving were not consistently receiving the care outlined in their care plans. For instance, one resident with bladder and bowel incontinence was observed with long facial hair despite their care plan indicating a need for assistance with shaving. The resident's bathing records showed significant gaps between showers, and there was no documentation of refusals or re-offers of care. Another resident, who needed assistance with personal hygiene, was observed with facial stubble and crusty matter on their eyelashes over several days. Despite the resident's ability to shave with staff assistance, there was no documentation of refusals, and the resident expressed satisfaction when finally shaved. Similarly, other residents with cognitive impairments or physical limitations were not bathed according to their care plans, with records showing missed showers and no refusals documented. Interviews with staff revealed inconsistencies in following care plans and a lack of documentation for missed or refused care. The report highlights multiple instances where residents' care plans were not followed, resulting in inadequate personal hygiene care. Residents expressed dissatisfaction with the frequency of their showers, and some felt embarrassed due to poor hygiene. Staff interviews indicated that showers were sometimes missed and rescheduled, but documentation did not consistently reflect these actions. The Director of Nursing acknowledged the importance of adhering to care plans and the need for proper documentation of care refusals and re-offers.
Failure to Ensure Nursing Assistant Competency
Penalty
Summary
The facility failed to ensure that two nursing assistants, Staff V and Staff W, met the competency requirements as defined under State Law for license and certification. Staff V was hired on April 1, 2024, and Staff W on May 1, 2024, with both having pending nursing assistant licenses. Despite their pending status, both staff members were observed providing care and services to residents on multiple occasions in July 2024. This was in violation of the requirement that staff must have a nursing assistant certification before providing direct patient care, as confirmed by an interview with Staff X, an administrator from a sister facility.
Deficiency in Staff Training on Dementia and Behavioral Health
Penalty
Summary
The facility failed to ensure that five out of eight sampled staff members received the mandated training on dementia and behavioral health. This deficiency was identified through interviews and a review of competency training records. Specifically, Staff W, a Nursing Assistant; Staff BB, a Cook; Staff JJ, an LPN; and Staff KK and Staff LL, both RNs, had not received any training on dementia and behaviors. During an interview, Staff C, a Clinical Resource Nurse, emphasized the importance of dementia and behavior training for staff to meet the needs of residents, indicating that such training should be provided to new employees and conducted annually thereafter. The 2024 Facility Assessment Tool also documented that training requirements applied to full-time, part-time, and contracted staff.
Failure to Ensure Dignified Catheter Care
Penalty
Summary
The facility failed to provide catheter care in a dignified manner for Resident 13, who was diagnosed with neurogenic bladder and utilized a urinary catheter. During multiple observations from July 8 to July 16, 2024, the urine collection bag of Resident 13's catheter was noted to be attached to the bed without being covered by a privacy bag. This was observed on several occasions, including when the resident was asleep in their bed. In an interview, the Director of Nursing acknowledged that the urine collection bag should have been placed in a privacy bag, identifying it as a dignity issue.
Failure to Provide Bariatric Commode for Resident
Penalty
Summary
The facility failed to provide a bariatric commode for a resident, identified as Resident 24, who required it due to their obesity and the inability to use the standard bathroom facilities in their room. The resident, who was admitted with a history of obesity and falls, was assessed to need partial assistance with activities of daily living and used a motorized wheelchair for mobility. Despite being oriented and able to communicate their needs, the resident was not provided with the necessary toileting equipment, which they expressed would improve their quality of life and dignity. Interviews with staff revealed that the resident was making progress in physical therapy and was capable of stand pivot transfers with assistance. Staff acknowledged the resident's need for a bariatric commode, and the Director of Nursing mentioned that a commode had been ordered, although no documentation was provided to confirm this. The lack of appropriate toileting equipment in the resident's room placed them at risk for diminished independent functioning and a loss of dignity and comfort.
Failure to Inform Residents of Advance Directive Rights
Penalty
Summary
The facility failed to inform and provide written information to residents about their right to formulate an advance directive, as required by regulations. This deficiency was identified for two residents during a review of their records. Resident 17, who was admitted to the facility with diagnoses including a stroke, lung disease, and depression, did not have documentation of being informed about advance directives until more than four months after admission. Similarly, Resident 33, admitted with heart disease, high blood pressure, and chronic pain, also lacked documentation of being informed about their right to form an advance directive. During an interview, the Director of Nursing stated that advance directives were offered upon admission and during the initial care conference. However, the records for these residents did not reflect that this information was provided, indicating a failure in the facility's process to ensure residents are informed of their rights regarding advance directives.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to report and investigate allegations of abuse involving two residents, Resident 28 and Resident 40, as required by state regulations. Resident 28 reported being mocked by staff and other residents, and specifically mentioned an incident where another resident, Resident 14, slapped them on the buttocks. This incident was observed by Staff J, who reported it to the staffing coordinator, Staff N. However, there was no documentation of this incident in Resident 14's medical chart, the facility's Accident and Incident Report Log, Grievance Log, or the Washington State Secure Tracking and Reporting System (STARS). The Director of Nursing Services, Staff B, confirmed that the incident should have been reported to the State Agency. Resident 40 was involved in multiple altercations with other residents, which were not reported to the State Agency. These incidents included pushing another resident to the ground, making a threatening statement to a resident, and throwing a bag of chips at a resident. The facility conducted internal investigations and concluded that Resident 40's actions were not intentional and did not result in harm. Staff B, the Director of Nursing Services, believed that these incidents did not require reporting because they were either verbal outbursts or not witnessed by staff, and no lasting effects were observed. The facility's failure to report these incidents to the State Agency as required by their own procedures and state regulations placed residents at risk for additional abuse and unmet care needs. The facility's procedures mandate that all staff immediately report any allegations of abuse to their supervisor and the State Survey Agency, yet this protocol was not followed in these cases. The lack of documentation and reporting indicates a significant oversight in the facility's abuse prevention and reporting processes.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents, Resident 28 and Resident 40. Resident 28 reported being slapped by another resident, Resident 14, and filed a police report. Despite the incident being witnessed by a staff member, there was no documentation or investigation initiated in the facility's records, including the medical chart, incident report log, grievance log, or the state incident reporting platform. Staff interviews revealed that the facility's abuse prevention procedures were not followed, as the incident was not reported to the state agency, and no immediate interventions were documented to ensure resident safety. In another case, Resident 40 was involved in two separate incidents where they exhibited aggressive behavior towards other residents. On one occasion, Resident 40 was found in another resident's room, making threatening statements. Despite these incidents, there was no documentation or investigation conducted to determine if abuse had occurred. Staff interviews indicated a lack of awareness and understanding of the need to log and investigate such incidents, as they were dismissed as mere verbal outbursts or because staff managed to redirect the resident without further incident.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care plan interventions for a resident identified as being at high risk for falls. The resident, who had dementia and was dependent on nursing staff for transfers, was observed multiple times alone in their room while seated in a wheelchair, contrary to the care plan instructions. The care plan, revised in October 2023, specifically stated that the resident should not be left alone in their room when in a wheelchair, yet observations on several occasions in July 2024 showed the resident alone, leaning over in their wheelchair with their upper body on the bed. Interviews with staff confirmed awareness of the resident's fall risk and the care plan's instructions. A nursing assistant acknowledged that the resident should not be left alone in their room for safety reasons. The Director of Nursing also confirmed that staff were instructed to either transfer the resident to bed or move them to a visible area, such as the nurse's station, when in a wheelchair. Despite these instructions, the resident was repeatedly left alone, indicating a failure to adhere to the care plan designed to prevent falls.
Medication Administration Delay and Storage Issue
Penalty
Summary
The facility failed to provide timely administration of medications according to accepted standards of clinical practice during a medication cart review. This deficiency was observed with one of the two medication carts reviewed, where eight medication cups, each labeled with a different resident's name, were found in the top drawer of the cart. These medications had been prepared for administration at 2:00 PM but were not given to the residents because they were unavailable at the time. This practice of pre-pouring medications and storing them in the cart drawer is contrary to the guidelines set by the Institute for Safe Medication Practices, which identifies such delays as a contributing factor to medication errors and a risk to patient safety. During interviews, Staff R, a Medication Technician, confirmed that they had prepared the medications but could not administer them due to the residents' unavailability. Staff R stated they were instructed by Staff B, the Director of Nursing (DON), to label the medication cups and store them in the cart drawer if residents were unavailable. However, Staff B acknowledged that medications should be prepared and administered immediately and expressed skepticism about the improbability of eight residents being unavailable simultaneously. This inconsistency in practice and procedure contributed to the risk of medication errors and compromised the quality of care provided to the residents.
Failure to Implement Bowel Management Protocol
Penalty
Summary
The facility failed to implement its bowel management protocol for a resident, identified as Resident 26, who was reviewed for constipation. The facility's policy required nursing staff to administer Milk of Magnesia (MOM) or Miralax after 72 hours without a bowel movement (BM), followed by a suppository and an enema if necessary. Despite this protocol, Resident 26 experienced multiple instances of constipation, with no BMs recorded for several days at a time, yet the required bowel medications were not administered as ordered. The Medication Administration Record (MAR) showed that bowel medications were neither administered nor documented as offered or refused during these periods. Resident 26, who was cognitively intact and required maximum assistance for mobility and toileting, had diagnoses including multiple sclerosis, hemiplegia, and depression. Interviews with facility staff revealed a lack of awareness and adherence to the bowel management protocol. A medication technician claimed the resident had no constipation issues, while an LPN acknowledged the importance of offering bowel medications after 48-72 hours without a BM. The Director of Nursing confirmed that alerts were in place for when a resident had gone 48 and 72 hours without a BM and acknowledged that the resident should have received the as-needed bowel medications.
Failure to Monitor Weights and Notify Physician of Condition Changes
Penalty
Summary
The facility failed to ensure accurate and timely weight monitoring for Resident 1, who had a history of dementia, malnutrition, and nutritional deficiency. Despite a care plan revision instructing weekly weigh-ins, the resident experienced a significant weight discrepancy that was not promptly addressed. A nutrition progress note indicated a suspected error in the resident's weight, but a reweigh was delayed for almost a month, during which time the resident's weight returned to their normal range. This inconsistency in monitoring placed the resident at risk for unrecognized weight changes and nutritional complications. For Resident 17, the facility did not notify the physician of a change in the resident's condition, which impacted their nutrition. The resident, who had malnutrition and swallowing difficulties, experienced significant weight loss over several months. A dietary recommendation to add margarine or sugar to meals was not implemented, and the resident's condition worsened with increased nausea and a positive COVID-19 test, leading to hospitalization. The physician was unaware of these developments, which could have prompted further medical intervention. These failures contributed to the resident's continued weight loss and nutritional decline.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to ensure that residents had current and complete oxygen orders and did not maintain oxygen equipment in a clean manner for four residents. Resident 39, diagnosed with COPD and chronic respiratory failure, had an incomplete oxygen order that did not specify the number of liters needed. Observations revealed that the oxygen concentrator was unclean, with thick dust on the filter and surrounding areas. The resident's personal oxygen concentrator was found empty on multiple occasions, and staff confirmed the importance of keeping filters clean to prevent respiratory infections. Resident 16, who was cognitively intact and had diagnoses including heart failure, asthma, and sleep apnea, was using oxygen at night without a physician's order or care plan interventions. The oxygen tubing was not labeled with a change date, and the concentrator's filter was covered in thick dust. Staff interviews revealed a lack of a set schedule for changing tubing and cleaning filters, and it was confirmed that Resident 16 did not have a current order for oxygen or for changing the tubing and filter. Resident 14, with diagnoses including Post-Polio Syndrome and lung disease, had a physician's order for oxygen and weekly cleaning of the oxygen equipment. However, observations showed that the concentrator's filters were unclean with thick dust and debris. Despite replacing the filters, the compartmental areas remained dusty. Resident 27, diagnosed with acute respiratory failure, had no documented physician orders for oxygen or routine tube changes. Observations showed the resident using oxygen, but staff indicated the resident was no longer on oxygen, leading to confusion about the resident's care plan.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide person-centered pain management for Resident 294, who had a history of stroke, sacral ulcer, and quadriplegia. The resident was cognitively intact and dependent on staff for all care. Despite having physician orders for Gabapentin, Oxycodone, and Baclofen, the resident's pain levels were consistently high, particularly at night, with no documentation of physician contact or additional pain management interventions. The care plan included non-pharmacological interventions like repositioning, but these were not consistently documented or performed. Observations and interviews revealed that Resident 294 frequently reported severe pain levels, often rating their pain as 7 out of 10 or higher. The resident expressed dissatisfaction with the pain management, stating that the medications were not effective and that they were not repositioned during the night. Despite receiving a new bed and mattress, the resident continued to experience significant pain, indicating that the non-pharmacological interventions were insufficient or not properly implemented. Interviews with staff, including the Director of Nursing Services, confirmed that there was a lack of documentation and communication with the physician regarding the resident's unmanaged pain. The facility's process for managing uncontrolled pain was not followed, as evidenced by the absence of documented pain evaluations and physician assessments. The Physician's Communication Book contained an undated entry requesting a review of the resident's pain, but it was not clear if this was acted upon in a timely manner.
Failure in Discharge Planning for a Resident
Penalty
Summary
The facility failed to provide medically related social services to ensure the highest practicable well-being for a resident, identified as Resident 28. The resident, who was admitted in May 2023, was assessed to have no cognitive impairment and was independent in most activities of daily living (ADLs), except for bathing. Despite expressing a desire to live elsewhere, the resident did not receive assistance with discharge planning. Interviews revealed that the social services staff had not documented any inquiries for alternate living arrangements, nor had they contacted the State Social Worker to assist with discharge planning. Additionally, there was no Level 2 PASRR completed to determine if specialized mental health services would be beneficial for the resident's appropriate placement. Observations and interviews with staff indicated that the resident was functionally independent and capable of performing ADLs such as bed mobility, transfers, and personal hygiene. However, the resident's mental health issues were noted to interfere with her ability to live independently. Despite this, there was no documented effort to explore less restrictive environments, such as an adult family home, which staff believed would be suitable for her. The lack of documented discharge planning and failure to engage necessary resources placed the resident at risk for a decreased quality of life.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure the timely disposal of expired medications and proper storage of narcotics in the medication storage room. During an observation, it was found that the refrigerator contained expired influenza vaccines and Tuberculin that had not been discarded after the required 30 days. Additionally, narcotic medications were stored in a white box within the refrigerator that was not locked as required. These lapses were confirmed during an interview with the Director of Nursing, who acknowledged that the expired medications should have been discarded and the narcotics should have been secured in a locked container. Furthermore, an audit of the medication cart revealed an insulin pen that was opened but not dated with the opening or discard date. The Medication Technician was unaware of when the insulin pen had been opened. A Registered Nurse confirmed that insulin should be dated when opened and discarded after 30 days to ensure its effectiveness. These deficiencies indicate a failure to adhere to professional standards for medication management, potentially compromising medication efficacy and security.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
