Colonial Vista Post-acute & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wenatchee, Washington.
- Location
- 625 Okanogan Ave, Wenatchee, Washington 98801
- CMS Provider Number
- 505413
- Inspections on file
- 34
- Latest survey
- August 22, 2025
- Citations (last 12 mo.)
- 38
Citation history
Health deficiencies cited at Colonial Vista Post-acute & Rehab Center during CMS and state inspections, most recent first.
A resident with cerebral palsy and dysphagia, requiring a modified diet and supervision during meals to prevent choking, was repeatedly left unsupervised while eating. Staff were unaware of the resident's swallowing precautions, and the resident reported relying on another resident for support during meals due to lack of staff monitoring.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident in a LTC facility was forced to move rooms due to a change in their payor source, despite their right to refuse the transfer. The resident, who was cognitively intact and undergoing skilled therapy, expressed a desire to appeal the insurance decision and reluctance to move due to past negative experiences. The facility moved the resident's belongings without consent, violating their rights.
The facility failed to maintain safe food holding temperatures during a lunch meal preparation, with food items stored in a steam table at temperatures below the safe holding level of 135 F. Staff Z, the cook, did not recheck food temperatures before serving, and Staff AA, the Food Service Manager, confirmed the oversight, placing residents at risk for foodborne illness.
The facility failed to discard expired food items in the kitchen, posing a risk of foodborne illness to residents. Expired items were found in both dry storage and the walk-in refrigerator, including orange juice concentrate, cranberry cocktail, tortillas, Worcestershire sauce, baking soda, and oranges. Interviews with dietary staff revealed a lack of adherence to protocols for monitoring and discarding expired foods.
The facility failed to provide a written notice of bed hold to two residents or their representatives during hospital transfers, as required by policy. One resident with a history of stroke and heart attack was transferred due to chest pain, and another with digestive surgery aftercare and diabetes was transferred for abdominal pain. Staff interviews indicated inconsistent adherence to the bed hold notice procedure.
The facility failed to provide adequate care and monitoring for residents, including improper wound care, lack of skin assessments, and insufficient bowel management. Residents with conditions such as peripheral vascular disease, diabetes, and lymphedema experienced missed dressing changes, undocumented skin issues, and inadequate bowel movement tracking. Staff interviews revealed lapses in following care protocols and documentation practices.
The facility failed to ensure the safety of residents who smoked by not properly assessing their ability to smoke safely and not securing their smoking paraphernalia. A resident with intact cognition had smoking materials unsecured due to a missing lock box, while another with moderately impaired cognition stored smoking materials in an unlocked drawer. Additionally, a resident with asthma was observed smoking unattended without a care plan or assessment. The facility also failed to store a portable oxygen tank safely, as it was found unsecured in a room repurposed for PPE storage.
The facility failed to document and address Advanced Directives (AD) for two residents, risking their end-of-life care preferences. One resident, capable of making decisions, believed their POLST was their AD, but lacked a documented Living Will. Another resident, with impaired cognition, had no evidence of AD discussion or formulation, despite expectations for ADs to be addressed and documented.
A resident with diabetes and functional quadriplegia was not properly monitored for pressure injuries, leading to the development of new skin impairments. Despite a care plan requiring weekly skin checks and documentation, the facility failed to consistently follow these protocols. Observations showed untreated open areas on the resident's buttocks, and staff interviews revealed lapses in communication and documentation, exacerbated by a transition to a new medical record system.
A resident with a gastrostomy and severe malnutrition did not receive the prescribed enteral feeding formula due to improper labeling and substitution without physician approval. The facility failed to follow its policy and professional standards, risking expired or inaccurate nutrition delivery.
The facility failed to implement proper infection control measures during medication administration and in a contact precautions room. A nurse handled medications without performing hand hygiene, and staff entered a contact precautions room without PPE, contrary to posted instructions. Interviews confirmed expectations for hand hygiene and PPE use were not met.
A malfunctioning handicap push plate at the main entrance of the facility has been out of service since July 2023, affecting residents' ability to enter and exit independently. A resident reported delays in receiving assistance, while staff confirmed that repair bids were denied by the corporation due to cost concerns.
A facility failed to provide trauma-informed care for a resident with PTSD by not identifying or documenting their triggers in the care plan. The resident, with a history of PTSD, anxiety, and depression, reported triggers like news, loud noises, and interactions with men, which were not addressed in their care plan. Staff interviews revealed the absence of a trauma assessment and the need for a better system to manage such residents.
Failure to Provide Required Meal Supervision for Resident with Dysphagia
Penalty
Summary
The facility failed to provide adequate supervision during meals for a resident with cerebral palsy and dysphagia, who was at risk for choking. The resident's medical record indicated a need for a regular texture diet with soft, bite-sized pieces and thin liquids with straws, as well as monitoring and supervision during meals to observe for choking, coughing, or holding food in the mouth. Despite these documented needs and care plan interventions, multiple observations showed the resident eating meals in the activity room without any staff supervision present. Interviews confirmed that nursing staff were unaware of the resident's swallowing precautions and did not provide the required supervision during meals. The resident reported relying on another resident for support during meals due to fear of choking and stated that staff did not monitor them while eating. Staff interviews further revealed a lack of awareness regarding the resident's dietary and supervision needs, resulting in the resident being left unsupervised during multiple meal times.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Honor Resident's Right to Refuse Room Transfer
Penalty
Summary
The facility failed to honor a resident's right to refuse a room transfer when their payor source changed. Resident 1, who was cognitively intact and required assistance for daily activities, was admitted with diagnoses including respiratory failure, diabetes, and chronic kidney disease. The resident was participating in skilled therapy services with the goal of regaining strength to discharge home. When the resident's insurance no longer covered their stay, the facility informed them of the need to move to a semiprivate room due to financial constraints. Despite the resident's expressed desire to appeal the insurance decision and their reluctance to move due to a previous negative experience, the facility proceeded with the room transfer. The facility's policy allowed residents to refuse room transfers if the purpose was to relocate them from a Skilled Nursing unit to a Long-Term Care unit. However, the facility moved Resident 1's belongings to the new room while they were out at an appointment, effectively forcing the transfer without their consent. Staff interviews confirmed that the resident was upset about the move and felt their rights were violated. The facility's administrator acknowledged that the resident had the right to refuse the transfer, but this right was not honored, leading to the deficiency.
Failure to Maintain Safe Food Holding Temperatures
Penalty
Summary
The facility failed to maintain safe food holding temperatures during a lunch meal preparation, which was observed on September 26, 2024. The food items, including baked chicken, ground chicken, brown gravy, carrots, green beans, rice, and chicken, were stored in a steam table with temperatures ranging from 119 F to 134 F, all below the safe holding temperature of 135 F. Staff Z, the cook, admitted to placing the food in the warmer for about 20 minutes, with pureed and bite-sized food placed about 45 minutes prior to temperature testing. Staff Z only checked the food temperatures upon removing them from the oven and did not recheck them before serving, leading to the deficiency. During an interview, Staff AA, the Food Service Manager, confirmed that food temperatures should have been checked prior to serving to ensure they were at safe levels. Staff AA also stated that the prepared food should not be placed in the steam tables until 20-30 minutes before serving. The failure to follow the correct process for holding and rechecking food temperatures placed all residents at risk for foodborne illness due to the potential growth of harmful pathogens in food held at unsafe temperatures.
Expired Food Items Found in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in its kitchen by not discarding expired foods, which placed all residents at risk for foodborne illness. During a general tour of the kitchen, surveyors observed expired items in both the dry storage and the walk-in refrigerator. Specifically, the dry storage contained expired orange juice concentrate, thickened cranberry cocktail, various sizes of flour and corn tortillas, Worcestershire sauce, and baking soda. Additionally, the walk-in refrigerator housed a box of oranges that had surpassed their use-by date. Interviews with the facility's dietary staff revealed a lack of adherence to protocols for monitoring and discarding expired foods. Staff BB, a cook, acknowledged that it was the dietary staff's responsibility to ensure expired foods were discarded. Similarly, Staff AA, the Food Service Manager, admitted that the team was collectively responsible for monitoring food expiration dates and discarding expired items. Staff AA further noted that the process of checking expiration dates when receiving and storing new orders had not been consistently followed.
Failure to Provide Bed Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to issue a written notice of bed hold to residents or their representatives at the time of hospital transfer, as required by their policy. This deficiency was identified for two residents during a review of hospital transfers. Resident 62, who was admitted with diagnoses including a stroke and heart attack, was transferred to the hospital after complaining of chest pain. The medical record showed no documentation that a notice of bed hold was provided to Resident 62 or their representative. Similarly, Resident 214, who had diagnoses including aftercare for surgery on the digestive system and diabetes, was transferred to the emergency room due to abdominal pain. There was no documentation that a notice of bed hold was given to Resident 214 or their representative. Interviews with facility staff revealed that the responsibility for providing the notice of bed hold was not consistently followed, leading to the deficiency.
Deficiencies in Resident Care and Monitoring
Penalty
Summary
The facility failed to provide ongoing assessments and monitoring in accordance with professional standards of practice for five residents, leading to deficiencies in care. Resident 7, who had peripheral vascular disease and venous/arterial ulcers, experienced a lack of timely dressing changes, resulting in foul-smelling wounds and unchanged dressings for several days. Despite orders for daily dressing changes, these were not consistently followed, and weekly skin checks were often missed. The Director of Nursing Services acknowledged that the nursing staff, including travel nurses, did not adhere to the expected procedures for wound care and skin assessments. Resident 23, with cirrhosis and diabetes, had multiple bruises and a skin tear that were not documented or monitored as required. The facility's policy mandated weekly skin assessments, but these were not completed, and the bruises and skin tear were not recorded in the resident's treatment records. The Director of Nursing Services confirmed that the nursing staff failed to document and monitor the resident's skin issues as expected. Resident 25, with diabetes, heel ulcers, and lymphedema, did not have proper documentation of wound sizes or conditions, making it difficult to assess the effectiveness of treatments. Similarly, Resident 122, with diabetes and severe lymphedema, lacked documentation of wound assessments and edema monitoring. The facility's electronic health record system did not include necessary assessment forms, and staff were not documenting their findings in progress notes. Additionally, Resident 1, who experienced constipation, did not receive appropriate bowel management, with significant gaps in bowel movement documentation and lack of physician notification. Staff interviews revealed inconsistencies in following bowel management protocols and documentation practices.
Failure to Ensure Smoking and Oxygen Safety
Penalty
Summary
The facility failed to ensure the safety of residents who smoked by not properly assessing their ability to smoke safely and not securing their smoking paraphernalia. Resident 23, who had an intact cognition and required assistance for daily living activities, was observed with cigarettes and a lighter in their coat pocket, which was left on an unused wheelchair. The resident stated they had no place to lock up their smoking materials, and the facility was aware that the resident's lock box was missing. Resident 30, with moderately impaired cognition, was found to keep their smoking materials in an unlocked nightstand drawer and in their shirt pocket, despite being evaluated as safe to smoke independently over 17 months ago without a recent reassessment. Resident 164, who had moderately impaired cognition and asthma, was observed smoking unattended and had smoking materials stored openly in their room without a smoking care plan or assessment. The resident's smoking paraphernalia was found in a clear plastic container and in their purse on the nightstand. Staff interviews revealed that residents who smoke should have their materials locked up and be assessed for safety, but this was not consistently done for Resident 164. Additionally, the facility failed to store a portable oxygen tank safely. An unsecured oxygen tank was found in a room previously used for oxygen storage, which had been repurposed for PPE storage. Staff interviews indicated a lack of awareness and education regarding the change in the room's use, leading to the improper storage of the oxygen tank. This oversight placed residents at risk for avoidable accidents and potential fire hazards.
Failure to Document and Address Advanced Directives
Penalty
Summary
The facility failed to properly document and address Advanced Directives (AD) for two residents, which could potentially compromise their end-of-life care preferences. Resident 1, who was cognitively intact and capable of making their own decisions, believed their POLST form was their AD. However, there was no documentation of a Living Will in their medical record, despite having a Durable Power of Attorney for Healthcare. The care plan indicated that the POLST reflected Resident 1's AD wishes, but there was no evidence of further discussion or documentation regarding their end-of-life care preferences. Resident 10, who had severely impaired cognition and was unable to make decisions, also lacked proper documentation and discussion regarding ADs. The facility's Social Services Director mentioned that AD forms were offered upon admission and revisited quarterly, but there was no evidence that Resident 10's AD was formulated or discussed. The resident's representative confirmed that while the POLST form was reviewed, there was no discussion or information provided about formulating an AD. The facility administrator expected ADs to be addressed and documented, but this was not reflected in the records for Resident 10.
Failure to Prevent and Monitor Pressure Injuries
Penalty
Summary
The facility failed to adequately assess, monitor, or treat skin conditions to prevent the development of facility-acquired pressure injuries for a resident. The resident, who had a history of diabetes and functional quadriplegia, was admitted with a Stage 3 pressure injury and required substantial assistance for mobility and hygiene. Despite having a care plan that included monitoring and documenting skin conditions, the facility did not consistently follow these protocols. The resident's care plan indicated the need for weekly skin checks and documentation of any skin impairments. However, the September 2024 Treatment Administration Record showed lapses in treatment, with no treatment recorded on specific dates and a lack of documentation for new skin impairments. Observations revealed two open areas on the resident's buttocks, which were not new, yet there was no evidence of updated treatment orders or physician notification. Interviews with staff revealed a breakdown in communication and documentation processes. The Resident Care Manager was unaware of the current skin issues, and the Director of Nursing Services expected weekly assessments and care plan updates, which were not completed. The transition to a new medical record system contributed to the oversight, as assessments were not recreated, leading to missed documentation and treatment opportunities.
Failure to Ensure Proper Enteral Feeding Practices
Penalty
Summary
The facility failed to ensure appropriate treatment and services related to enteral feedings for a resident, identified as Resident 214, who was at risk due to expired and/or inaccurate enteral nutrition. Resident 214 was admitted with a gastrostomy and severe protein-calorie malnutrition, requiring substantial assistance for daily activities and having moderately impaired cognition. Observations revealed that the enteral feeding (EF) pump was not running, and the EF containers and tubing were not properly labeled with the necessary information such as date, time, and initials of the licensed nurse (LN) responsible. Additionally, the facility substituted the prescribed Vital AF 1.2 formula with Jevity 1.2 without notifying the registered dietician or obtaining a physician's order for the substitution, despite having the prescribed formula in stock. The facility's policy required that EF bags and supplies be changed every 24 hours and labeled with specific information to prevent microbial growth and ensure accurate administration. However, observations showed that the EF bags were not labeled correctly, and the resident did not receive the prescribed formula. Interviews with the registered dietician and the facility administrator confirmed that the staff did not follow the physician's orders or professional standards of practice. The administrator expected the nursing staff to adhere to these standards and to contact the physician if a substitution was necessary, which was not done in this case.
Infection Control Deficiencies in Medication Handling and PPE Use
Penalty
Summary
The facility failed to implement proper infection prevention and control measures during medication administration and when entering a contact precautions room. During an observation, a registered nurse (Staff M) was seen handling medications without performing hand hygiene. Staff M picked up a pill that fell onto the medication cart with bare hands and placed it into a medication cup, then handled additional medications without using gloves. After administering the medications to a resident, Staff M did not perform hand hygiene before preparing medications for the next resident. Interviews with the Infection Preventionist and the Director of Nursing Services confirmed that the expectation was for staff to use hand hygiene before and after administering medications and between residents. Additionally, the facility did not ensure the use of personal protective equipment (PPE) in a contact precautions room. Staff N, a nursing assistant, entered a resident's room with a contact precautions sign without wearing gloves or a gown, contrary to the posted instructions. Staff N stated they were informed by the charge nurse and infection preventionist that PPE was not necessary unless providing hands-on care. Similarly, Staff O, the Social Services Director, entered the same room without PPE and acknowledged the mistake after reading the sign. The facility's administrator expected all staff to follow the posted precautions.
Handicap Push Plate Malfunction at Main Entrance
Penalty
Summary
The facility failed to maintain a safe and functional environment for residents, staff, and visitors due to the handicap push plate on the main entrance door being out of service. This issue was identified during an interview with a resident who reported that the push plate had not been working for a long time, requiring them to rely on staff assistance to enter and exit the facility. The resident expressed frustration over the delay in receiving assistance, which hindered their ability to move freely as they wished. Further interviews with facility staff revealed that the Maintenance Director and Administrator were aware of the issue, which had persisted since July 2023. Despite obtaining multiple bids to repair the door, the corporation denied the requests due to cost concerns. Both the Maintenance Director and Administrator acknowledged the importance of fixing the door to ensure residents' safety and autonomy, as well as to facilitate emergency services access.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident identified as a trauma survivor. Specifically, the facility did not identify or document the triggers related to the resident's Post-Traumatic Stress Disorder (PTSD) in their care plan. The resident, who had a history of PTSD, anxiety, and depression, reported triggers such as watching the news, loud noises, and interactions with men, which caused agitation, tearfulness, and anxiety. Despite this, the resident's care plan lacked any trauma-informed interventions or strategies to address these triggers. Interviews with facility staff, including the Social Service Director and the Director of Nursing Services, revealed that the resident's triggers were not assessed or included in the care plan. The staff acknowledged the absence of a trauma assessment and the need for a better system to manage residents with trauma histories. This oversight placed the resident at risk for experiencing unidentified triggers and potential re-traumatization, as the staff was not adequately informed on how to manage the resident's specific needs.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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