Colville Health And Rehabilitation Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Colville, Washington.
- Location
- 1000 East Elep Street, Colville, Washington 99114
- CMS Provider Number
- 505275
- Inspections on file
- 29
- Latest survey
- May 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Colville Health And Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of aggressive behaviors repeatedly engaged in verbal and physical abuse toward multiple peers, including hitting, grabbing, scratching, and yelling. Staff failed to consistently identify, report, or investigate these incidents as abuse, and interventions such as frequent safety checks and behavioral monitoring did not prevent further altercations. Other residents experienced fear and physical injuries as a result, and the facility did not adequately protect residents from abuse as required by policy.
Multiple residents with cognitive and physical impairments experienced repeated falls, some resulting in serious injuries such as fractures and hospitalizations, due to the facility's failure to consistently monitor, supervise, and implement effective fall prevention interventions. Care plans were not adequately revised after incidents, required neurological checks were sometimes omitted, and staff did not always follow or document care plan instructions, leading to continued risk and harm.
A facility failed to provide enough nursing staff to meet the needs of residents with high acuity, leading to inadequate supervision, repeated falls, and resident-to-resident altercations. Several residents suffered serious injuries, including fractures and hospitalizations, due to insufficient staff, delayed responses, and care plans not being updated after incidents. Staff and resident council feedback confirmed ongoing concerns about long call light wait times and unmet care needs.
Two residents experienced significant medication errors when an LPN administered a much higher dose of insulin than prescribed to one resident, resulting in multiple episodes of symptomatic hypoglycemia requiring rescue interventions, and another resident did not receive ordered doses of an anticoagulant and an injectable diabetes medication due to failures in medication procurement and communication. Staff interviews revealed gaps in orientation, competency checks, and documentation, with incomplete reporting to providers and inconsistent follow-up on missed high-alert medications.
The facility did not ensure an RN was on duty for at least eight consecutive hours each day as required, with several days lacking RN coverage. LPNs provided care during these times and contacted the DON as needed, but staff acknowledged the absence of required RN coverage and reported challenges in securing RN staff.
Administration failed to identify and address patterns of abuse, provide adequate supervision and nursing staff, ensure proper medication administration, and implement effective infection control, resulting in harm to multiple residents and staff. Several deficiencies were repeat citations, and leadership was not fully aware of the extent of the issues until informed by surveyors.
The facility did not maintain an effective QAPI program, failing to identify and address repeated falls, medication errors, and staffing issues. Incident tracking logs were incomplete, and some residents experienced recurrent altercations and repeat falls resulting in hospitalizations and fractures. QAPI committee meetings lacked consistent implementation and evaluation of PIPs, and documentation of corrective actions was insufficient.
The facility's QAA/QAPI program failed to identify and address multiple critical deficiencies, including unrecognized resident-to-resident abuse, inadequate provider notification for changes in condition, repeated falls with injuries, insufficient behavioral health services, medication errors, and ineffective infection control during a Norovirus outbreak. The QAA committee did not meet required standards, lacked key members, and did not implement effective interventions, resulting in widespread harm and immediate jeopardy for residents.
The facility did not ensure the Infection Preventionist attended or contributed to quarterly QAA committee meetings, resulting in a lack of infection control data review and no infection control Performance Improvement Projects. This deficiency was associated with a Norovirus outbreak affecting multiple residents and staff.
A Norovirus outbreak spread across all nursing units, affecting numerous residents and staff, due to failures in infection control practices. Staff did not consistently use PPE, perform hand hygiene, or follow isolation signage, and there was confusion about required precautions. The outbreak was not promptly reported to health authorities, and ill staff were allowed to return to work before meeting CDC-recommended exclusion periods. Communication lapses and unclear policy review further contributed to the deficiency.
A non-functioning and non-audible call light system was observed, with call lights not making any sound in hallways and some being obscured by speaker boxes. Staff and resident council interviews confirmed ongoing issues, including long wait times for assistance and a lack of audibility for over a year. The maintenance director acknowledged frequent malfunctions of the annunciator and insufficient monitoring or repair of the system.
Mandatory effective communication training was not documented for multiple direct care staff, including LPNs, RNs, and nursing assistants. Employee files lacked evidence of completed training, and staff interviews confirmed the absence of documentation for required communication training.
The facility did not inform two residents or their representatives of their right to have their bed held during hospitalizations, as required by policy. One resident with moderate cognitive impairment and another with severe cognitive impairment and behavioral issues were transferred to the hospital multiple times without documentation that bed-hold rights were communicated or that the required notices were provided at the time of transfer.
A resident with severe cognitive impairment and escalating aggressive behaviors was involved in multiple altercations with peers. The facility failed to consistently identify, report, and investigate these incidents as potential abuse, did not update or revise care plan interventions after each event, and did not track or analyze incidents through QAPI as required by policy. Staff interviews confirmed inconsistent application of abuse prevention procedures and inadequate protection of residents.
The facility did not properly coordinate PASRR assessments and behavioral health services for three residents with mental health diagnoses. One resident did not receive recommended behavioral health services, another experienced delays in required PASRR Level II evaluation despite ongoing psychiatric symptoms, and a third had an incorrect PASRR Level I screening prior to admission, delaying needed evaluation and services.
The facility did not consistently complete required documentation during hospital transfers for two residents, omitting key information such as the reason for transfer, unmet care needs, facility interventions, and details communicated to the receiving hospital. Staff interviews confirmed that expected documentation practices were not followed, resulting in incomplete records for multiple hospitalizations.
Staff did not notify providers when three residents experienced significant changes in condition, including extremely low blood sugar, persistently low blood pressure, and elevated blood sugar levels. Required documentation of assessments, interventions, and provider notifications was missing, despite clear orders and facility policy. Clinical leadership confirmed the lack of provider notification and documentation for these events.
The facility did not ensure that nurses and nurse aides had documented training or competency assessments in diabetes management, medication administration, PTSD, SUD, GDR, trauma informed care, fall management, or incident root cause analysis. Multiple staff, including LPNs, RNs, and NAs, lacked evidence of required training, despite caring for residents with complex medical and mental health needs. Leadership confirmed the absence of documentation for these competencies.
Two residents with significant behavioral health needs did not receive necessary behavioral health services or appropriate care planning. One resident with a history of substance abuse and a PASRR Level II determination did not have required behavioral health documentation or referrals, despite ongoing non-compliance and behavioral issues. Another resident with major depressive disorder and delusions did not receive a Level II PASRR assessment or behavioral health interventions, and declined telehealth counseling due to lack of in-person providers. Care plans were not updated to address ongoing behavioral health concerns, and regular review meetings were not held.
A resident with complex medical needs was discharged without proper documentation supporting the stated reason for discharge, and the facility failed to notify the State LTC Ombudsman of multiple hospital transfers. Staff interviews and records did not support claims that the resident endangered others, and the resident's representative was not adequately informed. The facility's lack of documentation and communication led to deficiencies in both discharge planning and regulatory notification.
Staff failed to perform required hand hygiene during meal service, with multiple instances observed where staff touched residents, wheelchairs, and clothing protectors, and then interacted with other residents or handled food without completing hand hygiene. Staff interviews confirmed knowledge of hand hygiene protocols, but these were not consistently followed during the observed meal service.
The governing body did not provide adequate oversight, resulting in unaddressed resident-to-resident abuse, insufficient nursing staff leading to falls and injuries, medication errors causing harm, and poor infection control that led to widespread illness among residents and staff. Leadership was only partially aware of these issues prior to the survey.
The facility did not maintain up-to-date documentation showing that staff were educated about the risks and benefits of the COVID-19 vaccine, were offered the vaccine, or had their vaccination status properly recorded. Interviews revealed confusion over responsibility for tracking vaccinations, incomplete records in employee files, and an outdated tracking spreadsheet, all of which contributed to the deficiency.
The facility did not provide or document required QAPI training for all staff, including LPNs, RNs, and nursing assistants. Review of staff files and the QAPI plan showed no evidence of completed training or a defined training schedule, and the administrator was unable to supply documentation when requested.
Mandatory Compliance and Ethics training was not provided to multiple staff, including LPNs, RNs, and nursing assistants, as evidenced by missing documentation in employee files and the administrator's inability to produce records when requested.
A resident with moderate cognitive impairment, who had a payee due to impulsivity, had a color copy of their bank card and handwritten PIN number scanned into their electronic health record, making this sensitive financial information accessible to all nursing staff. Staff interviews confirmed that such information should be stored securely and not included in the health record.
Surveyors identified that two residents were affected by environmental deficiencies, including damaged walls and baseboards, missing rubber protectors on wheelchair brake extenders, and broken or missing floor tiles in two units. The Maintenance Director was aware of some issues but lacked a formal schedule for room checks and was unaware of the missing wheelchair protectors.
A resident with severe cognitive impairment and escalating behavioral issues was given a PRN injectable antipsychotic without adequate documentation to justify its use for a specific medical symptom. Facility staff and leadership acknowledged that the medical record lacked sufficient detail to support the administration of the medication.
A resident with dementia, depression, and a history of violent behavior, who is also a veteran, exhibited frequent yelling, screaming, and distressing outbursts, especially at night. Despite these behaviors and staff awareness of the resident's background, the facility did not assess for PTSD or implement trauma-informed interventions, and staff reported limited training in trauma-informed care. The facility's behavioral care plan and psychosocial evaluation did not address possible trauma or PTSD, resulting in unmet behavioral health needs.
Surveyors found that insulin pens were not labeled with the date opened and expired Bisacodyl suppositories were present in both a medication cart and the medication room. Two residents received insulin from pens that lacked proper labeling, and expired medications were not removed from inventory as required by facility policy.
A resident with dementia, a history of falls, and a recent femur fracture was identified as high risk for elopement, with recommendations for 15-minute safety checks and a Wanderguard device. Despite these measures being care planned, staff did not consistently perform or document the required checks, and the Wanderguard was not in place. The resident exited the facility unnoticed and was later found outside without injury.
A facility failed to notify the police of an alleged sexual abuse incident involving a resident. A hospitality aide reported the allegation to the DON, but the police were not informed. The Administrator assumed there was no immediate danger and believed the aide had already contacted the police. The police confirmed they were not notified until the state agency informed them.
The facility failed to consistently provide showers for several residents, leading to poor hygiene and diminished quality of life. A resident with movement disorders received only one shower in a month, while another with seizures had two showers. A resident with intellectual disabilities experienced a 10-day gap between showers, and a resident with Alzheimer's received two showers despite a preference for twice-weekly showers. Staffing shortages and the absence of a dedicated shower aide contributed to these inconsistencies.
A resident with heart disease and diabetes was injured during a transfer using a sit-to-stand lift when their arm sling became caught around their neck, causing them to become unresponsive. The staff left the resident unattended to seek help, resulting in the resident falling to the floor. The facility was unaware of the sling's involvement until informed by the hospital, and the investigation was incomplete as the responsible staff member was no longer employed.
The facility failed to ensure accurate completion of PASARR for two residents, leading to potential risks of inappropriate placement and unmet mental health care needs. One resident remained in the facility beyond the 30-day exemption period without an updated PASARR, and another resident did not have an updated PASARR following a significant change of condition.
The facility failed to develop a comprehensive care plan for a resident with peripheral vascular disease, congestive heart failure, and diabetes, leading to unmet care needs. Despite documented skin evaluations showing open areas and blisters, the care plan only included weekly skin assessments without specific wound care interventions.
The facility failed to provide necessary assistance during mealtimes for a resident with severe cognitive impairment and Alzheimer's dementia. Despite the care plan requiring supervision and cueing, the resident was observed without assistance, leading to food spills and the resident not consuming their meals. Staff acknowledged the need for assistance but did not follow the care plan.
The facility failed to ensure that a resident with severe cognitive impairment was engaged in meaningful activities, often leaving them alone in a dark room without interaction. Despite the resident's enjoyment of music and need for sensory stimulation, staff did not include them in activities, leading to a diminished quality of life.
The facility failed to provide effective bowel management for two residents, leading to unmet care needs and an emergency room visit for one resident. Despite having orders for various laxatives, the facility did not follow the bowel protocol, resulting in residents experiencing discomfort and requiring hospital intervention. Staff interviews revealed inconsistencies in following the bowel management protocol and a lack of documentation regarding bowel movements and interventions.
The facility failed to provide adequate supervision and assess a resident for smoking safety. A resident with a history of stroke was observed smoking without a smoking apron, dropping a lit cigarette multiple times, and having burn holes in their clothing. The last smoking assessment was outdated, and staff confirmed the need for a more recent assessment.
A resident with chronic pain was not provided with their PRN Hydrocodone 5 mg tablets for several days and was not offered alternative pain relief. The resident reported pain, but no Tylenol or non-medication interventions were provided, and there was no communication with the physician about the unavailability of the medication.
The facility failed to collaborate with the dialysis center and accurately monitor a resident's fluid restriction. The Dialysis Communication form was not filled out on multiple dates, and there were inconsistencies in the recorded fluid intake, compromising the resident's care.
The facility failed to address pharmacist recommendations for a resident's Peridex mouthwash usage in a timely manner. Recommendations made in January, February, and March 2024 were not documented in the MAR until March 4, 2024. The Resident Care Manager confirmed the delay, mistakenly believing they had a week to implement the recommendations.
The facility failed to maintain a medication error rate below 5 percent, resulting in a 7.41 percent error rate. A nurse administered eye drops without the required waiting period for one resident, and another nurse gave a multivitamin lacking the prescribed Folic Acid to another resident. Both errors were acknowledged by the respective nurses.
The facility failed to ensure appropriate hand hygiene during meal service in one dining room. Staff members were observed touching various items and residents without sanitizing their hands, despite being aware of the protocols. This was discussed with the Administrator and the DON.
The facility failed to ensure accurate submission of direct care staffing information to CMS for Quarter 3 of 2023. The HR Manager did not include Registered Dietician hours, resulting in reported staffing levels lower than mandated requirements.
The facility failed to follow physician orders for two residents with urinary catheters, leading to a risk of UTIs. Orders for catheter changes were not updated in the Treatment Administration Records, and there was no documentation of catheter changes for several months.
Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to identify, report, protect, assess, and prevent a pattern of resident-to-resident verbal and physical abuse, particularly involving a resident with severe cognitive impairment and a history of aggressive behaviors. Staff documented multiple incidents where this resident engaged in hitting, punching, kicking, grabbing, scratching, yelling, and making threats toward other residents. Despite these repeated altercations, the facility did not consistently recognize these events as abuse, nor did they analyze the circumstances or implement effective interventions to prevent recurrence. The facility's own policies required staff to observe, assess, care plan, and monitor residents exhibiting behaviors that could lead to conflict, but these measures were not adequately followed. The resident in question had a documented history of severe cognitive impairment, dementia, and worsening verbal and physical behaviors that interfered with care and placed others at risk. Over several months, this resident was involved in at least 11 documented altercations with 10 different peers, including incidents of physical aggression such as hitting with objects, grabbing, scratching, and verbal abuse. Nursing progress notes and incident logs revealed additional unreported or inadequately investigated incidents, with some resulting in physical injuries to other residents, such as skin tears and scratches. Staff interviews confirmed that the resident's behaviors were unpredictable and escalated quickly, often resulting in fear and distress among other residents. Despite the frequency and severity of these incidents, the facility did not consistently treat verbal altercations as potential abuse unless threats were involved, and physical altercations were not always thoroughly investigated or reported. The care plan interventions implemented, such as 15-minute safety checks and behavioral monitoring, were insufficient to prevent further incidents. Staff acknowledged that the resident's behaviors placed others at risk and that the facility had not adequately protected residents from abuse, as required by policy and regulation.
Removal Plan
- Reviewed Resident 19's medications
- Placed Resident 19 on one to one supervision until lower level of care was determined to be appropriate
- Educated all staff to the abuse prevention policies and procedures
- Interviewed all residents to determine feeling safe and secure in the facility
Failure to Prevent Repeated Falls and Injuries Due to Ineffective Supervision and Intervention
Penalty
Summary
The facility failed to provide effective monitoring, supervision, and implementation of interventions to prevent repeated falls and injuries for multiple residents. For one resident with severe cognitive impairment and a history of falls, there were at least 15 documented falls, some resulting in serious injuries such as a dislocated hip, femur fracture, and back fracture. The facility did not consistently review or revise care plan interventions after each fall, and there were omissions in required neurological checks and documentation. Staff education on fall prevention was not always documented, and some falls were not included in the facility’s incident log. Another resident with dementia, impaired vision, and a history of frequent falls experienced 36 falls over a period of time, resulting in various injuries including abrasions, contusions, lacerations, and head injuries, with several hospital transfers. The care plan interventions remained largely unchanged despite repeated falls, and the facility continued to rely on ineffective strategies such as reminders to use the call light, even though the resident was impulsive and forgetful. There was no evidence that the facility evaluated the reasons for failed interventions or increased supervision, and staff interviews confirmed that increased monitoring was not attempted despite ongoing falls. A third resident, dependent on staff for transfers due to left-sided weakness from a stroke, fell while left unattended on the toilet, resulting in a fracture to the eye socket and left lower leg. The care plan had instructed staff to stay with the resident during toileting, but this intervention was not followed. The facility’s investigation acknowledged that staff left the resident unattended despite existing care plan instructions. Across these cases, the facility failed to assess, evaluate, and implement effective interventions to prevent repeated falls and injuries, and did not ensure that staff consistently followed care plan instructions or documented required assessments.
Removal Plan
- Placed both Resident 19 and 50 on one to one (1:1) supervision.
- Educated all staff to the policies and procedures for accident prevention and fall interventions, including notification to management of ineffective fall interventions.
- Reviewed accidents to ensure care planned interventions were resident specific.
- Reviewed Resident 19 and 50's care plans and ensured interventions were pertinent to the root-cause of the falls.
Failure to Provide Adequate Staffing and Supervision Resulting in Resident Harm
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in inadequate supervision and unsafe care for multiple residents with high acuity and complex care requirements. Staffing levels were determined by census and minimum regulatory requirements, rather than by the actual acuity and care needs of the resident population. Staff interviews and resident council feedback confirmed that the facility was routinely short-staffed, leading to excessively long call light wait times, delayed responses to resident needs, and staff being required to perform duties outside their roles to compensate for shortages. The staffing guide used by the facility was based on headcount rather than resident acuity, and staff frequently reported being overworked and unable to provide adequate supervision, especially during night shifts and when 1:1 monitoring was required. Three residents experienced significant harm as a result of these staffing deficiencies. One resident with severe cognitive impairment and behavioral issues was involved in repeated resident-to-resident altercations and sustained multiple falls, resulting in serious injuries including a dislocated hip, femur fracture, and back fracture. Despite being placed on frequent safety checks and having care plan interventions, the resident continued to experience falls and altercations, with care plans not being reviewed or revised after each incident. Another resident, dependent on staff for toileting and transfers, fell multiple times, sustaining fractures to the eye socket and leg, and was left unattended on the toilet despite care plan instructions. A third resident with dementia and a history of frequent falls experienced 36 falls over a year, resulting in various injuries and hospital transfers, with care plan interventions not consistently updated after each fall. Documentation and interviews revealed that the facility did not consistently review or revise care plans following incidents, and staff were unable to provide the level of supervision required for residents at high risk for falls or with behavioral challenges. Grievance logs and resident council feedback highlighted ongoing concerns about insufficient staffing, long wait times for assistance, and unmet care needs. Staff acknowledged that some falls and altercations could have been prevented with adequate staffing, and that the facility's reliance on agency staff and minimum staffing guides was insufficient to address the actual needs of the resident population.
Significant Medication Errors Involving Insulin Overdose and Missed High-Alert Medications
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed for two residents, resulting in significant medication errors. One resident with diabetes and end-stage kidney disease received an injection of Lantus insulin that was 7.2 times their prescribed dose, which was intended for a different resident. This error occurred when a recently licensed LPN, who was still orienting, administered the pre-drawn insulin syringe to the wrong resident after becoming confused during a simultaneous medication pass for multiple residents. The resident experienced an extended period of symptomatic hypoglycemia, requiring rescue medications on five separate occasions to normalize blood sugar levels and symptoms. Documentation of the administration of rescue medications and adherence to the hypoglycemic protocol was incomplete in the medical record. Another resident, who was cognitively intact and had diagnoses including diabetes and atrial fibrillation, did not receive their ordered doses of an anticoagulant (Xarelto) and an injectable medication (Ozempic) used to manage weight and blood sugar. The MAR indicated that the anticoagulant was marked as not available due to a pharmacy backorder, despite the medication being present in the facility's emergency stock. There was no documentation of staff efforts to procure the medication or notify the provider of the missed dose. Additionally, the resident missed multiple scheduled doses of Ozempic due to delays in medication procurement and lack of clear communication regarding the medication's source and billing, with no documentation explaining the missed doses in the progress notes. Interviews with staff revealed gaps in orientation, competency verification, and communication regarding medication administration and error reporting. The LPN involved in the insulin error had not received a medication competency checklist until after the incident and was primarily performing tasks outside the LPN role during orientation. Nursing leadership acknowledged that high-alert medications like insulin and anticoagulants require careful monitoring and reporting, but reviews and follow-up on missed doses were inconsistent or absent. The provider was not fully informed of the extent of the resident's hypoglycemic episodes and rescue interventions.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for a minimum of eight consecutive hours each day, seven days a week, as required by regulation. A review of the 30-day staffing pattern revealed that there was no RN on duty for at least eight hours on several specific dates. Interviews with staff, including an LPN, Resident Care Manager, Staffing Coordinator, Director of Nursing, and Administrator, confirmed that there were days without RN coverage. Staff reported that LPNs managed care during these times and contacted the Director of Nursing as needed, but acknowledged the absence of an RN on duty as required. The staffing coordinator noted difficulties in obtaining RN coverage and stated that the Director of Nursing was notified when coverage could not be arranged.
Widespread Administrative Failures Lead to Harm, Repeat Citations, and Immediate Jeopardy
Penalty
Summary
Facility administration failed to effectively utilize resources to maintain compliance with federal regulatory requirements, resulting in multiple deficiencies. Specifically, administration did not identify, report, or assess a pattern of abuse related to resident-to-resident altercations, particularly involving one resident, and failed to implement interventions for potential abuse incidents involving several other residents. There was also a lack of adequate supervision and nursing staff, which led to falls and substantial injuries for multiple residents. Additionally, the administration did not provide necessary behavioral or mental health services for some residents, and failed to ensure medications were administered as prescribed, resulting in harm to at least one resident. The facility's infection control program was not implemented according to acceptable standards, leading to illness among a significant number of residents and staff. The administration also failed to utilize the Quality Assurance and Improvement Program (QAPI) to address and follow up on identified concerns in a timely manner. Several of these deficiencies were repeat citations, indicating that previous corrective measures were not maintained or sustained. During interviews, facility leadership acknowledged awareness of some issues but were not fully informed of the extent of the problems until notified by the survey team.
Failure to Maintain Effective QAPI Program and Incident Tracking
Penalty
Summary
The facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program. Despite having a policy and plan outlining the QAPI process, the facility did not consistently identify deficiencies, implement corrective actions, or evaluate the effectiveness of those actions. QAPI committee meeting minutes over several months showed repeated incidents of falls, including repeat falls and at least one fall resulting in a fracture, as well as medication errors and ongoing staffing challenges. However, there was a lack of Performance Improvement Projects (PIPs) in place for most of the review period, and when PIPs were implemented, there was insufficient documentation of tracking, trending, or evaluating their effectiveness. Additionally, the facility's accident and incident tracking log was incomplete, lacking essential information such as date, time, nature, and location of incidents, as well as actions taken and notifications made. Some residents experienced recurrent verbal and physical altercations and repeat falls that led to hospitalizations and fractures. Interviews with facility leadership confirmed that while data was collected and concerns were prioritized, the QAPI process did not result in timely or effective interventions to address ongoing issues, and documentation of corrective actions and their outcomes was lacking.
Failure of QAA/QAPI Program to Identify and Address Widespread Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) program, as evidenced by the inability to identify, analyze, and address multiple critical care deficiencies. The QAA committee did not meet the required frequency, lacked required members such as the Infection Preventionist, and failed to track and trend data to identify performance improvement opportunities. As a result, the facility did not recognize or act upon compromised care and services, leading to a pattern of resident harm and immediate jeopardy situations. Specific deficiencies included the failure to identify, report, and prevent a pattern of resident-to-resident verbal and physical abuse, particularly involving a resident with known aggressive behaviors. Staff did not recognize these incidents as abuse, nor did they analyze the circumstances or implement effective interventions. Additionally, the facility failed to ensure timely provider notification for residents experiencing significant changes in condition, such as extremely low blood sugars, low blood pressures, and elevated blood sugars, which prevented appropriate clinical intervention. Other areas of deficiency included inadequate monitoring and supervision to prevent falls, resulting in repeated injuries and hospital transfers for several residents. The facility also failed to provide necessary behavioral health services, ensure accurate medication administration, and maintain effective infection prevention and control during a Norovirus outbreak, which affected a significant number of residents and staff. Furthermore, the facility did not ensure sufficient staffing to meet resident acuity and care needs, contributing to repeated falls and abuse incidents. These failures were acknowledged by facility leadership, who confirmed that no corrective actions had been attempted except for falls, and that existing performance improvement projects were ineffective.
QAA Committee Lacked Required Infection Preventionist Participation, Leading to Norovirus Outbreak
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee that met at least quarterly with all required members, specifically omitting the Infection Preventionist from participation. Review of QAPI committee meeting minutes over four consecutive quarters showed no documentation of attendance or input from the Infection Preventionist, and no infection prevention and control data was presented. The Infection Preventionist confirmed in an interview that they had not participated in any QAPI meetings, were not monitoring infection control practices for trends, and had not initiated any infection control Performance Improvement Projects. As a result of these lapses, the facility's interdisciplinary QAA team was unable to effectively identify and address processes and outcomes related to infection control practices and disease management. This deficiency coincided with a Norovirus outbreak, during which 27 of 61 residents and 33 staff members contracted the highly contagious gastrointestinal illness, as documented in the facility's GI outbreak line listing.
Failure to Implement Effective Infection Control During Norovirus Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a Norovirus outbreak, resulting in the spread of the virus to all three nursing units, affecting 27 out of 61 residents and 33 out of 86 staff members. Surveyors observed multiple instances where staff did not follow established infection control protocols, such as failing to don appropriate personal protective equipment (PPE), not performing hand hygiene, and not posting or following correct isolation signage. In several cases, residents with indwelling devices or active gastrointestinal symptoms did not have Enhanced Barrier Precautions (EBP) or Contact Precautions signage or PPE carts at their room entrances, and staff were unclear about which precautions were required. The facility did not promptly report the Norovirus outbreak to the State Survey Agency or the local health department as required. The Infection Preventionist was unaware of the need to notify the State Survey Agency and only contacted the Department of Health ten days after the first case was identified. Additionally, the local health department confirmed that outbreak reporting was required and had not been received. Communication breakdowns were evident, as staff were not consistently reporting new cases of illness among residents and staff to the Infection Preventionist, and the outbreak line list was incomplete, missing several affected individuals. Staff members who became ill with Norovirus were instructed to return to work after being symptom-free for only 24 hours, contrary to CDC guidelines recommending a 48-hour exclusion. There were also instances where staff worked while still symptomatic, including one LPN who worked a double shift with a documented fever. Staff interviews revealed confusion regarding the use of PPE, the difference between EBP and Contact Precautions, and inconsistent practices in posting and following precaution signage. The facility's infection prevention policies were not clearly reviewed or updated, and staff were unsure who was responsible for policy review.
Non-Functioning and Non-Audible Call Light System
Penalty
Summary
The facility failed to maintain a resident call light system that was both functional and audible, as required. Multiple observations over several days revealed that call lights, while visibly lit above resident rooms and on the indicator board at the nurses' station, were not audible in the hallways. Staff interviews confirmed ongoing issues with the audibility of the call light system, with some call lights also being obscured from view by overhead paging system speaker boxes. The Resident Council reported excessively long wait times for call light responses, sometimes up to an hour, and confirmed that the call lights did not make any sound. Staff, including nursing assistants and registered nurses, acknowledged the lack of audibility and visibility of the call lights, with one staff member stating the system had not been audible for over a year. The Maintenance Director explained that the annunciator, the part of the system responsible for making the call lights audible, frequently malfunctioned and was not consistently repaired. Despite conducting monthly facility rounds, the Maintenance Director had not received work orders regarding the non-audible call light system and had not increased the frequency of checks to ensure proper function. During further observations, attempts to activate the call light system resulted in no audible alerts, and the only sound detected was an unrelated intermittent beep. The facility administrator stated that staff were expected to ensure the call light system was visible, audible, and in working order.
Lack of Documented Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory effective communication training to all 10 sampled direct care staff members, including LPNs, RNs, and nursing assistants, as required. Review of employee files for these staff members showed no documentation of completed effective communication training. During interviews, the Clinical Resource Nurse reported that a previous administrator had conducted a lunch and learn session on effective communication, but there was no signature sheet or other documentation to verify staff attendance or completion of the training. Another staff member confirmed the expectation that staff should receive adequate training to meet resident needs, but there was no evidence that this had occurred for the staff reviewed.
Failure to Inform Residents of Bed-Hold Rights During Hospital Transfers
Penalty
Summary
The facility failed to inform residents and/or their representatives about their right to have their bed held during hospitalizations, as required by policy and regulation. Specifically, for two of four sampled residents reviewed for hospitalizations, there was no documentation that staff provided the necessary bed-hold notices at the time of, or shortly after, transfer to the hospital. The facility's policy required two notices: one at admission and another at the time of transfer or within 24 hours in emergencies, but these were not consistently provided or documented. For one resident with moderate cognitive impairment who was their own responsible party, there was no documentation of the reason for hospital transfer or evidence that the resident was informed of their bed-hold rights during two separate hospitalizations. Nursing progress notes and census records confirmed the absence of this required communication and documentation. Staff interviews further confirmed that the expected process of informing and documenting bed-hold rights was not followed in these instances. Another resident with severe cognitive impairment and significant behavioral issues was transferred to the hospital multiple times for various reasons, including falls and behavioral disturbances. Review of nursing and provider progress notes for each transfer revealed no documentation that the resident or their representative was informed of their right to hold their bed or that the bed-hold policy was reviewed at the time of transfer. Staff interviews corroborated that this information should have been provided and documented, but it was not.
Failure to Implement Abuse Prevention Policy and Investigate Resident-to-Resident Altercations
Penalty
Summary
The facility failed to implement its abuse prevention policy for a resident with severe cognitive impairment who exhibited worsening verbal and physical behaviors. The resident was involved in multiple resident-to-resident altercations, including both physical and verbal aggression, over several months. Despite the facility's policy requiring identification, reporting, and investigation of potential abuse, many incidents were not properly documented, investigated, or reported to the State Survey Agency as required. In several cases, incident reports contained only a single statement with no additional staff or resident interviews, and there was no documentation that abuse or neglect was ruled out. The resident's care plan was not consistently updated or revised following each altercation, and interventions were not re-evaluated for effectiveness or modified to prevent recurrence. Although some interventions, such as 15-minute safety checks and providing items for the resident to rummage through, were implemented, there was no evidence that these were reviewed or adjusted after subsequent incidents. Additionally, several altercations were not included in the facility's incident tracking log, nor were they reported or investigated as required by policy. The facility's QAPI committee minutes lacked documentation showing that allegations of abuse, investigations, and corrective actions were tracked or analyzed for patterns or systemic issues. Interviews with staff revealed a lack of consistent understanding and application of the abuse policy, particularly regarding verbal altercations. Staff acknowledged that the resident's behaviors placed others at risk and that the facility had not adequately protected residents from abuse, nor had it addressed all incidents as potential abuse according to policy.
Failure to Coordinate PASRR Assessments and Behavioral Health Services
Penalty
Summary
The facility failed to coordinate with the State-designated authority to ensure that residents with mental disorders received integrated care according to their needs, as required by the Pre-Admission Screening and Resident Review (PASRR) program. For one resident, the PASRR Level II recommendations for specialized behavioral health services were not implemented, and there were no orders or documentation of behavioral health referrals or provider evaluations. Another resident did not have a timely PASRR Level II evaluation completed despite ongoing symptoms of delusions and distressing hallucinations, and there was a lack of documented follow-up with the PASRR evaluator after an initial backlog was reported. Additionally, a third resident's PASRR Level I screening was completed incorrectly prior to admission, failing to identify a history of depression and the need for a Level II evaluation, which was only requested after the resident began exhibiting behaviors post-admission. These deficiencies were identified through observation, interviews, and record reviews, which revealed that the facility did not ensure PASRR processes were correctly and timely followed for three residents with significant mental health needs. The lack of coordination and follow-through with PASRR requirements resulted in missed opportunities for behavioral health interventions and services as indicated by the residents' assessments and diagnoses.
Failure to Document Required Information During Resident Hospital Transfers
Penalty
Summary
The facility failed to ensure that services provided consistently met professional standards of practice for two of four sampled residents who were reviewed for hospitalizations. Specifically, the facility did not complete required hospital transfer documentation for these residents, omitting critical information such as the basis for hospital transfer, specific resident needs that could not be met by the facility, attempts made by the facility to meet those needs, services available at the receiving hospital, and details of information conveyed to the receiving provider. This lack of documentation was identified through observation, interviews, and record review. For one resident with complex medical conditions including cancer, hypertension, and a pacemaker, there was no documentation of the nurse's assessment prior to hospital transfer, the care needs identified, discussions with the resident, the reason for transfer, notifications to the provider or emergency contacts, or information sent to the hospital. The facility's policy required timely and comprehensive documentation of resident status, needs, and services, but these requirements were not met in this case. Staff interviews confirmed that the expected documentation, including use of the Emergent Transfer form and detailed progress notes, was not completed. Another resident with severe cognitive impairment and behavioral issues was transferred to the hospital multiple times for various reasons, including falls and combative behaviors. In several instances, documentation was missing regarding the specific needs the facility could not meet, attempts to address those needs, services available at the hospital, and information conveyed to the receiving provider. Staff acknowledged these omissions during interviews and confirmed that the required documentation was not consistently completed for hospital transfers.
Failure to Notify Providers of Significant Changes in Resident Condition
Penalty
Summary
Facility staff failed to notify providers of significant changes in condition for three residents, as required by facility policy and provider orders. For one resident with end-stage kidney disease and diabetes, staff did not notify the provider after the resident experienced a critically low blood sugar of 46 mg/dl, exhibited lethargy, low oxygen saturation, and expressed distress. Documentation was missing for blood sugar rechecks, oxygenation status, provider notification, and administration of glucose gel, despite clear orders to notify the provider in such events. Another resident with a history of stroke and hypertension experienced multiple episodes of extremely low blood pressure over several days while being treated for gastroenteritis. Although medication was held appropriately, there was no documentation of provider notification or assessment related to the abnormal blood pressure readings. Staff interviews confirmed that abnormal vital signs should have been reported to the provider, but this was not done or documented. A third resident with diabetes had several blood sugar readings above 300 mg/dl, as well as missing blood sugar measurements, without any documentation that the provider was notified as ordered. Progress notes did not explain the missing measurements or indicate that further instructions were sought from the provider for the management of elevated blood sugars. Clinical leadership acknowledged the lack of documentation and provider notification for these events.
Lack of Staff Competency Evaluation and Training in Key Care Areas
Penalty
Summary
The facility failed to develop and implement a system to evaluate and document staff competencies in essential care areas, including diabetes management, medication administration, PTSD, Substance Use Disorders (SUD), Gradual Dose Reductions (GDR), trauma informed care, fall management, and incident root cause analysis. Review of personnel files for eight sampled staff members, including LPNs, RNs, and Nursing Assistants, revealed no evidence of training or competency assessments in these areas. Staff interviews confirmed that they had not received adequate training or competency evaluations related to these topics. The facility assessment indicated that the resident population included individuals with diabetes, histories of SUD, trauma/PTSD, anxiety, cognitive impairment, and other mental health conditions, requiring specialized and individualized care. Further interviews with facility leadership, including the Resident Care Manager, Director of Nursing, and Clinical Resource Nurse, confirmed the absence of documentation for staff training in PTSD, SUD, GDR, or trauma informed care. The computerized training system and skills fairs used by the facility did not provide evidence of staff competency in these critical areas. The Administrator acknowledged the expectation that staff should have adequate training and competencies to meet the needs of the resident population, but the records did not support that this was occurring.
Failure to Provide Behavioral Health Services and Care Planning
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for two residents with identified behavioral health needs. One resident, who was cognitively intact and had a history of end-stage kidney disease, diabetes, and alcohol dependence, was admitted with a Level II PASRR determination indicating a need for specialized behavioral health services. However, the resident's electronic medical record did not contain the required Psychiatric Evaluation Summary, and no behavioral health referrals or support were documented despite ongoing non-compliance with dialysis, medications, and dietary restrictions, as well as episodes of anger, irritability, and verbal abuse toward staff. The care plan lacked specific goals and interventions related to behavioral health needs, and staff interviews revealed that behavioral health services were not implemented due to the absence of the evaluation summary and changes in behavioral health providers. Another resident, with a history of stroke, major depressive disorder with psychotic symptoms, and delusional disorder, exhibited ongoing delusions, self-isolation, and distressing hallucinations. The resident's care plan included some general interventions but did not address their ongoing psychosocial needs or provide additional goals and interventions for their behavioral health concerns. Despite repeated indications for a Level II PASRR psychiatric evaluation, the assessment was not present in the resident's record, and there were no behavioral health referrals or provider progress notes for an extended period. The resident declined telehealth counseling sessions, and the facility did not have in-person behavioral health providers available, resulting in the resident not receiving counseling services after admission. Staff interviews confirmed that care plans were not consistently updated to reflect residents' behavioral health needs, and regular care plan review meetings had not occurred as intended. The lack of timely behavioral health assessments, absence of documented interventions, and failure to provide access to behavioral health services contributed to the deficiency, leaving residents without necessary support for their behavioral health conditions.
Failure to Provide Medically-Related Social Services and Notify Ombudsman During Transfers and Discharges
Penalty
Summary
The facility failed to provide appropriate medically-related social services to meet residents' needs during transfers to the hospital and discharges to the community. Specifically, for one resident with complex medical conditions, including Parkinson's disease, seizures, anxiety, depression, and a recent leg amputation, the facility did not ensure that the basis for discharge was supported by documentation in the medical record. The resident was assessed as cognitively intact but dependent on staff for several activities of daily living (ADLs) and had previously expressed a desire to remain in the facility until fitted with a prosthesis and able to secure appropriate caregiver support in the community. Despite this, the facility issued a 30-day discharge notice citing endangerment to the safety of others, but there was no documentation in the medical record or incident logs to support that the resident had engaged in behaviors that endangered themselves or others. Staff interviews and progress notes did not corroborate the stated reason for discharge, and the discharge summary later listed 'Condition Improved' as the reason for discharge, which contradicted the original notice. Additionally, the facility failed to notify the Office of the State LTC Ombudsman of 37 hospital transfers over a five-month period. The facility's policy required notification of the Ombudsman for planned discharges, but staff were unaware that hospital transfers also required notification. As a result, the Ombudsman was not informed of any of the hospital transfers, which prevented the Ombudsman from advocating for residents' rights during these transitions. Staff interviews confirmed that the practice of notifying the Ombudsman for hospital transfers was not in place, and the responsible staff member had not received training on this requirement. The facility's discharge planning policy required the interdisciplinary team to document the evaluation of residents' discharge needs, the discharge plan, and discussions with the resident or their advocate. However, in the case reviewed, there was no evidence that the discharge was based on a thorough assessment or that the resident's needs and preferences were adequately considered or documented. The lack of documentation and communication with the resident's representative further contributed to the deficiency, as the representative was not kept informed of the discharge process or the reasons behind it.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
Staff in the facility failed to perform required hand hygiene (HH) during meal service in one of two observed dining rooms. Multiple instances were observed where staff, including agency nursing assistants and other personnel, placed clothing protectors on residents, touched residents' hair, neck, clothing, wheelchairs, and other surfaces, and then proceeded to interact with other residents or handle food items without completing HH in between these activities. Specific examples included staff touching residents and their wheelchairs, handling clothing protectors, and serving or assisting with food and beverages without performing HH as required by professional standards and facility policy. Interviews with staff confirmed their awareness of the HH requirements, including the need to perform HH after touching residents, wheelchairs, or clothing, and before handling food. Despite this knowledge, observations showed repeated failures to adhere to these protocols during the meal service. These actions were directly observed and documented by surveyors, and the deficiency was cited under the relevant state regulations.
Governing Body Failed to Oversee Abuse, Staffing, Medication, and Infection Control
Penalty
Summary
The governing body failed to provide adequate oversight and monitoring of the facility's appointed Corporate Officers/Administrator and the Director of Nursing, resulting in multiple deficiencies. There was a failure to identify, report, and assess a pattern of abuse related to resident-to-resident altercations, particularly involving one resident, as well as a failure to address or implement interventions for potential incidents of abuse involving several other residents. Additionally, the governing body did not ensure sufficient nursing staff to supervise residents and provide timely care, which led to falls and substantial injuries for multiple residents. The facility also failed to administer medications as prescribed, resulting in significant medication errors and harm to at least one resident. The infection control program was not implemented appropriately, leading to the spread of a contagious disease that affected 27 out of 61 residents and 33 staff members. The report also notes that previous citations related to accident hazards and infection control were not sustained, as evidenced by repeat deficiencies. During interviews, facility leadership acknowledged awareness of some issues but were not fully informed about the extent of the problems until notified by the survey team.
Failure to Document COVID-19 Vaccine Education and Status for Staff
Penalty
Summary
The facility failed to maintain adequate documentation that staff were educated about the risks and benefits of the COVID-19 vaccine, were offered the vaccine, and that their vaccination status was properly recorded. According to the facility's policy revised in August 2023, staff education and re-education regarding the COVID-19 vaccine should be documented in employee files, and staff should have the opportunity to accept or refuse the vaccine at any time. However, interviews revealed that the Infection Preventionist was unsure who was responsible for tracking staff vaccinations, and the Human Resources staff only had documentation for new employees, with no clear process for ongoing or annual vaccine offers or education. Additionally, the facility's vaccination tracking spreadsheet had not been updated since 2023. A review of an employee file showed that documentation of vaccine declination was only present from 2020, with no evidence of annual education or declination forms. Staff confirmed that they had not been offered the vaccine in several years and had not signed annual declination forms. The Infection Preventionist also noted that the position had been vacant prior to their start in February 2025, contributing to the lack of updated records. These findings indicate that the facility did not follow its own policy or regulatory requirements for documenting COVID-19 vaccine education, offers, and status for staff.
Failure to Provide Mandatory QAPI Training to All Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to all staff as required. Review of the facility's QAPI plan revealed that it did not specify the type or frequency of training to be provided. Examination of employee files for ten sampled staff members, including licensed practical nurses, registered nurses, and nursing assistants, showed no documentation of completed QAPI training. During interviews, the administrator was unable to produce any records demonstrating that the required training had been conducted for these staff members by the conclusion of the survey.
Failure to Provide Mandatory Compliance and Ethics Training
Penalty
Summary
The facility failed to provide mandatory Compliance and Ethics training to 9 out of 10 sampled staff members, including licensed practical nurses, registered nurses, and nursing assistants. Review of employee files revealed no documentation indicating that these staff had received the required training. During interviews, the administrator was unable to produce evidence of completed training for the identified staff, despite multiple requests for documentation. This lack of training was confirmed through both record review and staff interviews.
Failure to Secure Resident Financial Information
Penalty
Summary
The facility failed to maintain the confidentiality and security of a resident's financial information. A color copy of a bank card, including the handwritten PIN number, was scanned into the resident's electronic clinical health record, making it accessible to any nursing staff with access to the system. This action was confirmed through record review and staff interviews. The resident involved had moderate cognitive impairment, was able to verbalize needs, and had a payee assigned to manage finances due to impulsivity and a tendency to send money to family members, which was not in their best interest. Staff interviews revealed that bank cards are considered valuables at high risk for loss or theft and should be stored securely to prevent unauthorized access. The Social Services Coordinator and the DON both acknowledged that the bank card and PIN should not have been stored in the electronic health record. The Administrator stated that staff are expected to maintain and store bank card information securely to prevent unauthorized access.
Failure to Maintain Safe and Homelike Environment and Equipment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations of disrepair and unsafe equipment. In one resident's room, the wall behind the bed was gouged and dented from the headboard, and the baseboard had scuffed and peeling paint. Another resident's wheelchair was found to have bilateral metal brake extenders without rubber protectors, which are intended to cover the metal ends and prevent injury. Additionally, broken and missing floor tiles were observed in two separate units: near an exit door on one unit, where a rug had been placed over the damaged area, and in a special care unit, where a gouged tile area was noted. During interviews, the Maintenance Director acknowledged awareness of the broken and missing tiles and the lack of a formal schedule to check room conditions, stating that repairs were planned or would be addressed as rooms became vacant. The Maintenance Director also indicated that monthly checks were performed on wheelchairs, but was unaware of the missing protectors on the wheelchair brake extenders. These deficiencies were identified during observations and interviews, and were shared with facility staff.
Insufficient Documentation for PRN Injectable Antipsychotic Administration
Penalty
Summary
A resident with severe cognitive impairment and worsening behavioral symptoms, including verbal and physical aggression, was administered an as-needed injectable antipsychotic (Haldol) without sufficient documentation to justify its use for a specific medical symptom. The resident had a history of agitation, combative behaviors, and was recently seen in the emergency room for confusion and delirium, where an oral antipsychotic was given and an order for injectable Haldol as needed was prescribed upon discharge. Facility records showed the injectable antipsychotic was administered, but the behavior documentation at the time did not indicate a clear medical necessity for its use. Interviews with facility staff, including the Resident Care Manager and Director of Nursing, confirmed that as-needed antipsychotic medications should be limited, require adequate diagnosis, and must be supported by detailed documentation in the medical record. Review of the resident's records revealed poor documentation and insufficient justification for the administration of the injectable antipsychotic, which was acknowledged by facility leadership as not meeting the required standards for use.
Failure to Assess and Address PTSD Symptoms in Veteran Resident
Penalty
Summary
The facility failed to identify, assess, and address potential signs and/or symptoms of Post Traumatic Stress Disorder (PTSD) for one resident who was reviewed for mood and behavior. The resident, a Navy veteran with diagnoses including dementia, depression, and violent behavior, exhibited severe cognitive impairment and worsening verbal and physical behaviors that interfered with care and the living environment. Despite frequent episodes of yelling, screaming, and distress—often occurring at night and sometimes while the resident was asleep—there was no documented assessment or intervention specifically targeting possible PTSD or trauma-related symptoms. Facility policy required monitoring and assessment for signs of trauma and PTSD, as well as staff training in trauma-informed care. However, the resident's behavioral care plan only addressed general behavioral symptoms related to dementia and poor impulse control, without considering trauma or PTSD as a potential underlying cause. The psychosocial evaluation noted the resident was a veteran and had no family support, but did not identify any significant traumatic events, and the resident was described as unwilling to discuss trauma. Nursing progress notes documented ongoing episodes of yelling, screaming, and distressing outbursts, particularly at night, with some entries noting the resident was unaware of their own behavior or reported having bad dreams. Interviews with staff revealed a lack of trauma-informed care training and an absence of specific assessment or interventions for PTSD, despite staff awareness that the resident was a veteran and exhibited behaviors consistent with trauma-related symptoms. The Social Services Coordinator and DON both acknowledged that the resident had not been assessed for PTSD, and no interventions had been implemented to address the recurrent nightmares or night terrors. The facility's failure to follow its own policy and to provide trauma-informed care resulted in unmet behavioral health needs for the resident.
Failure to Label Insulin Pens and Remove Expired Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure medications were labeled in accordance with accepted professional standards and that expired medications were removed from inventory. Specifically, insulin pens in one of two medication carts were found without the date they were opened, and expired Bisacodyl suppositories were present in both a medication cart and the medication room. The facility's policy required medications to be discarded by their expiration date or earlier, and insulin pens to be dated when opened to ensure proper disposal after 28 days. Staff interviews confirmed that the usual practice was to date insulin pens and discard expired medications, but these procedures were not followed in the instances observed. Medical record reviews showed that one resident had been receiving Lantus insulin daily since early April, and another had received Novolog insulin as needed multiple times in May. The lack of labeling on the insulin pens made it unclear whether they were within the safe usage period. The presence of expired Bisacodyl suppositories in both the medication cart and medication room further demonstrated a lapse in medication management and inventory control.
Failure to Supervise High Elopement Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident assessed as high risk for elopement. The resident had diagnoses including a right femur fracture, dementia with behavioral disturbance, muscle weakness, and a history of falls, and required substantial assistance with activities of daily living. Multiple assessments identified the resident as a high elopement risk, recommending 15-minute safety checks and the use of a Wanderguard device. Despite these recommendations, the resident was allowed to sit outside the front door when agitated, with staff instructed to check for safety and appropriate clothing. However, documentation and interviews revealed that the required 15-minute safety checks were not consistently performed or documented, and the Wanderguard was not in place prior to the resident's elopement. On the day of the incident, the resident was last seen in the dining room, but during the next scheduled safety check, staff could not locate the resident. A facility search was initiated, and the resident was found a block away, upright in their wheelchair, with no injury identified. Interviews with staff confirmed a lack of awareness and completion of the required safety check forms, and the DON acknowledged that the Wanderguard should have been in place as previously recommended. The failure to implement and document the recommended safety measures resulted in the resident leaving the facility without staff knowledge.
Failure to Notify Police of Alleged Sexual Abuse
Penalty
Summary
The facility failed to notify the police of an allegation of sexual abuse involving a resident. The incident report documented that a hospitality aide informed the Director of Nursing about the alleged abuse by another aide. The facility notified the state agency and the resident's representative, but there was no documentation of local law enforcement being informed. During an interview, the Administrator admitted to not notifying the police, believing there was no immediate danger and assuming the aide had already done so. The police confirmed they had not been notified until informed by the state agency.
Inconsistent Shower Provision for Residents
Penalty
Summary
The facility failed to consistently provide showers for four out of five sampled residents, which placed them at risk for poor hygiene and diminished quality of life. Resident 1, who had a disorder of movement and muscle tone, was dependent on staff for showers and preferred two showers per week. However, the resident only received one shower in a month, with no documentation of refusals or encouragement to shower. Resident 2, diagnosed with seizures and requiring maximum assistance, received only two showers in a month. Resident 3, with intellectual disabilities and requiring setup assistance, had inconsistent shower schedules, receiving showers once a week and then experiencing a 10-day gap. Resident 4, diagnosed with Alzheimer's Disease and requiring maximum assistance, also received only two showers in a month, despite a preference for twice-weekly showers. Interviews with staff revealed that the facility no longer had a dedicated shower aide, leading to inconsistent shower schedules. Staff D, a CNA, mentioned that if a resident refused a shower, they would reapproach the resident twice and offer a bed bath if refusals continued. Staff A, the RCM, confirmed that residents were supposed to receive showers twice a week, but the shower aide was often pulled to the floor due to staffing shortages, causing rescheduling of showers. Staff B, the Staffing Coordinator, stated that a CNA was assisting with showers three days a week, and they attempted to find CNAs for weekend showers. The Administrator acknowledged the inconsistency in providing showers and identified it as a problem the facility was working to address.
Resident Injury During Transfer Due to Improper Use of Sit-to-Stand Lift
Penalty
Summary
The facility failed to ensure that a resident was free from injury during a transfer using a sit-to-stand lift. The resident, who had diagnoses including heart disease and diabetes, required maximum assistance with bed mobility and was dependent on transfers. During a transfer to the commode, the resident's arm sling became caught and wrapped around their neck, causing them to become unresponsive. The staff member, a nursing assistant, left the resident unattended in the lift to seek help, during which time the resident fell to the floor. Upon review, it was found that the facility was unaware of the sling's involvement until informed by the hospital. The resident was sent to the hospital, where they arrived alert and oriented, with abrasive areas on their neck. The hospital documented a strangulation event due to the sling getting caught in the lift. The facility's investigation was incomplete as the staff member who conducted it was no longer employed there. The resident was subsequently evaluated by therapy and changed to a Hoyer lift for future transfers.
Failure to Complete Accurate PASARR for Residents
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) was completed accurately for two residents, leading to potential risks of inappropriate placement and unmet mental health care needs. Resident 10, who was admitted with diagnoses of depression and schizophrenia, had a Level I PASARR completed by the hospital, which indicated that a Level II PASARR was not required due to an exempted hospital stay. However, the resident remained in the facility beyond the 30-day exemption period without an updated Level I PASARR being completed, as confirmed by Staff E, Social Services, during an interview. Resident 20, who returned to the facility after a below-the-knee amputation and had diagnoses including anxiety and a psychotic disorder, also did not have an updated PASARR following a significant change of condition. The last PASARR for Resident 20 was completed in 2019, and no new PASARR was conducted after the significant change in 2024. Staff E confirmed the need for a new Level I PASARR for Resident 20 during an interview. These oversights in PASARR completion were identified through observation, interview, and record review, highlighting the facility's failure to meet regulatory requirements for mental health assessments.
Failure to Develop Comprehensive Care Plan for Resident with Wounds
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with wounds, leading to unmet care needs. The resident had significant medical conditions including peripheral vascular disease, congestive heart failure, and diabetes, which placed them at risk for skin breakdown. Despite documented skin evaluations showing open areas and blisters on the resident's buttock and legs, the care plan only included weekly skin assessments without specific interventions for wound care or preventative measures. This deficiency was confirmed by the Resident Care Manager, who acknowledged that the care plan should have included interventions for wound healing.
Failure to Assist Resident During Mealtimes
Penalty
Summary
The facility failed to provide necessary assistance during mealtimes for a resident with severe cognitive impairment and Alzheimer's dementia. The resident required partial to moderate assistance for eating, as documented in their care plan, which included supervision, set-up assistance, and cueing at mealtimes. However, on multiple occasions, the resident was observed without any staff assistance, leading to food and liquid being spilled and the resident not consuming their meals. Despite the presence of several staff members, no one intervened to assist or cue the resident to eat during these observations. During interviews, staff members acknowledged that the resident required extensive assistance to eat and that the care plan interventions were known but not followed. The resident's nutritional care plan indicated a risk for nutritional problems due to Alzheimer's dementia, and the resident's meals and supplements were supposed to be monitored and documented. However, the lack of assistance during mealtimes was evident, as the resident was left unattended and did not consume their meals, which was confirmed by staff observations and interviews.
Failure to Engage Resident in Meaningful Activities
Penalty
Summary
The facility failed to ensure that Resident 15, who had severe cognitive impairment and was dependent on staff for all care, was engaged in meaningful activities that met their interests. Despite the resident's documented enjoyment of music and the need for sensory stimulation, continuous observations revealed that the resident was often left alone in a darkened room without any interaction or engagement. On multiple occasions, the resident was observed sitting in their wheelchair in a dark room with no television or radio on, and staff did not interact with or engage the resident in any activities during these times. Interviews with staff confirmed that Resident 15 required full assistance to participate in activities and that it was inappropriate for the resident to be left alone in a dark room. The Activity Director acknowledged that the resident should have been included in sensory activities and music programs but was not. The Resident Care Manager also stated that two-hour rounding was supposed to be done for residents sitting alone in their rooms, and it was inappropriate for Resident 15 to be left in such conditions. The facility's failure to engage Resident 15 in meaningful activities placed the resident at risk for boredom and diminished quality of life.
Failure to Provide Effective Bowel Management
Penalty
Summary
The facility failed to provide effective bowel management for two residents, leading to unmet care needs and an emergency room visit for one resident. Resident 26, who had diagnoses including diabetes and septicemia, did not have a bowel movement for seven days after admission, and no bowel medications were offered or administered during that time. Despite having orders for various laxatives, the facility did not follow the bowel protocol, resulting in the resident experiencing discomfort and requiring hospital intervention. Staff interviews revealed that the bowel management protocol was not consistently followed, and there was a lack of documentation regarding bowel movements and interventions. Resident 33, who had moderate cognitive impairments and required assistance with toileting, also experienced lapses in bowel management. The resident's care plan included instructions for bowel management when opiates were ordered, but the facility failed to administer the prescribed laxatives during periods of constipation. The Medication Administration Records (MAR) showed that the resident did not receive the bowel medications as ordered, and there was no documentation explaining the omissions. Staff confirmed that the bowel protocol should have been followed but was not. Resident 37, who required moderate to substantial assistance with toileting, similarly did not receive appropriate bowel management. The resident had multiple instances of constipation, but the facility did not administer the prescribed laxatives according to the bowel protocol. The MAR indicated that the resident did not receive the bowel medications as ordered, and there was no documentation to explain the omissions. Staff interviews confirmed that the bowel protocol was not followed, leading to the resident's unmet care needs.
Failure to Provide Adequate Supervision and Smoking Safety Assessment
Penalty
Summary
The facility failed to provide adequate supervision and assess a resident for smoking safety. Resident 37, who had a history of stroke resulting in weakness and paralysis on their right side, was observed smoking without a smoking apron. During the observation, the resident dropped a lit cigarette multiple times, which rolled onto their clothing and was picked up by another resident. The resident's smoking care plan indicated they were independent with smoking but required assistance to get to the smoking area. However, the last smoking assessment was completed on 08/18/2023, and no further assessments were documented as required quarterly or annually. On multiple occasions, Resident 37 was seen struggling to handle the cigarette, resulting in burn holes in their clothing and residual cigarette ashes. Staff interviews confirmed that the resident should have had a more recent smoking assessment. The facility's failure to conduct timely smoking assessments and provide adequate supervision led to the observed safety hazards while the resident was smoking.
Failure to Provide Needed Pain Management
Penalty
Summary
The facility failed to provide necessary pain management for a resident with osteoarthritis, migraines, and chronic pain syndrome. The resident, who was able to communicate their needs, reported being out of their Hydrocodone 5 mg tablets for about three days and was not offered any alternative pain relief. Nursing staff informed the resident that there was nothing else they could do. The resident's Medication Administration Records for May 2024 showed physician orders for acetaminophen every four hours as needed, Hydrocodone 10/325 mg three times per day, and Hydrocodone 5/325 mg daily as needed for migraine pain. However, the resident did not receive the PRN Hydrocodone 5/325 mg from May 6 through May 8, 2024, despite reporting pain rated as a four on a scale of 1-10 on the evening of May 8, 2024. No Tylenol or non-medication interventions were offered during this time, and there was no documented communication with the physician regarding the unavailability of the PRN pain medication. In an interview on May 16, 2024, the Resident Care Manager confirmed that the resident had been out of their PRN Hydrocodone 5/325 mg pain medication from May 6 through May 10, 2024, and acknowledged that the physician should have been notified. This failure to provide needed pain management placed the resident at risk of uncontrolled pain and a diminished quality of life.
Failure to Collaborate with Dialysis Center and Monitor Fluid Restriction
Penalty
Summary
The facility failed to consistently collaborate care with the dialysis center and accurately monitor the fluid restriction for a resident with end-stage renal disease who was dependent on dialysis. The Long Term Care Facility Outpatient Dialysis Services Coordination Agreement required documentation of collaboration and communication between the facility and the dialysis center. However, the Dialysis Communication form was not filled out by the dialysis clinic on multiple dates, and there was no documentation in the resident's record regarding the incomplete documentation. This lack of documentation and communication could lead to unrecognized complications and unmet care needs for the resident. Additionally, the facility did not accurately monitor the resident's fluid restriction as per the provider's orders. The resident had a fluid restriction order of 1000 ml per day, with specific amounts to be given during each shift. However, the Medication Administration Record (MAR) showed inconsistencies in the amount of fluids provided, with varying amounts recorded on different days. Staff M, the Resident Care Manager, was unsure which fluid restriction was followed by the nursing staff and acknowledged that night shift was responsible for calculating the total fluid intake. This inconsistency in monitoring fluid intake further compromised the resident's care.
Failure to Address Pharmacist Recommendations in a Timely Manner
Penalty
Summary
The facility failed to ensure that recommendations from the pharmacist were addressed in a timely manner for one resident reviewed for unnecessary medications. Specifically, the Consultant Pharmacy Report recommended that the resident should not brush their teeth, rinse mouth, eat, or drink following the use of Peridex mouthwash, and this instruction should be added to the Medication Administration Record (MAR). This recommendation was made in January, February, and March of 2024, but no response from the provider or nursing staff was documented until March 4, 2024. During an interview, the Resident Care Manager confirmed that the pharmacy recommendations were received and should have been added to the MAR in a timely manner, mistakenly believing they had a week to do so.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5 percent, resulting in a 7.41 percent error rate during medication administration for two of four sampled residents. Specifically, for Resident 2, a registered nurse administered Brimonidine eye drops followed immediately by Refresh eye drops without waiting the required five minutes between different eye medications. The nurse acknowledged the mistake during an interview following the observation. For Resident 9, a registered nurse administered a Multivitamin with Minerals instead of the prescribed Multivitamin with Folic Acid 400 micrograms. Upon review of the electronic medical record and the medication bottle, the nurse confirmed that the administered multivitamin did not contain the required Folic Acid and acknowledged the error. These actions led to a medication error rate exceeding the acceptable threshold, placing residents at potential risk for not receiving the full therapeutic effect of their medications.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure appropriate hand hygiene was performed during meal service in one of the two dining rooms. During a lunch observation, Staff W, the Admissions Coordinator, was seen preparing coffee, touching straws, tablecloths, clothing protectors, and adjusting a resident's glasses without performing hand hygiene in between these tasks. Staff W also gave a cleansing wipe to a resident, passed trays, and opened food items without sanitizing their hands. Additionally, Staff W assisted four residents to eat, touching various items and residents without performing hand hygiene in between. Staff X, a Nursing Assistant, moved a chair, fixed a resident's clothing protector, and then assisted another resident with drinks and food without sanitizing their hands. Staff U, another Nursing Assistant, picked up unclean dishes and then grabbed clean washcloths to assist residents without performing hand hygiene in between tasks. Interviews with Staff X, Staff U, and Staff W revealed that they were aware of the hand hygiene protocols but failed to follow them during the meal service. Staff X and Staff U acknowledged that they should have performed hand hygiene before and after passing meal trays and touching various items to prevent the spread of germs. Staff W also admitted that they should have sanitized their hands after touching different items to prevent cross-contamination. The observations and interviews were discussed with the Administrator and the Director of Nursing, highlighting the lack of adherence to hand hygiene protocols during meal service.
Failure to Accurately Submit Staffing Information to CMS
Penalty
Summary
The facility failed to ensure that direct care staffing information was correctly electronically submitted to the Centers for Medicare and Medicaid Services (CMS) for Quarter 3 of 2023. This failure was identified during a review of the Certification and Survey Provider Enhanced Reports (CASPER) Payroll-Based Journal Staffing Data Report, which showed that the facility reported staffing levels lower than the mandated requirements. During an interview, the Administrator stated that the Human Resource (HR) Manager was responsible for submitting the PBJ information and confirmed that the numbers submitted were those in the CASPER report. The HR Manager acknowledged that Registered Dietician hours had not been included in the submission, leading to the inaccurate data reported to CMS.
Failure to Follow Physician Orders for Urinary Catheter Changes
Penalty
Summary
The facility failed to follow physician orders for two residents who had urinary catheters, placing them at risk for possible urinary tract infections (UTIs). Resident 1, who had a stroke and was able to communicate their needs, had a physician's order from a urologist to have their catheter changed every four weeks. However, the Treatment Administration Record (TAR) for February, March, and April 2024 did not reflect this order, and there was no documentation that the catheter had been changed during this period. Similarly, Resident 2, who had kidney disease and was severely cognitively impaired, was diagnosed with a UTI related to the urinary catheter after being sent to the hospital. The hospital discharge instructions indicated that the catheter should be changed every month, but this order was not added to the TAR, and there was no documentation of the catheter being changed in February, March, and April 2024. Interviews with staff revealed that the process for updating orders from outside physician appointments or hospital visits was not consistently followed. Staff A, an LPN, stated that Resident Care Managers (RCMs) were responsible for adding new orders to the electronic system, but if RCMs were not available, floor staff would review and input the information. Staff B, an RN, confirmed that catheters should be changed based on physician orders, and Staff C, the Director of Nursing, acknowledged that the orders should have been added to the residents' TARs. This failure to update and follow physician orders for catheter changes led to the deficiency identified in the report.
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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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