Corwin Center At Emerald Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Redmond, Washington.
- Location
- 10901 - 176th Circle Northeast, Redmond, Washington 98052
- CMS Provider Number
- 505478
- Inspections on file
- 25
- Latest survey
- April 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Corwin Center At Emerald Heights during CMS and state inspections, most recent first.
A resident with Alzheimer's disease was observed picking up a loose pill from the hallway and handing it to a certified nursing assistant, while expired syringes were found in the medication storage room. Staff confirmed that medications should be securely stored and expired supplies discarded, but these procedures were not followed.
Surveyors found that staff used expired sanitizing solution test strips, failed to discard expired food items in kitchen storage and a resident-use refrigerator, and transported uncovered food items through hallways during meal delivery. Staff interviews confirmed these actions were not in accordance with facility food safety policies.
Four residents experienced deficiencies in recordkeeping, including a medication order with incorrect behavioral monitoring instructions, an insulin order lacking hold parameters, a PASARR form missing a depression diagnosis, and a bed positioning device that was loose but not specifically documented as inspected. Staff interviews confirmed these documentation and monitoring lapses.
Surveyors observed that staff failed to properly use PPE, including not changing soiled N95 masks between rooms on Droplet Precautions, and did not perform required hand hygiene during meal tray delivery for three residents. Additionally, a resident's indwelling urinary catheter drainage bag was repeatedly found touching the floor, contrary to facility policy. Staff interviews confirmed these practices did not meet infection control standards.
The facility did not accurately complete MDS assessments for three residents, with errors in recording weights and failure to properly code constipation based on documented bowel movement frequency. Staff interviews confirmed that the MDS entries did not reflect the most current and accurate information from resident records.
The facility did not accurately complete PASARR forms or make timely Level II referrals for three residents with diagnoses of depression or anxiety. Staff interviews confirmed that required diagnoses were either not marked or not referred for further evaluation, contrary to facility policy.
A resident with fragile skin did not receive scheduled weekly skin checks on two occasions, as required by their care plan and facility policy. Nursing staff documented that the checks were missed because the resident was sleeping, but did not attempt the assessment later or communicate the need to the next shift. Facility leadership confirmed that weekly skin checks were expected and should have been completed as ordered.
A resident with dementia and poor appetite experienced significant unaddressed weight loss, with staff failing to notify the RD or provider as required by policy. Despite care plan interventions for nutritional monitoring and supplementation, the resident's decreased intake and weight loss were not properly communicated or documented.
A resident receiving insulin therapy was not adequately monitored for hypoglycemia or hyperglycemia, and there were no documented parameters for when to hold insulin or notify the provider. Staff confirmed that monitoring and parameters were expected but not present in the MAR or TAR, resulting in a deficiency in safe medication management.
A resident received an influenza vaccine without documented evidence that they or their representative were provided education on the risks and benefits of the vaccine, as required by facility policy. Staff interviews confirmed that this education should have been given and documented, but no such record was found in the resident's medical file.
A resident with significant mobility and cognitive impairments was found to have a loose bed positioning device that was not properly secured or regularly inspected. Multiple staff confirmed the device's condition, and documentation revealed that bed positioning devices were not specifically listed for inspection during routine room rounds, leading to the deficiency.
A resident with dementia, depression, and a history of falls exited the facility unsupervised and sustained a serious injury after staff failed to provide adequate supervision, accurate risk assessment, and timely interventions. Other residents at risk for elopement were also not properly identified or monitored, and staff were unaware of required safety devices or lacked necessary physician orders.
Several residents identified as at risk for elopement did not have timely or comprehensive care plans in place, and required interventions such as WanderGuard monitoring were not consistently ordered or implemented. Staff interviews revealed a lack of awareness about which residents were at risk and what interventions were needed, despite facility policies requiring individualized care plans and monitoring protocols.
A facility failed to document the administration of oxycodone for a resident, despite evidence from the narcotic book showing doses were taken. Staff interviews revealed that nurses did not record the medication in the MAR, contrary to facility policy, placing the resident at risk for uncontrolled pain and medication errors.
A resident on hospice care experienced misappropriation of morphine due to discrepancies in medication counts, which were not promptly reported or investigated by the facility. An LPN was suspected of poor practices, and the DNS failed to notify authorities or conduct a thorough investigation, leading to ongoing medication misappropriation.
A facility failed to report allegations of controlled medication misappropriation for a resident within the required timeframe. Despite noticing discrepancies in the morphine count on multiple occasions, staff did not report these to the State Agency until several days later, placing the resident at risk. The DNS was aware of the discrepancies but did not consider them reportable, and a new employee was suspected of contributing to the issue.
A resident on hospice care experienced discrepancies in their morphine medication, which were reported by staff but not promptly investigated by the facility. Despite multiple reports of inconsistencies in medication counts and potential diversion by an LPN, the facility failed to take immediate action, leaving the resident at risk for pain and misappropriation.
The facility failed to ensure proper hand hygiene practices in the kitchen, as observed when a cook changed gloves multiple times without washing hands. Both the training cook and the Director of Food and Beverage confirmed that the correct procedure was not followed.
The facility failed to discard expired Levothyroxine and properly label an open vial of Tubersol, as observed during interviews with an LPN and the DON. These lapses in medication management placed residents at risk of receiving expired or compromised medications.
The facility failed to ensure proper hand hygiene during soiled linen collection, proper disinfection of medical equipment between resident uses, and the inclusion of a flow diagram in its water management program. Staff members did not adhere to hand hygiene and equipment disinfection protocols, and the water management plan lacked necessary documentation.
The facility failed to maintain dignity while assisting a resident with Alzheimer's during meals. A nurse was observed standing over the resident instead of being seated and at eye level, contrary to the care plan and facility expectations.
A resident's missing electric toothbrush was not logged or investigated by the facility, despite being reported by the resident and their representative. The facility's grievance log did not include the incident, and staff failed to follow the policy for handling such grievances.
The facility failed to prevent physical abuse among residents, involving incidents where a resident with severe cognitive impairment had altercations with two other residents, leading to physical confrontations. Staff intervened and assessed for injuries, but the facility acknowledged they could not have predicted or prevented the incidents.
A resident experienced increasing verbal abuse from their roommate, which was documented by an LPN but not reported to the State Agency or logged in the incident log as required. The DON and Administrator confirmed that the incident should have been reported and investigated.
The facility failed to transmit resident assessment data to CMS within the required timeframe for a resident. The discharge MDS with an ARD was 83 days late. The MDS Nurse acknowledged the oversight, and the DON confirmed that the MDS should have been completed and transmitted timely.
The facility failed to accurately assess a resident's medication regimen during the MDS assessment, marking the resident for anticoagulant medication instead of antiplatelet medication. The error was identified during a review of the MAR and confirmed by the MDS Nurse and DON.
The facility failed to revise comprehensive care plans for three residents, leading to unmet care needs. One resident's care plan did not include oxygen use, another's did not address frequent refusals of wound treatment, and a third's did not reflect refusals to get out of bed after a fall. Staff acknowledged these oversights, but the care plans were not updated in a timely manner.
The facility failed to follow insulin orders and clarify medication parameters for two residents, leading to potential medication errors. One resident received Digoxin and Metoprolol without proper hold parameters, and another received Insulin Aspart outside the prescribed sliding scale range.
The facility failed to monitor for signs of bruising or bleeding in a resident on anticoagulant therapy and did not follow a physician's order for insulin sliding scale administration for another resident. These failures were confirmed through observations, record reviews, and staff interviews.
The facility failed to maintain, label/date, and properly store oxygen nasal cannula/tubing for two residents, leading to potential risks of respiratory infections and related complications. Observations revealed that the oxygen tubing was unlabeled and not stored in a bag when not in use, contrary to facility policy. Staff confirmed the tubing should have been dated and stored properly.
The facility failed to ensure monthly pharmacy recommendations were followed up on by the physician for a resident. The pharmacy Consultation Report did not show a response from the physician and was not signed, which was confirmed during a review with the DON.
The facility failed to maintain an effective Antibiotic Stewardship Program by not implementing antibiotic use protocols and not utilizing standardized tools and criteria. Two residents were prescribed antibiotics without proper documentation and follow-up, and the antibiotic stewardship line listing was incomplete and not updated.
Improper Medication Storage and Expired Supplies Found
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications and medical supplies as required by policy. During observation, a resident with Alzheimer's disease was seen picking up a pill from the hallway floor and handing it to a certified nursing assistant. Interviews with staff confirmed that medications should be stored securely in medication carts or containers, and that loose pills should not be present on the ground or in the cart. Additionally, an inspection of the medication storage room revealed expired medical supplies, including a box of 100 Medline syringes and three boxes of BD syringes, all past their expiration dates. Staff interviews confirmed that expired supplies should have been discarded, and that daily checks and random audits were supposed to prevent such occurrences. The presence of expired supplies and unsecured medication constituted a failure to follow the facility's own policies regarding medication storage and disposal.
Expired Test Strips, Improper Food Storage, and Uncovered Food Transport
Penalty
Summary
Surveyors identified multiple failures in the facility's food service operations. In both the Fire Side Grill Kitchen and Main Kitchen, staff were found using expired sanitizing solution test strips to check the effectiveness of sanitizing solutions. The Executive Chef acknowledged that all available test strips were expired and had not been replaced. In the Main Kitchen Dry Storage Room, unopened bottles of coconut aminos, balsamic vinegar, and Sriracha hot honey were observed to be past their use-by dates and had not been discarded as required by facility policy. Staff confirmed that these expired food items should have been removed from storage. Additionally, in the resident-use refrigerator, a half loaf of bread and a container of soup brought in by family members were found to be past the three-day limit for consumption and had not been discarded, contrary to facility policy. During meal tray delivery, staff were observed transporting uncovered food items, such as mandarin oranges and cake, through hallways to resident rooms, despite facility policy requiring all food items to be covered during transport. Staff interviews confirmed that these practices did not align with established food safety and handling protocols.
Incomplete and Inaccurate Resident Records and Documentation
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate for four residents, resulting in deficiencies related to medication orders, documentation, and monitoring. For one resident, a multivitamin order incorrectly included instructions to monitor for combative behavior, which staff confirmed was entered by mistake and did not reflect the resident's needs. Another resident receiving insulin glargine had orders that lacked required parameters for when to hold the medication or notify the provider, contrary to facility policy and staff expectations. A third resident's Preadmission Screening and Resident Review (PASARR) form was found to be incomplete, as it did not document a diagnosis of depression that was present on the resident's face sheet. Staff acknowledged that the PASARR form should have been updated to accurately reflect the resident's diagnosis, in accordance with facility policy. Additionally, a resident's bed positioning device was observed to be loose on multiple occasions, but the facility's room rounds form did not specifically list or document regular inspection of bed positioning devices. Staff indicated that these devices were considered part of the bed or furniture and were checked under general room or furniture repair sections, but the documentation did not specifically address the condition or monitoring of the positioning device.
Deficient Infection Control Practices: PPE, Hand Hygiene, and Catheter Care
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) and hand hygiene practices, as well as appropriate handling of an indwelling urinary catheter drainage bag, as observed during surveyor visits. One staff member, a Nursing Assistant Certified (NAC), was seen wearing a soiled N95 mask when exiting a Droplet Precautions room and did not change to a new mask before entering other resident rooms, despite a PPE cart being available outside the rooms. Interviews with staff revealed inconsistent understanding and application of the facility's policy regarding when and where to change masks after providing care to residents on Droplet Precautions. Hand hygiene deficiencies were also observed during meal tray delivery to three residents. A staff member delivered meal trays, adjusted bedside tables, and moved walkers for multiple residents without performing hand hygiene before entering or after leaving the rooms, or between tasks. The staff member later acknowledged that hand hygiene should have been performed at these times, and supervisory staff confirmed that this was the expected practice according to facility policy. Additionally, the facility failed to maintain proper care of an indwelling urinary catheter for a resident with urinary retention and benign prostatic hyperplasia. The resident's catheter drainage bag was observed hanging under the bed and touching the floor on multiple occasions. Staff interviews confirmed that the drainage bag should not have been in contact with the floor and that a barrier should have been used to prevent this. These failures were directly observed and confirmed by multiple staff members during interviews.
Inaccurate MDS Assessments for Weight and Constipation
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, specifically regarding weights and constipation status. For one resident, the weight recorded in the MDS did not match the most current weight documented in the resident's weight record during the look-back period. Similarly, another resident's MDS weight entry was inconsistent with the actual weight recorded in the facility's records. In both cases, staff interviews confirmed that the weights entered into the MDS were inaccurate and should have reflected the most recent documented weights. Additionally, the facility did not accurately code constipation for a resident who had only two bowel movements during the seven-day look-back period, as defined by the RAI manual. The staff responsible for coding relied on the presence of hard stools rather than the frequency of bowel movements, resulting in the omission of constipation in the MDS assessment. Interviews with staff confirmed that the MDS should have indicated constipation based on the documented bowel movement frequency.
Failure to Accurately Complete PASARR Forms and Refer for Level II Evaluation
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASARR) forms were completed accurately and that timely referrals for Level II PASARR evaluations were made for residents with diagnoses of serious mental illness (SMI) or related conditions. Specifically, for three residents reviewed, there were discrepancies between the residents' documented diagnoses and the information recorded on their Level I PASARR forms. For one resident with major depressive disorder and anxiety disorder, the Level I PASARR indicated these diagnoses but did not trigger a Level II evaluation referral as required. Another resident with a diagnosis of depression had a Level I PASARR that did not mark depression in the SMI section, and no Level II referral was made. A third resident with anxiety had this diagnosis marked on the PASARR, but again, no Level II referral was indicated. Interviews with facility staff, including the Social Services Associate, Director of Nursing Services, and Administrator, confirmed that the PASARR forms were not completed in accordance with facility policy and that required referrals for Level II evaluations were not made when indicated by the residents' diagnoses. The staff acknowledged the inaccuracies and omissions in the PASARR process, which resulted in the failure to identify and refer residents with SMI or related conditions for further evaluation as required by regulation.
Missed Weekly Skin Checks for Resident with Fragile Skin
Penalty
Summary
Facility staff failed to provide resident-centered care and treatment in accordance with professional standards of practice by not completing scheduled weekly skin care evaluations for one resident with fragile skin, as required by the resident's care plan and facility policy. The care plan, revised in November 2024, specified weekly skin checks due to the resident's propensity for bruising and skin tears, and the Treatment Administration Record (TAR) showed standing orders for these checks. However, documentation revealed that on two separate occasions, the weekly skin checks were not performed, with staff noting the resident was sleeping as the reason for omission. Interviews with facility staff, including a Registered Nurse, Resident Care Manager, and Director of Nursing, confirmed that the expectation was for weekly skin checks to be completed as per the care plan. The staff acknowledged that the checks were missed and that the nurse should have either attempted the check at another time or communicated the need to the next shift. The lack of documentation and failure to perform the required skin assessments constituted a deviation from both facility policy and the resident's individualized care plan.
Failure to Monitor and Respond to Significant Weight Loss
Penalty
Summary
The facility failed to monitor and respond to significant weight loss for a resident with dementia who was at risk for altered nutritional status and poor appetite. The resident's care plan required that a nutritional supplement be offered if less than 50% of a meal was consumed, and that the Registered Dietitian (RD) monitor weights and oral intake. Despite these interventions, the resident experienced a weight loss of 12.93% over less than two months, with documented meal consumption often below 25%. Review of records and staff interviews revealed that significant weight losses were recorded on two occasions, but there was no documentation that the provider, RD, or Speech Language Pathologist were notified as required by facility policy. Staff interviews confirmed that the expected notifications and documentation did not occur, and the RD was unaware of the resident's weight loss. The deficiency was identified through observation, record review, and staff interviews, showing a lack of adherence to the facility's own policy for monitoring and responding to significant weight changes.
Failure to Monitor and Document Insulin Parameters and Adverse Effects
Penalty
Summary
The facility failed to ensure adequate monitoring and documentation of adverse side effects and parameters for insulin administration for one resident receiving insulin therapy. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed that there were no documented orders or ongoing monitoring for signs and symptoms of hypoglycemia or hyperglycemia, despite the resident receiving scheduled doses of insulin Glargine and Humalog. The resident's care plan included interventions to monitor for symptoms of both hypoglycemia and hyperglycemia, but this was not reflected in the MAR or TAR, and staff interviews confirmed that there was no documentation of such monitoring. Additionally, the insulin orders for the resident did not include specific parameters for when to hold the medication or notify the provider based on blood glucose levels. Staff interviews, including those with the Resident Care Manager and Director of Nursing Services, confirmed that they expected such parameters to be present and that the lack of these parameters and monitoring was not in accordance with facility policy. The absence of documented monitoring and clear parameters for insulin administration constituted a failure to comply with requirements for safe medication management.
Failure to Document Education on Influenza Vaccine Risks and Benefits
Penalty
Summary
The facility failed to ensure that a resident received education regarding the potential risks and benefits when being offered the influenza vaccine. According to the facility's own policy, residents or their legal representatives must be provided with information and education about the benefits and potential side effects of the influenza vaccine prior to administration, and this education must be documented in the resident's medical record. For one resident, documentation showed that the flu shot was administered per the resident's direction, but there was no record in either the electronic or paper clinical record that the required education on risks and benefits was provided. Interviews with staff confirmed that the expectation was to provide and document this education, typically using a Vaccine Information Statement (VIS). However, the Infection Preventionist was unable to locate documentation that the education was given to the resident in question, and the Director of Nursing confirmed that such documentation should have been present. This lack of documentation indicated noncompliance with both facility policy and regulatory requirements.
Failure to Secure and Inspect Bed Positioning Devices
Penalty
Summary
The facility failed to ensure that bed rails, used as positioning devices, were properly secured and regularly checked for safety for one resident. Multiple observations over several days revealed that the resident's left side positioning device was loose and able to wiggle. The resident, who had diagnoses including Parkinson's disease, hemiplegia, and dementia, reported using the devices to assist with turning in bed and confirmed that the left device was loose. Staff interviews confirmed that the device was not secure and should have been, and that the process for addressing such issues involved submitting a work order and notifying management. Review of facility policies and documentation showed that while bed positioning devices were expected to be checked during weekly room rounds, the room rounds form did not specifically list these devices for inspection. Instead, checks were documented under general categories such as "Is the room in good repair" and "Furniture in good repair." The Director of Facilities stated that bed positioning devices were not included in routine maintenance checks, and the Administrator clarified that managers were expected to check these devices as part of the bed during room rounds. However, the loose device was only identified when a work order was submitted, indicating a lack of specific, documented inspection for bed positioning devices.
Failure to Supervise and Assess Residents at Risk for Elopement and Falls
Penalty
Summary
The facility failed to provide adequate supervision and accurate assessment for residents at risk of elopement and falls, resulting in a significant incident where a resident exited the facility unsupervised and sustained a serious injury. The resident, who had a history of adjustment disorder, insomnia, depression, moderate dementia, repeated falls, anxiety disorder, and unsteadiness, was assessed as being at risk for both elopement and falls. Despite this, the resident did not have an elopement care plan in place, and staff failed to implement or escalate interventions after the resident was previously found outside the facility near exit doors. Documentation indicated that staff were aware of the resident's wandering and exit-seeking behaviors, but communication breakdowns and lack of timely review of progress notes led to missed opportunities for intervention. On the night of the incident, the resident was found outside the facility by a bystander, having fallen from their wheelchair and sustaining a right elbow fracture that required hospital admission. Staff interviews revealed that the resident was able to self-propel in a wheelchair and had previously been redirected from exit doors, but no effective measures such as a wanderguard or increased supervision were put in place prior to the elopement. The door used by the resident was not alarmed unless a wanderguard was present, and the resident did not have one at the time. Staff responsible for reviewing progress notes and implementing interventions did not act on documented concerns, and the resident's risk was not properly communicated or addressed in care planning. Further review of other residents at risk for elopement revealed similar deficiencies in assessment accuracy, identification in the facility's elopement risk book, and monitoring interventions. Several residents with multiple diagnoses of dementia or mental illness had their elopement risk scores calculated incorrectly, resulting in under-identification of risk. Additionally, residents with documented need for wanderguards did not have corresponding physician orders for monitoring placement and function, and staff were often unaware of which residents had these devices. The facility's failure to follow its own policies for assessment, care planning, and supervision placed multiple residents at risk for elopement, falls, and injury.
Failure to Develop and Implement Comprehensive Elopement Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents identified as being at risk for elopement. Multiple residents, as determined by their Elopement Risk Evaluations, were found to be at risk, yet their care plans either lacked appropriate interventions or were not initiated in a timely manner. For example, one resident with a high elopement risk score had a care plan that included the use of a WanderGuard device, but there were no corresponding physician orders to monitor the device's placement and function until after the survey date. Staff interviews revealed a lack of awareness regarding which residents were at risk and whether interventions such as WanderGuard were in place or being monitored as required by facility policy. Other residents who were identified as at risk for elopement did not have any elopement care plans in place at the time of review, despite their risk status being documented. Staff members, including nursing assistants, LPNs, and RNs, consistently stated that residents at risk for elopement should have individualized care plans, yet these were missing or delayed for several residents. In some cases, care plans were only initiated after the survey process had begun, indicating a lapse in timely care planning and implementation. Facility policies required individualized, interdisciplinary care plans for residents at risk of elopement, as well as specific monitoring protocols for devices like WanderGuard. However, the review of records and staff interviews demonstrated that these policies were not consistently followed. The lack of timely and comprehensive care planning for residents at risk of elopement resulted in unmet care needs and the potential for negative outcomes, as staff were not always aware of residents' risk status or the interventions required to ensure their safety.
Failure to Document Narcotic Administration
Penalty
Summary
The facility failed to ensure proper documentation of narcotic medications for a resident, leading to a deficiency in medication management. The facility's policy required that the administration of medications be recorded in the resident's medical record, including the date, time, dosage, route of administration, and the signature and title of the person administering the drug. However, the Medication Administration Record (MAR) for a resident showed no documentation of oxycodone administration on two specific dates, despite evidence from the narcotic book indicating that doses were taken out for the resident on those days. Interviews with staff revealed that the nurses did not document the administration of oxycodone in the MAR as expected. Staff members acknowledged the oversight, with one nurse admitting they were probably busy and failed to chart the medication. The Director of Nursing also confirmed that the medication should have been documented in the MAR. This lack of documentation placed the resident at risk for uncontrolled pain and medication errors, as the facility did not adhere to its own medication administration policy.
Failure to Protect Resident from Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect a resident from the misappropriation of controlled medications, specifically morphine, which was intended for pain management. The facility's policy required nursing staff to count controlled drugs at the end of each shift, with both the incoming and outgoing nurses verifying and signing off on the count. However, discrepancies in the morphine count for a resident on hospice care were reported multiple times, indicating potential misappropriation. The morphine was found to be at incorrect levels, and in some instances, the medication appeared altered, with a different color and odor. The investigation revealed that a new employee, an LPN, was suspected of poor nursing practices, including leaving keys unattended and being difficult to locate during shifts. Despite these issues, the facility's Director of Nursing Services (DNS) did not immediately notify the State Agency, resident representatives, or the police about the discrepancies. The DNS assumed that discrepancies were expected with liquid medications and did not thoroughly investigate the initial reports of morphine diversion. Interviews with staff indicated that the discrepancies were noticed but not always reported to management. One staff member admitted to not reporting a discrepancy, which was a mistake. The facility's administrator expected staff to follow policies to protect residents from misappropriation, but the failure to act promptly and investigate thoroughly led to the deficiency. The lack of timely communication and investigation potentially contributed to the ongoing misappropriation of medications, affecting the resident's care and quality of life.
Failure to Timely Report Medication Misappropriation
Penalty
Summary
The facility failed to timely report allegations of misappropriation of controlled medication to the State Agency within the required timeframe for one resident. The facility's policy required that any discrepancies in narcotic medication counts be reported to the Director of Nursing Services (DNS) or designee. However, despite noticing discrepancies in the morphine count for a resident on multiple occasions, the staff did not report these discrepancies to the State Agency until several days later. This delay in reporting placed the resident at risk for potential unidentified abuse and lack of protection from misappropriation. The report details that on January 11, 2025, a registered nurse (RN) identified a discrepancy in the morphine count for a resident, finding less morphine than expected. The nurse reported this to the DNS, who instructed the nurse to measure the amount with another nurse and correct the narcotic ledger. Despite further discrepancies being noted on January 12 and January 13, 2025, the DNS did not report these to the State Agency, believing the discrepancies were expected with liquid medications. It was not until January 17, 2025, that the State Agency was notified of the allegations. Interviews with staff revealed that the DNS was aware of the discrepancies but did not consider them reportable. Additionally, the facility's investigative report indicated that a new employee was suspected of poor nursing practices, which may have contributed to the discrepancies. The failure to report these discrepancies in a timely manner was a violation of the facility's policy and federal and state law, as it delayed the investigation and potential intervention to protect the resident from misappropriation.
Failure to Investigate Medication Misappropriation
Penalty
Summary
The facility failed to timely initiate and thoroughly investigate an allegation of misappropriation of controlled medication for a resident on hospice care. The resident had an order for morphine concentrate oral solution to be administered three times a day for pain. Discrepancies in the morphine count were first reported by a registered nurse, who noticed that the expected amount of morphine did not match the actual amount available. Despite reporting these discrepancies to the Director of Nursing Services, the allegations were not promptly investigated, and the staff involved continued to work without further inquiry. Further discrepancies were noted by other staff members, including differences in the color and odor of the morphine bottles for multiple residents. These inconsistencies were linked to a new employee, an LPN, who had been reported for poor nursing practices, such as leaving keys unattended and being frequently absent during shifts. Despite these reports, the facility did not take immediate action to investigate or address the potential medication diversion, and the staff member in question remained on the schedule. Interviews with staff and collateral contacts revealed a lack of communication and follow-up regarding the reported discrepancies. Staff members who reported the issues were not contacted for further investigation, and the facility failed to notify the state agency, resident representatives, or law enforcement in a timely manner. The failure to investigate these allegations thoroughly and promptly placed the resident at risk for pain, ongoing misappropriation, and potential abuse.
Failure to Perform Proper Hand Hygiene in Kitchen
Penalty
Summary
The facility failed to ensure proper hand hygiene practices in the Fireside Grill Skilled Kitchen, as observed during a survey. Staff W, a cook, was seen changing gloves multiple times without performing hand hygiene in between. Specifically, Staff W removed used gloves and put on clean ones without washing hands, both before and after handling food items with utensils. This was observed on two separate occasions within a short time frame. Staff U, who was training Staff W, acknowledged that the correct procedure was to wash hands before and after glove use, as per their food training. Both the Director of Food and Beverage and the Registered Dietician confirmed that the expectation was for all kitchen staff to follow proper hand hygiene practices. The facility's policy and training materials also emphasized the importance of hand hygiene to prevent contamination and the spread of infection.
Expired Medication and Improper Labeling
Penalty
Summary
The facility failed to discard expired medication and properly label an open vial of Tubersol. During an observation and interview, it was found that the Cedar Medication Cart contained a bottle of Levothyroxine with an expiration date of 12/16/2023. Staff M, an LPN, acknowledged that the medication was expired and should have been disposed of properly. This indicates a failure to adhere to the facility's policy on the storage of medications, which mandates that expired drugs should be returned to the dispensing pharmacy or destroyed. Additionally, a joint observation and interview with the Director of Nursing revealed that the Cedar Medication Storage Refrigerator contained an opened and undated multi-dose vial of Tubersol. Staff B confirmed that the vial should have been labeled with an open date and that all expired medications should be discarded according to the facility's policy. These lapses in medication management placed residents at risk of receiving expired or compromised medications.
Infection Control Deficiencies in Hand Hygiene, Equipment Disinfection, and Water Management
Penalty
Summary
The facility failed to ensure proper hand hygiene practices and the correct use of gloves during soiled linen collection by a janitor, identified as Staff Z. Staff Z was observed collecting soiled linens from various rooms and changing gloves without performing hand hygiene in between glove changes. When questioned, Staff Z admitted to not performing hand hygiene due to the unavailability of hand sanitizer in the hallway, despite a hand sanitizer being present in the entryway of a nearby room. Staff Z also stated they were not instructed to perform hand hygiene between glove changes, which is contrary to the facility's policy on hand hygiene revised in November 2017. Additionally, the facility failed to properly disinfect medical equipment between resident uses. Staff AA, a CNA, was observed taking vital signs of two residents consecutively without sanitizing the equipment in between. Similarly, Staff J and Staff K, both CNAs, were observed using a sit-to-stand transfer lift for different residents without disinfecting the equipment before and after each use. Both staff members acknowledged that their practice was to sanitize the equipment before and after use but failed to do so in these instances. The Director of Nursing confirmed that staff were trained in proper hand hygiene and equipment disinfection but did not adhere to these practices. The facility also failed to ensure that its water management program included a flow diagram assessing the potential growth of Legionella or other waterborne pathogens. The facility's Water Management Plan, dated November 2023, lacked a flow diagram of the building water systems, which is a requirement based on nationally accepted standards. The Facilities Director and the Administrator acknowledged the absence of the flow diagram and stated that the water management program should be updated to include it.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to provide care and services in a manner that maintained and promoted dignity while assisting with meals for Resident 16. Resident 16, who has Alzheimer's and is dependent on staff for eating, was observed attempting to eat their lunch unsuccessfully. Staff R, a Registered Nurse, was seen standing over Resident 16 while assisting with the meal, rather than being seated and at eye level as expected. Staff R stated there was no chair in the room and that they were busy on the floor, indicating a preference to either sit or stand based on their comfort. The care plan for Resident 16 required one-on-one eating assistance at every meal, which was not properly followed. The Director of Nursing confirmed that staff are expected to be seated and at eye level when assisting residents with meals.
Failure to Log and Investigate Missing Item
Penalty
Summary
The facility failed to ensure that a missing item was logged and investigated for one of the residents, specifically Resident 23. The resident reported a missing electric toothbrush, and their representative informed the facility about it. Despite this, the grievance was not logged in the facility's grievance log from December 2023 through April 2024. Interviews with staff revealed that the appropriate grievance form was not filled out, and the incident was not properly investigated or documented as per the facility's policy. The Social Services Associate and the Administrator both confirmed that no grievance report was filed for the missing item, even though it was listed in the resident's inventory list. Further investigation showed that the electric toothbrush might have been accidentally thrown away by a privately hired caregiver, but this information was not formally logged or investigated. The Director of Nursing and the Administrator were unaware of the missing item until the survey. The failure to log and investigate the missing item placed Resident 23 at risk for a decreased sense of security and a diminished quality of life, as the facility did not follow its own policy for handling grievances and missing items.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure residents were free from physical abuse, as evidenced by incidents involving three residents. Resident 37, who had severe cognitive impairment, was involved in two altercations. The first incident occurred when Resident 4, also with severe cognitive impairment, dumped cold water on Resident 37, leading to a physical confrontation where both residents ended up hitting each other. The second incident involved Resident 33, who had moderate cognitive impairment, and was slapped by Resident 37 after a verbal altercation. Both incidents were witnessed by staff members who intervened to separate the residents and assessed them for injuries, finding none in both cases. The facility's incident logs and investigation reports detailed these events, showing that the altercations took place in the Great Room, a common area for residents. Staff members provided statements confirming their observations and actions during the incidents. Despite the interventions, the facility's administration acknowledged the incidents but stated that they could not have predicted or prevented them. The facility's policy on abuse prevention, which was revised in September 2019, mandates that residents be protected from abuse, neglect, and harm. However, the incidents involving Residents 37, 33, and 4 indicate a failure to uphold this policy, as the residents experienced physical confrontations that were not adequately prevented or foreseen by the facility's staff and administration.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure that allegations of abuse were reported to the State Agency as required for one resident. Specifically, Resident 30, who was admitted to the facility, experienced increasing verbal abuse from their roommate. Despite the resident's complaints and the documentation by Staff P, a Licensed Practical Nurse, the incident was not logged in the facility's incident log nor reported to the State Agency as mandated by the facility's policy. Staff P acknowledged discussing the situation with Staff S, the Resident Care Manager, but did not escalate the matter to the Administrator immediately as required. During interviews, Staff B, the Director of Nursing, confirmed that the incident should have been reported to the State Agency within the specified time frame and logged in the incident log. Staff B admitted to seeing the documentation of verbal abuse but did not interpret it as an abuse allegation. The Administrator also confirmed that the abuse allegation should have been reported and investigated. This oversight placed Resident 30 at risk for potential unidentified abuse and lack of protection from abuse.
Failure to Transmit Resident Assessment Data Timely
Penalty
Summary
The facility failed to transmit resident assessment data to the Centers for Medicare & Medicaid Services within the required timeframe for one resident, identified as Resident 5. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, discharge Minimum Data Set (MDS) must be completed no later than 14 days after the Assessment Reference Date (ARD) and submitted within 14 days of the MDS completion date. Resident 5's discharge MDS with an ARD of 12/29/2023 was not completed or submitted and was 83 days late. During an interview and joint record review, the MDS Nurse acknowledged the oversight and admitted to missing the completion and submission of the discharge MDS. The Director of Nursing also confirmed that the MDS should have been completed and transmitted in a timely manner.
Inaccurate Medication Coding in MDS Assessment
Penalty
Summary
The facility failed to accurately assess a resident's medication regimen, specifically for Resident 29, during the Minimum Data Set (MDS) assessment. The significant change of status MDS with an Assessment Reference Date (ARD) of 02/08/2024 incorrectly marked Resident 29 for anticoagulant medication instead of antiplatelet medication. A review of the February 2024 Medication Administration Record (MAR) showed that Resident 29 received Brillanta, an antiplatelet medication, twice a day during the look-back period, but did not have an order for an anticoagulant medication. This discrepancy was identified during an interview and joint record review with the MDS Nurse, who acknowledged the error and stated that the MDS should have been marked for antiplatelet medication instead of anticoagulant medication. The Director of Nursing (DON) confirmed that the expectation was for the MDS to be completed accurately. The failure to correctly code the medication placed Resident 29 at risk for unidentified or unmet care needs and a diminished quality of life. The report references the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, which provides coding instructions for high-risk drug class medications based on their pharmacological classification. The facility's oversight in following these guidelines led to the inaccurate assessment of Resident 29's medication regimen.
Failure to Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to revise comprehensive care plans for three residents, leading to unmet care needs and a diminished quality of life. Resident 11, who was admitted on [DATE], used oxygen at night, but their care plan did not include oxygen use despite orders for continuous oxygen therapy and weekly tubing changes. Staff members acknowledged that the care plan should have been updated to reflect this need, but it was not done in a timely manner. Resident 9, admitted on [DATE], had a stage three pressure ulcer and a treatment plan for wound care. However, the resident frequently refused the sacrum wound treatment, and these refusals were documented in the Treatment Administration Record (TAR). Despite this, the care plan did not include any alternatives or interventions to address the refusals, and staff members were unaware of the consistent refusals, indicating a lack of communication and care plan updates. Resident 20, admitted on [DATE], was observed to be in bed continuously over several days and had refused to get out of bed multiple times due to fear after a fall. These refusals were documented in the progress notes but were not reflected in the comprehensive care plan. Staff members confirmed that the care plan should have been revised to include these refusals, but it was not done, leading to a failure in addressing the resident's needs adequately.
Failure to Follow Insulin and Medication Orders
Penalty
Summary
The facility failed to follow insulin orders and clarify medication orders to ensure parameters were in place for two residents, leading to potential medication errors. For Resident 11, who was admitted with a diagnosis of atrial fibrillation, the facility did not have hold parameters for Digoxin and Metoprolol Succinate. Despite the pharmacy consultation report recommending holding Digoxin if the heart rate was below 55, Resident 11 received both medications on two occasions when their pulse was below this threshold. Staff interviews confirmed that the parameters were not in place and should have been clarified with the physician. For Resident 1, the facility failed to adhere to the prescribed insulin sliding scale. Resident 1 had a physician's order for Insulin Aspart to be administered based on specific blood sugar levels. However, on one occasion, a former Director of Nursing Services administered three units of Insulin Aspart when Resident 1's blood sugar level was 134, which was below the sliding scale range. This action was confirmed during a joint record review and interview with the current Director of Nursing, who acknowledged the error.
Failure to Monitor Anticoagulant Therapy and Follow Insulin Sliding Scale Orders
Penalty
Summary
The facility failed to monitor for signs and symptoms of bruises or bleeding on a resident receiving anticoagulant therapy and failed to follow a physician's order related to insulin sliding scale administration. Resident 41, who was admitted with diagnoses including atrial fibrillation and multiple fractures, was prescribed Enoxaparin for Deep Vein Thrombosis prophylaxis. Despite the physician's order to monitor for bruising and bleeding, there was no documentation of such monitoring in the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR). Observations revealed large bruises on the resident's abdomen, which were not documented in the nursing progress notes or weekly skin assessments. Staff interviews confirmed the lack of monitoring and documentation for anticoagulation therapy as required by the facility's policy. Resident 1, who was prescribed Insulin Aspart with a specific sliding scale for blood sugar levels, had a blood sugar level of 134, which was below the sliding scale range. However, the former Director of Nursing Services administered three units of Insulin Aspart, contrary to the physician's order. This discrepancy was confirmed during a joint record review and interview with the current Director of Nursing. The facility's failure to adhere to the physician's orders for insulin administration and to monitor for anticoagulation therapy placed the residents at risk for adverse consequences and complications.
Failure to Properly Maintain and Store Oxygen Tubing
Penalty
Summary
The facility failed to maintain, label/date, and properly store oxygen nasal cannula/tubing for two residents, leading to potential risks of respiratory infections and related complications. Resident 11's oxygen tubing was observed multiple times to be unlabeled and not stored in a bag when not in use. On one occasion, the nasal cannula was found on the ground, and the resident stepped on it, expressing reluctance to use it afterward. Staff L confirmed that the tubing should have been dated and stored properly, as per facility policy. Similarly, Resident 2's oxygen tubing was also found to be unlabeled during an observation. Staff L acknowledged that the tubing should have been labeled and dated. The Director of Nursing confirmed that the facility's policy required oxygen tubing to be changed weekly, labeled, and stored in a bag when not in use. These observations and interviews indicate a failure to adhere to the facility's oxygen administration policy, thereby compromising the residents' respiratory care.
Failure to Follow Up on Monthly Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure monthly pharmacy recommendations were followed up on by the physician for one resident, leading to a deficiency. The facility's policy required the physician or other responsible parties to act upon the recommendations contained in the Medication Regimen Review (MRR) or provide an explanation if rejected. However, for Resident 40, the pharmacy Consultation Report dated 03/06/2024 did not show a response from the physician and was not signed by the physician. During a joint record review and interview with the Director of Nursing (DON), it was confirmed that the pharmacy recommendation report had no response from the physician, which was against the facility's expectations and policy.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective Antibiotic Stewardship Program by not implementing antibiotic use protocols for two residents and not utilizing standardized tools and criteria. Specifically, the facility did not use the Loeb Minimum Criteria or the SBAR toolkit to ensure appropriate antibiotic prescribing. This failure was evident in the cases of two residents who were prescribed antibiotics without proper documentation and follow-up. Resident 43 had a urine analysis completed, but the organism column was left blank, and the resident received Macrobid without an updated urine culture. Similarly, Resident 38 had a urine analysis with results pending, received Levofloxacin, but had no resolved date documented. The facility's antibiotic stewardship line listing was incomplete and not updated as expected by the Director of Nursing/Infection Preventionist. Interviews with staff revealed that they did not use the SBAR tool or Loeb Minimum Criteria, relying instead on the McGeer Criteria. The Director of Nursing/Infection Preventionist acknowledged that the antibiotic stewardship line listing was not properly maintained and that mapping for the first quarter of 2024 was incomplete. This lack of adherence to the facility's own policy and standardized criteria placed residents at risk for potential adverse outcomes associated with inappropriate and unnecessary antibiotic use.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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