Cottesmore Of Life Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Gig Harbor, Washington.
- Location
- 2909 14th Avenue Northwest, Gig Harbor, Washington 98335
- CMS Provider Number
- 505499
- Inspections on file
- 28
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Cottesmore Of Life Care during CMS and state inspections, most recent first.
Surveyors found that the facility failed to follow its fall management protocol for multiple high-risk residents, including not maintaining beds in low position, not ensuring call lights and assistive devices were within reach, and not updating at least one fall risk assessment as required. Several residents with conditions such as dementia, hemiplegia, muscle weakness, repeated falls, and epilepsy were observed in high (waist-level) beds, and some reported that staff routinely left beds elevated after care despite their fear of falling. One resident with a history of brain hemorrhage and prior falls, assessed as high fall risk, fell from bed shortly after admission and was found on the floor with seizure activity, while another resident with repeated falls had a care plan for call light within reach but was observed with the call light hanging behind the bed. Staff, including CNAs, an LPN, the RCM/RN, and the DON, acknowledged that high fall risk residents’ beds should be low and call lights within reach, yet observations and records showed these practices were not consistently implemented.
The facility failed to maintain sanitary conditions in the kitchen and resident refrigerators, with missing temperature logs, undated food items, and improper hygiene practices by staff. Observations showed cooked meals left without temperature control and unlabeled food in storage. Interviews confirmed these practices did not meet facility expectations.
The facility failed to provide written notification to the SLTCO and residents or their representatives for hospital transfers of four residents. Interviews and record reviews revealed that required notifications were not documented, placing residents at risk of inappropriate discharge and lack of advocacy. Staff acknowledged the oversight, with the Social Services Director admitting that SLTCO notifications had not been completed in recent months.
The facility failed to provide written bed-hold notices to residents or their representatives during hospital transfers, affecting three residents with various medical conditions. The Director of Nursing Services acknowledged the oversight, and the Social Service Director confirmed the nursing department's responsibility for this documentation.
The facility failed to complete accurate PASARR assessments for three residents, leading to a lack of necessary Level II evaluations. One resident with mental health conditions did not receive a timely Level II evaluation due to an incorrect PASARR Level I assessment. Another resident's PASARR Level I was not transmitted, resulting in no Level II evaluation, and a third resident was not referred for a Level II evaluation despite a change in condition. Staff interviews confirmed these deficiencies.
The facility failed to update care plans and conduct timely care conferences for three residents, leading to discrepancies in care. A resident's care plan inaccurately indicated a PICC line and lacked detailed fluid restriction instructions. Two other residents did not have care conferences after their quarterly assessments, as confirmed by staff.
The facility failed to provide adequate care for residents with CHF, edema, and bowel management needs, leading to deficiencies. Two residents with CHF did not receive proper weight monitoring or provider notification of changes, and their recliners were unplugged, preventing leg elevation. Additionally, four residents did not receive timely bowel management interventions, and one resident lacked a hospice care plan. Another resident did not receive a speech evaluation upon readmission, despite hospital orders. These failures highlight the facility's lack of adherence to care protocols and documentation.
The facility failed to securely store medications and biologicals for three residents, as required by policy. A resident with multiple diagnoses had unsecured medications in their room over several days. Another resident with asthma and lung cancer had an inhaler unsecured, and a third resident with chronic kidney disease had a topical pain patch unsecured. The DON acknowledged the expectation for secure storage, indicating a policy adherence failure.
A facility failed to periodically review a resident's advanced directive (AD) as required. The resident, who had heart and kidney failure, received information about establishing an AD but did not have it reviewed until nearly a year later. The Social Services Director and Regional President confirmed the oversight, despite the facility's policy to review ADs quarterly.
The facility failed to ensure the safety of personal items for a resident with dementia, who lost their glasses and was unable to read without them. No grievance was logged for the missing glasses, contrary to protocol. Additionally, another resident's room was not maintained in a homelike manner, as a plastic bag was tied to a light fixture pull cord, which was not a cleanable surface.
The facility failed to provide appropriate pressure ulcer care for two residents. One resident continued outdated treatment due to unimplemented new orders, while another developed new pressure injuries that were not documented or addressed. The lack of communication and documentation led to deficiencies in care.
The facility failed to provide adequate hydration for a resident at risk of dehydration and did not properly monitor or document fluid intake for another resident on fluid restriction due to heart and kidney failure. Observations showed a lack of available fluids for one resident, while documentation for the other resident's fluid intake was incomplete, leading to inadequate monitoring.
The facility failed to manage oxygen therapy for two residents, one with CHF and another with COPD, by not following provider orders or initiating care plans. Observations showed discrepancies in oxygen administration, with one resident receiving less than the ordered amount and another receiving oxygen without any documented order. The DON acknowledged these deficiencies.
A resident with chronic pain and a provider's order for MS Contin did not receive the medication from November 2024 through January 2025, despite frequently reporting high pain levels. The facility failed to adhere to the care plan and provider's order, resulting in unmet needs and potential delays in treatment.
A facility failed to secure a contract with a dialysis provider for a resident with heart and kidney failure, who required dialysis three times a week. Despite having a provider order detailing the dialysis schedule and location, the facility's Regional President confirmed the absence of a necessary contract to ensure proper care coordination.
The facility failed to implement non-pharmacological interventions before administering as-needed pain medication to two residents, leading to unnecessary medication use. One resident with chronic pain received Roxicodone multiple times without documented non-pharmacological attempts, while another resident with infections and diabetes received oxycodone without such documentation. Staff interviews confirmed the lack of adherence to the facility's pain management policy.
A resident with multiple health issues, including dysphagia and broken teeth, did not receive necessary dental care after admission to the facility. Despite a provider's order for dental care as needed and an MDS assessment indicating dental issues, no referral was made. Interviews with staff revealed an expectation for a referral that was not fulfilled, placing the resident at risk of difficulty eating and reduced quality of life.
A resident with malnutrition, diabetes, and depression experienced delays in receiving necessary dental services, including new dentures, despite expressing discomfort and the need for dental care. The facility's records showed missed and rescheduled dental appointments, and a denture request form lacked a dentist's signature. Staff acknowledged the delay in addressing the resident's dental issues.
The facility failed to maintain accurate medical records for two residents, leading to potential risks. A resident was incorrectly documented as being on droplet precautions for RSV, which had resolved, while another was inaccurately noted as needing isolation precautions for RSV and MRSA. Staff confirmed these errors were due to incorrect documentation practices.
The facility failed to meet professional standards for two residents with PICC lines, leading to potential medical complications. Required measurements and proper securement were not documented or performed, resulting in one resident being hospitalized with septic shock, acute renal failure, and pneumonia.
Failure to Follow Fall Management Protocol for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents, specifically by not following its own fall management protocol. The facility’s policy required completion of fall risk assessments on admission, readmission, quarterly, with changes in condition, and after any fall, and referenced Lippincott procedures that directed staff to keep beds in the lowest position and call lights within reach. Surveyors found multiple instances where residents identified as high fall risk had beds left in a high (waist-level) position and call lights not within reach, and one resident had an outdated fall risk assessment. Staff interviews confirmed that the expectation was for high fall risk residents to have beds in low position and call lights within reach, and that these practices were considered standard of care. One resident with a history of subdural and subarachnoid hemorrhage, prior falls, muscle weakness, difficulty walking, and restlessness/agitation was admitted to the facility, assessed with a high fall risk score of 20, and care planned for bed in lowest position, use of a mechanical lift, appropriate footwear, and PT evaluation. Progress notes documented that this resident arrived confused and, later that same day, was found on the floor next to the bed with their head against the wall and legs tangled in bed sheets, experiencing seizure activity after a fall from bed. The risk management document noted the bed was in low position and the resident was agitated and confused, and the resident was sent back to the hospital for evaluation and treatment. Another resident with altered mental status, muscle weakness, repeated falls, and spinal stenosis had multiple documented falls, including rolling out of bed and being found on a floor mat with fecal matter on their face and floor. This resident had a high fall risk score of 20 and was care planned for call light within reach and other fall interventions, including bilateral mobility rails and floor mats. However, observation showed the bed placed against the wall with the call light hanging down behind the bed and not within reach, despite the resident being on the facility’s falling star protocol as indicated by a star on the door. A resident with cognitive impairment, muscle weakness, repeated falls, and unsteadiness on feet had multiple documented falls while attempting to use a urinal independently, exercising, and sliding from a chair in the dining room. This resident had a high fall risk score of 24 and a care plan requiring the call light and a reacher to be within reach. Observations on two separate days showed the resident sitting in a wheelchair next to a bed placed against the wall, with the call light hanging behind the bed and no reacher within reach, despite a falling star indicator on the door. The resident reported being unable to reach the call light and not knowing where the reacher was. Additional residents with diagnoses including adult failure to thrive, vascular dementia, muscle weakness, difficulty walking, hemiplegia/hemiparesis, repeated falls, unsteadiness on feet, chronic pain, epilepsy, and severe cognitive impairment were all assessed as high fall risk with fall risk scores ranging from 12 to 16. For several of these residents, surveyors observed beds in a high, waist-level position while the residents were in bed. Cognitively intact residents reported that staff left their beds at that height after providing care and one resident stated they feared falling while in bed and preferred the bed to be lower. For one severely cognitively impaired resident with epilepsy and vascular dementia, the most recent fall risk evaluation in the EHR was dated several years earlier and had not been updated quarterly as required by policy. Staff interviews with CNAs, an LPN, the Resident Care Manager/RN, and the DON/RN confirmed that high fall risk residents should have beds in low position, doors open, frequent checks, and call lights within reach, and that these expectations applied to all residents, including those not on the falling star program. The DON stated it was standard practice for all beds to be at sitting level or lower and that call lights should be within reach of all residents. Despite these stated expectations and policies, survey observations and record reviews showed that for multiple high fall risk residents, beds were left in high positions, call lights and assistive devices were not within reach, and at least one resident’s fall risk assessment was not updated per policy, constituting the identified deficiency.
Sanitation and Food Storage Deficiencies in Kitchen and Resident Refrigerators
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and resident refrigerators, leading to potential health risks for residents. Observations revealed missing temperature logs for refrigerators, undated and improperly stored food items, and cooked meals left without temperature control. Additionally, dry storage areas contained unlabeled and open food items. Staff were observed not adhering to hygiene protocols, such as touching garbage cans after hand hygiene and not wearing hairnets properly. Interviews with the Food Service Director and Regional President confirmed that these practices did not meet the facility's expectations. They acknowledged that food should be dated and sealed once opened, and that proper temperature controls should be maintained. The staff's failure to follow hygiene protocols and the improper storage and labeling of food items were identified as deficiencies that could compromise resident safety.
Failure to Notify SLTCO and Residents of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of the reason for transfer to the hospital to the Office of State Long-Term Care Ombudsman (SLTCO) and/or to the resident or their representative for four residents reviewed for hospitalization and/or discharge. This deficiency was identified through interviews and record reviews, which revealed that the facility did not document the required notifications for Residents 32, 54, 95, and 26. Resident 32, who had diagnoses including heart failure and diabetes, was hospitalized multiple times without SLTCO notification. Similarly, Resident 54, with congestive heart failure and kidney disease, was discharged to the hospital without written notification to the resident or SLTCO. Interviews with facility staff, including the Director of Nursing Services and the Social Services Director, confirmed that the SLTCO notifications were not completed as required. Staff members acknowledged the oversight, with the Social Services Director admitting that SLTCO notifications had not been done in recent months. The Director of Nursing Services also recognized the lack of documentation as unacceptable practice. These failures placed residents at risk of being inappropriately discharged and without access to an advocate who could inform them of their options and rights.
Failure to Provide Bed-Hold Notices
Penalty
Summary
The facility failed to provide written bed-hold notices to residents or their representatives at the time of transfer or discharge to the hospital, as required by regulations. This deficiency was identified for three residents who were reviewed for hospitalization or discharge. Resident 32, who had diagnoses including heart failure, kidney failure, and diabetes, was hospitalized twice, but there was no documentation in the electronic health record (EHR) indicating that a bed-hold was offered during these transfers. Staff B, the Director of Nursing Services, acknowledged that the bed-hold notices were not provided as they should have been. Similarly, Resident 95, who had conditions such as postprocedural hemorrhage and pancreatic cancer, and Resident 26, with diagnoses including cellulitis and atrial fibrillation, were both discharged with the anticipation of return, yet their EHRs lacked documentation of bed-hold notices. Staff F, the Social Service Director, confirmed that the nursing department was responsible for this documentation but could not provide any records of bed-holds for these residents. Staff B reiterated that the absence of bed-hold documentation was not acceptable practice.
Failure to Complete PASARR Assessments
Penalty
Summary
The facility failed to ensure accurate completion of Pre-Admission Screening and Resident Review (PASARR) assessments for three residents, which placed them at risk for unidentified mental health care needs. Resident 29 was admitted with multiple mental health conditions, including bipolar disorder, depression, and PTSD. The PASARR Level I assessment indicated no need for a Level II evaluation due to an exempted hospital discharge, but the resident did not discharge within the designated 30 days, necessitating a correction of the PASARR. Staff interviews confirmed the PASARR was incorrect and needed to be redone to ensure a Level II evaluation by the state evaluator. Resident 49, diagnosed with hemiplegia, dementia, and depression, required a PASARR Level II evaluation as indicated by the Level I assessment. However, the PASARR Level I was not transmitted to the PASARR coordinator, resulting in the absence of a Level II evaluation. Similarly, Resident 40, with diagnoses including dementia and traumatic subarachnoid hemorrhage, was recommended for a PASARR Level II evaluation due to a change in condition, but no documentation of a Level II evaluation was found. Staff interviews revealed that the necessary referrals for Level II evaluations were not completed, failing to meet the facility's expectations.
Failure to Update Care Plans and Conduct Timely Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised after each quarterly assessment for three of four sampled residents, which placed them at risk of not receiving required care. Resident 32, who was admitted with diagnoses including heart failure, kidney failure, and diabetes, had discrepancies in their care plan. The resident was unaware of being on a fluid restriction, despite a provider order for an 1800 ml fluid restriction. Additionally, the care plan inaccurately indicated the presence of a PICC line on the chest, which was not the case, and the care plan lacked detailed instructions on fluid distribution per shift. Resident 50 did not recall attending a care conference, and the records showed that the most recent care conference was held several months prior, with no subsequent conference after the quarterly MDS assessment. Similarly, Resident 22 reported that it had been several months since their last care conference, and the records confirmed that a care conference had not been held following their most recent quarterly MDS assessment. The facility's Social Services Director acknowledged difficulties in maintaining the care conference schedule, resulting in missed conferences for some residents. The Director of Nursing Services and other staff members confirmed that the care plans for these residents did not meet expectations, as they were not updated to reflect current needs and conditions. The lack of timely care conferences and inaccurate care plans could lead to residents not receiving appropriate care, as evidenced by the discrepancies found in Resident 32's care plan and the absence of care conferences for Residents 50 and 22.
Deficiencies in Care and Protocols for Residents
Penalty
Summary
The facility failed to provide adequate care and services consistent with standards of quality care for several residents, leading to multiple deficiencies. For Residents 57 and 71, the facility did not have a protocol for managing congestive heart failure (CHF) or edema, resulting in a lack of daily weight monitoring and failure to notify providers of significant weight gains and changes in condition. Resident 57 experienced increased swelling, redness, and drainage in the lower extremities without proper documentation or provider notification, and the resident's recliner was not functional, preventing leg elevation. Similarly, Resident 71 had swollen, red feet with drainage, and the facility's policy of unplugging recliners due to a previous fall incident prevented the resident from elevating their legs, exacerbating their condition. The facility also failed to implement effective bowel management protocols for Residents 7, 40, 57, and 78. Despite having orders for laxatives to be administered after 72 hours without a bowel movement, the facility did not follow through with these orders, leading to prolonged periods without bowel movements for these residents. Resident 40, for instance, experienced abdominal distention due to constipation, and the facility did not administer the prescribed laxatives in a timely manner. Interviews with staff revealed a lack of adherence to the bowel protocol and a failure to notify providers when the protocol was ineffective. Additionally, the facility did not maintain a comprehensive hospice care plan for Resident 40, as there was no hospice provider Plan of Care in the medical record. Furthermore, Resident 32, who was readmitted to the facility with a diagnosis of dysphagia, did not receive a speech evaluation upon return, despite hospital orders indicating the need for such an assessment. The lack of communication and documentation regarding the resident's dietary needs and the absence of a speech evaluation highlight the facility's failure to ensure appropriate care planning and coordination for residents with complex medical needs.
Failure to Securely Store Medications and Biologicals
Penalty
Summary
The facility failed to ensure that medications and biologicals were securely locked, as required by their policy and professional principles. This deficiency was observed in the cases of three residents. Resident 90, who had multiple diagnoses including a fracture of the right leg and respiratory failure, was found with multiple medications in pill form, inhalers, and nebulizing prescriptions unsecured on their nightstand and sink countertop. Despite being able to make their needs known, the medications remained unsecured over a period of observation from January 7, 2024, to January 8, 2025. Similarly, Resident 64, diagnosed with repeated falls, asthma, and lung cancer, was observed with an inhaler medication unsecured on an over-the-bed table. Resident 9, who had undergone a laminectomy and had chronic kidney disease, was found with a topical pain patch unsecured at their bedside. The Director of Nursing Services acknowledged that the expectation was for medications to be securely stored and locked, indicating a failure to adhere to the facility's storage policy.
Failure to Periodically Review Advanced Directive
Penalty
Summary
The facility failed to periodically review the advanced directive (AD) for Resident 32, who was readmitted with diagnoses including heart failure and kidney failure. The resident was capable of expressing their needs. The electronic health record indicated that Resident 32 received information about establishing an AD on February 26, 2024. However, the Social Services Director (SSD) confirmed that there was no periodic review of the AD until January 8, 2025, despite the facility's policy to review ADs during care conferences. The Regional President also stated that ADs were supposed to be reviewed quarterly, which did not occur in this case.
Deficiencies in Personal Property Safety and Homelike Environment
Penalty
Summary
The facility failed to ensure the safety and security of personal items for Resident 64, who was admitted with dementia and a cognitive communication deficit. Despite having adequate vision with corrective lenses, Resident 64 reported losing their glasses approximately a week before the survey. The facility did not log a grievance for the missing glasses, and interviews with staff revealed that no grievance form was initiated, which was against the facility's protocol. This oversight left Resident 64 unable to read, as their glasses were essential for their vision. Additionally, the facility did not maintain a homelike environment for Resident 50, who was admitted with muscle weakness and depression. Observations showed a plastic garbage bag tied to the metal pull cord of the overbed light fixture, which was not a cleanable surface. Resident 50 stated that a staff member had tied the bag to make the cord more accessible. Staff interviews confirmed that the presence of the bag was inappropriate and not in line with maintaining a clean and homelike environment.
Failure to Implement Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to implement appropriate pressure ulcer care for two residents, leading to deficiencies in their treatment. Resident 78, who had multiple diagnoses including heart disease and stroke, was admitted with a pressure ulcer on the sacrum. Despite having a care plan and orders for wound treatment, the facility did not update the Treatment Administration Records with the new orders from an outside wound provider. This resulted in the resident continuing with outdated treatment, as the Licensed Practical Nurse (LPN) and other staff were unaware of the changes. The Director of Nursing Services expected the new orders to be implemented, but this did not occur. Resident 72, admitted with conditions such as left tibial vein thrombosis and Alzheimer's disease, initially showed no unhealed pressure injuries. However, weekly skin assessments revealed blanchable redness and a black bruise on the heels, which were not properly documented or addressed. Observations showed worsening conditions, with the resident experiencing drainage and discoloration on the left leg and ankle. Despite these signs, there was no documentation of provider notification or wound assessment for the new pressure injuries on the heels. The Director of Nursing Services was not informed of these developments, and no updates were made to the care plan or orders. The lack of proper documentation, communication, and implementation of updated treatment orders for both residents highlights the facility's failure to adhere to professional standards for pressure ulcer care. This oversight placed the residents at risk for worsening conditions and demonstrated a breakdown in the facility's processes for managing pressure injuries.
Failure to Provide Adequate Hydration and Monitor Fluid Restrictions
Penalty
Summary
The facility failed to provide adequate hydration for Resident 40, who was at risk for dehydration due to dementia and a traumatic subarachnoid hemorrhage. Observations over several days showed that Resident 40 had no fluids available at the bedside, despite having dry lips and expressing thirst. Staff interviews revealed that water pitchers were supposed to be provided during rounds, but this was not done for Resident 40, which did not meet the expectations of the Director of Nursing Services. Additionally, the facility failed to monitor and document fluid intake for Resident 32, who was on a fluid restriction due to heart and kidney failure. Despite a provider order specifying a daily fluid limit, documentation in the medication administration record was incomplete, with many entries missing the amount of fluid consumed. Staff interviews indicated a lack of clarity and communication regarding the documentation of fluid intake, leading to inadequate monitoring of Resident 32's fluid restriction, which did not meet the facility's expectations.
Failure to Manage Oxygen Therapy for Two Residents
Penalty
Summary
The facility failed to manage oxygen therapy according to professional standards and the comprehensive person-centered care plan for two residents. Resident 71, diagnosed with congestive heart failure, had a provider order for continuous oxygen at two liters per minute via nasal cannula. However, observations revealed that the oxygen concentrator was running at one liter per minute, and the tubing was not in use, indicating a lack of adherence to the prescribed order. Additionally, there was no care plan initiated for Resident 71's oxygen use, which was acknowledged as a deficiency by the Director of Nursing Services. Resident 72, with multiple diagnoses including COPD and Alzheimer's disease, was observed receiving oxygen therapy without a corresponding care plan or provider order. The resident was seen with oxygen administered at varying rates, yet no documentation supported this treatment. The Registered Nurse confirmed the absence of a provider's order for Resident 72, and the Director of Nursing Services recognized the lack of a care plan and order as not meeting the facility's expectations.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for Resident 29, who was admitted with multiple health conditions including heart and kidney disease, osteoarthritis, and chronic pain. The resident's care plan included a focus on pain management with a goal for the resident to express pain relief. Despite having a provider's order for MS Contin, a narcotic pain medication, to be administered as needed for pain levels between 5-10 on a numeric scale, the medication was not administered from November 2024 through January 2025. Observations and interviews revealed that the resident frequently reported a pain level of 8 out of 10 and expressed that the nursing staff did not administer the prescribed MS Contin. Interviews with staff indicated a lack of adherence to the provider's order for administering MS Contin for breakthrough pain, as documented in the resident's MDS pain assessments. The Director of Nursing Services acknowledged that the medication should have been administered according to the provider's order, especially for breakthrough pain. The failure to administer the medication as ordered resulted in a delay in treatment and unmet needs for Resident 29, potentially affecting their quality of life.
Failure to Secure Dialysis Provider Contract
Penalty
Summary
The facility failed to secure an agreement or contract with a dialysis provider for a resident requiring dialysis services, which was necessary to ensure the coordination and provision of all required care and services. This deficiency was identified for a resident who had been readmitted to the facility with diagnoses including heart failure and kidney failure. The resident, who was capable of communicating their needs, was receiving dialysis treatment three times a week at a specified dialysis center. Despite the provider order indicating the dialysis schedule and location, the facility's Regional President acknowledged the absence of a contract with the dialysis center, which should have been in place to ensure proper care coordination.
Failure to Implement Non-Pharmacological Interventions Before Pain Medication
Penalty
Summary
The facility failed to consistently implement non-pharmacological interventions before administering as-needed pain medication to two residents, leading to the risk of unnecessary medication use. Resident 18, who had multiple diagnoses including chronic pain, was prescribed Roxicodone for pain management. However, the resident received the medication on multiple occasions without any documented attempts of non-pharmacological interventions. The facility's pain management policy required such interventions to be attempted prior to administering narcotics, but this was not adhered to, as confirmed by interviews with staff. Similarly, Resident 398, who had a history of infections and diabetes, was prescribed oxycodone for pain. The medication was administered on several occasions without documentation of non-pharmacological interventions being attempted first. Staff interviews revealed that the process for documenting these interventions was not followed, and the order for Resident 398 was missed. The Director of Nursing Services confirmed the expectation for non-pharmacological interventions to be documented, which was not met in these cases.
Failure to Provide Dental Care for Resident
Penalty
Summary
The facility failed to provide necessary dental services for a resident, identified as Resident 78, who was reviewed for dental care. The resident was admitted with multiple diagnoses, including heart disease, stroke, muscle weakness, dysphagia, and constipation. The Minimum Data Set (MDS) assessment dated November 4, 2024, indicated that the resident had obvious or likely cavities or broken natural teeth and was dependent on staff for activities of daily living. Despite these findings, the resident had not seen a dentist since admission, as confirmed by both observation and interview on January 7, 2025. The resident's care plan, dated November 14, 2024, included interventions for staff to assist with personal hygiene and oral care, yet there was no evidence of a dental referral being made. A provider's order from October 30, 2024, stated that the resident may have dental care as needed, but this was not acted upon. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing Services, revealed that the expectation was for a referral to be made following the MDS assessment, which did not occur. This oversight placed the resident at risk of difficulty eating and a diminished quality of life.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide prompt dental services for Resident 50, who was admitted with conditions including protein-calorie malnutrition, diabetes, and depression. The resident, who was edentulous and had upper dentures, reported that their upper dentures were chipped and caused pain, and they expressed a desire to obtain new lower dentures. Despite these issues being communicated to the staff, the necessary dental services were not provided in a timely manner. The resident's care plan acknowledged their oral health problems, and a dental visit document from September 2024 recommended new upper and lower dentures. However, the facility's records showed that Resident 50 was not included in a scheduled dental visit in December 2024, and a subsequent dental hygiene visit in January 2025 was rescheduled. Additionally, a denture request form lacked the required dentist's signature, although it was signed by a physician. Interviews with facility staff revealed that the resident's denture issues were not addressed promptly, and a referral for dentures should have been obtained sooner. This delay in providing necessary dental care placed the resident at risk for continued dental problems and a diminished quality of life.
Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for two residents, leading to potential risks for their care and quality of life. Resident 398, who was readmitted with conditions including MRSA, was incorrectly documented as being on droplet precautions for RSV, a condition that had already resolved. This error was identified through interviews with staff, who confirmed that the alert note was incorrect and that the resident no longer required such precautions. Similarly, Resident 71, admitted with congestive heart failure, was inaccurately documented as being on droplet and contact precautions for RSV and MRSA, despite no signs indicating the need for such measures. Observations confirmed the absence of isolation precautions, and staff interviews revealed that progress notes were inaccurately copied and pasted without proper updates. These documentation errors were acknowledged by the staff, highlighting a failure to maintain accurate medical records according to professional standards.
Failure to Adhere to PICC Line Management Standards
Penalty
Summary
The facility failed to ensure professional standards were met for two residents with PICC lines, leading to potential medical complications. For Resident 1, the facility did not document the required measurements of the upper arm circumference and the length of the external catheter upon admission and during dressing changes. Additionally, the dressing was not properly secured, and when the PICC line was noted to be coming out, a temporary dressing using gauze was applied, which did not meet the standards of care. This resulted in Resident 1 being sent to the hospital with septic shock, acute renal failure, and pneumonia, with the PICC line likely being the source of infection due to improper dressing and securement practices observed by the hospital staff upon arrival in the emergency department. For Resident 2, the facility also failed to document the necessary measurements of the upper arm circumference and the external catheter length upon admission and during dressing changes. The dressing change was not performed on the scheduled day, and the required measurements were marked as non-applicable in the Treatment Administration Record. Staff interviews confirmed that the expected practice was not followed, and the necessary baseline measurements were not obtained or documented, which is crucial for monitoring PICC line migration and preventing complications. The Director of Nursing Services acknowledged that the facility's policy and standards of care were not adhered to in both cases. The lack of proper documentation, measurement, and securement of PICC lines placed the residents at risk for serious complications, including bloodstream infections. The facility's failure to follow physician orders and professional standards of care for PICC line management was evident in the observations, interviews, and record reviews conducted during the survey.
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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