Crescent Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Yakima, Washington.
- Location
- 505 North 40th Avenue, Yakima, Washington 98908
- CMS Provider Number
- 505085
- Inspections on file
- 33
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Crescent Health Care during CMS and state inspections, most recent first.
A resident with Alzheimer’s dementia, anxiety disorder, osteoarthritis, impaired cognition, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift while a wedge-shaped bed bolster remained in place along the bed edge. The care plan addressed bed placement against the wall for fall prevention but did not include the bolster, and there was no physician order, assessment, care plan entry, or representative consent for its use. During the two-person lift transfer, the sling was already attached when staff raised the resident with the bed at working height; the sling became affected by the bolster, the lower sling loop came off the lift hook, and the resident slid from the sling onto the floor, partially onto the lift leg. The resident sustained a forehead laceration, left ankle injury with fracture, bruising, and pain. Staff later stated the bolster should have been removed or taken down and that the bed height was too high, and leadership acknowledged there were no written policies, documented training, or guidelines for mechanical lift use with bed bolsters.
A resident developed avoidable pressure injuries due to the facility's failure to consistently assess and implement interventions. Despite being at risk, the resident's skin condition was not adequately monitored, leading to pressure injuries on the heels and calf. Observations showed the resident often without prescribed heel protectors, and staff interviews revealed a lack of awareness and communication regarding necessary interventions. The DON acknowledged that required assessments were not completed, contributing to the resident's decreased quality of life.
Two residents experienced a decline in ROM and mobility due to the facility's failure to implement timely restorative therapy services, including the use of braces and splints. One resident developed hand contractures due to delayed therapy initiation, while another did not receive consistent splint application. Staff interviews revealed a lack of awareness and training, as well as staffing issues, contributing to the deficiency.
The facility failed to provide quarterly personal fund statements to three residents, each with varying cognitive and physical impairments. Despite the requirement to send these statements, the facility's administrator admitted that they had not been sent for almost a year, placing residents at risk of not having an accurate accounting of their personal funds.
The facility failed to resolve grievances voiced in Resident Council meetings and did not inform residents about the grievance process. A resident reported broken bathroom equipment, but the issue was not documented or addressed. Additionally, residents were unaware of how to file grievances or who the Grievance Officer was. The facility's informal process relied on department heads to address concerns without proper documentation or follow-up.
The facility failed to conduct accurate PASARR assessments for two residents, leading to a deficiency in care. One resident with depression and severe cognitive impairment and another with anxiety and moderately impaired cognition did not receive required level two evaluations. Staff were unaware of updated regulations and had not received training, contributing to the oversight.
The facility failed to provide trauma-informed care for three residents, including one with PTSD and another with significant personal losses. Care plans lacked trauma assessments and interventions, leaving residents' mental health needs unaddressed. Staff were unaware of recent traumas and did not document or manage triggers effectively.
The facility's kitchen had several maintenance deficiencies, including a broken floor under the oven, dusty appliances, leaking faucets, and improper storage of dry goods under a steam table. Additionally, dirty vents with exposed insulation were observed. Staff interviews revealed a lack of maintenance personnel and communication issues, with the Administrator unaware of these problems.
A resident with significant health issues was not provided adequate care to maintain bowel continence and personal hygiene, leading to multiple incontinent episodes and insufficient showering opportunities. The resident expressed dissatisfaction with the care, citing delays in assistance and a lack of a scheduled toileting program. Staff acknowledged the challenges in providing timely care due to resource constraints.
The facility failed to assess and monitor the use of physical restraints for two residents, leading to the use of roll bolsters without proper orders or consents. One resident with mood disorder and heart failure was immobilized in bed due to staffing issues, while another with stroke and dementia had limited movement. No assessments or consents were documented, placing residents at risk.
The facility failed to complete significant change assessments (SCAs) for two residents who experienced changes in their health status related to hospice and palliative care. One resident was discharged from hospice services without an SCA, and another experienced a decline in ADLs and was diagnosed with palliative care without an SCA. Staff interviews revealed confusion and lack of responsibility regarding the completion of MDS assessments, contributing to the deficiency.
A facility failed to update the PASARR Level I form for a resident newly diagnosed with mental health concerns, including anxiety and delusions. The resident was prescribed Ativan for agitation, but the PASARR assessment was not revised to reflect these changes. Staff interviews revealed a lack of awareness about the requirement to update PASARR forms for new mental health diagnoses.
The facility failed to update care plans for two residents, leading to inaccuracies in their documented care needs. One resident's care plan did not reflect their interest in activities or worsening vision, while another's inaccurately stated they could feed themselves. Staff confirmed these discrepancies, and the DON acknowledged the need for review.
The facility failed to provide consistent Restorative Aide (RA) programs for three residents, leading to a risk of functional decline. A resident with dementia and diabetes was not participating in RA programs due to fatigue and fear, while another with a history of stroke was not encouraged to self-feed or transfer. A third resident with ankylosing spondylitis did not receive prescribed exercises. Staffing issues and lack of training contributed to these deficiencies.
A resident with visual and hearing impairments felt isolated due to the lack of meaningful activities at the facility. Despite their interest in political science and news, they were unable to engage in these activities effectively. Staff interviews revealed no planned one-on-one activities, and the activities director was unsure how to meet the resident's needs.
The facility failed to conduct proper skin assessments and provide timely specialized services for residents. A resident with a urostomy did not have their skin condition properly documented or communicated to a physician. Another resident with Alzheimer's disease did not receive weekly skin and wound documentation as ordered. Additionally, two residents did not receive timely specialized services, including therapy and Botox injections, due to administrative oversights and lack of proper documentation.
A resident with lower back pain and anxiety experienced issues with unsafe bathroom equipment, including an unsecured toilet seat riser and broken handrails, leading to falls. Despite reporting these issues, staff failed to document or address them, resulting in a deficiency in ensuring a safe environment.
The facility failed to ensure residents were free from unnecessary psychotropic medications, as two residents were prescribed such medications without proper monitoring or documentation. One resident received Ativan without a stop date, and behavior monitoring was inconsistent. Another resident's antidepressant dosage was increased without complete behavior monitoring, and there was no signed consent for medication use. Staff interviews revealed a lack of adherence to protocols for informed consent and behavior monitoring.
A resident with complete hearing loss experienced miscommunications and unmet care needs due to the facility's failure to provide adequate communication support. Despite using a whiteboard and iPad, the resident expressed frustration over staff's inability to communicate effectively, particularly regarding medication information and personal care. The facility had not provided an interpreter, even three months after admission, leading to further communication issues.
A resident with multiple health issues experienced unmanaged pain and a delayed response to a change in condition, including an allergic reaction to an antibiotic. The resident's complaints of pain were not promptly addressed, leading to a delay in emergency care. Additionally, there was a lack of proper assessment and communication regarding the resident's allergic reaction, resulting in further complications.
The facility failed to maintain a cleanable and sanitary environment in three resident rooms, where worn and discolored tiles with black sticky substances were observed. A resident reported that their room was dirty and uncleanable. The Environmental Manager confirmed the uncleanable condition, attributing it to old and worn surfaces with glue seeping through the tiles.
Failure to Manage Bed Bolster Hazard During Mechanical Lift Transfer
Penalty
Summary
The deficiency involves the facility’s failure to identify and prevent an avoidable accident hazard related to the combined use of bed bolsters and mechanical lift transfers for a resident. The resident had Alzheimer’s dementia, anxiety disorder, osteoarthritis, moderately impaired cognition, was dependent on staff for grooming, bed mobility, and transfers, and was assessed as being at risk for falls. The resident’s fall care plan specified that the left side of the bed was to be placed against the wall to prevent falls or rolls out of bed, but there were no care plan interventions addressing the use of a bed bolster. The facility also lacked a physician order, assessment, care plan entry, or representative consent for the bolster that had reportedly been in use on the resident’s bed for a couple of years. On the day of the incident, staff used a mechanical lift to transfer the resident from bed to wheelchair while a wedge-shaped bolster remained along the right side of the bed, with the bed at working height. Nursing assistants involved in the transfer reported that the sling was already hooked to the lift and that, during the lift, the lower left sling loop came off the lift hook as the resident was moved over the side of the bed. Staff later acknowledged that the bolster wedge should have been removed or taken down before performing the mechanical lift transfer and that if the bolster is not moved, the sling can get caught on it. One NA stated they had not been told to remove bolsters for mechanical lifts, and another stated that looking back, the bed had been too high and the bolster should have been removed. As a result of the sling loop disconnecting from the lift hook, the resident slid out of the sling and fell to the floor, landing partially on the mechanical lift leg. The resident sustained a forehead laceration, bruising to the left arm and elbow, skin shearing, bruising, and swelling to the left ankle, and was transported to the hospital. The resident was diagnosed with a left ankle fracture, treated with a leg splint, and had a shallow scalp laceration. Upon return, the resident was observed yelling out and later groaning in pain, with visible bruising on the forehead. The DON, restorative nurse, and administrator acknowledged there were no written policies, documented training, or guidelines specific to mechanical lift transfers in conjunction with bed bolsters, and the administrator stated they were not aware that bolsters could be a hazard.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to consistently assess and implement interventions to prevent and manage pressure injuries (PIs) for Resident 30, who developed three avoidable PIs after admission. Resident 30 was admitted with diagnoses including kidney and heart failure, and was at risk for developing PIs. Despite this, the facility did not adequately monitor or document the condition of Resident 30's skin, leading to the development of PIs on the right heel, left heel, and left calf, which were not present upon admission. Observations revealed that Resident 30 was often found lying in bed without the use of prescribed heel protectors, which were intended to prevent pressure on the heels. The facility's Treatment Administration Record (TAR) showed orders to monitor and float the heels, but these interventions were not consistently implemented. Staff failed to document weekly heel assessments, and there were no treatment orders for the Stage 1 PI on the right heel. Additionally, the care plan did not include interventions for the left outer calf PI or the use of the air mattress overlay and heel protectors. Interviews with staff indicated a lack of awareness and communication regarding Resident 30's condition and the necessary interventions. Nursing assistants reported observing abnormalities but did not have a place to document these findings, and there was confusion about the use of heel protectors. The Director of Nursing Services acknowledged that weekly skin assessments and wound assessments were not being completed as required, and the Resident Care Managers were not updating care plans promptly due to their workload. This lack of consistent assessment and intervention contributed to the worsening of Resident 30's PIs and their decreased quality of life due to pain.
Failure to Implement Timely Restorative Therapy Services
Penalty
Summary
The facility failed to implement timely restorative therapy services, including the consistent use of braces and splints, to prevent avoidable reduction of range of motion (ROM) and mobility for two residents. Resident 27 developed right and left-hand contractures, which were not present upon admission and were not documented in subsequent assessments until much later. Despite a physician's diagnosis of a right-hand contracture, there was a significant delay in initiating a ROM restorative program, and no documentation indicated that such a program was in place for the resident's upper extremities. Observations confirmed the absence of necessary devices like dowels to aid in reducing contractures. Resident 20, who had a known contracture to the left hand, was supposed to be on a nursing restorative program that included the use of a splint. However, observations revealed that the splint was not consistently applied, and staff interviews indicated a lack of awareness and training regarding the resident's restorative program. Staff members reported being too busy or not trained to perform the necessary ROM exercises, leading to the program not being followed as required. Interviews with staff, including the Rehab Director and nursing assistants, highlighted systemic issues such as inadequate communication and training, as well as staffing shortages that contributed to the failure in providing necessary restorative care. The facility's administrator acknowledged the expectation for braces and splints to be applied as ordered and for residents showing a decline to be evaluated and treated promptly, which was not the case for these residents.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly personal fund statements to residents and/or their representatives, as required. This deficiency was identified for three residents, each with varying degrees of cognitive and physical impairments. Resident 20, diagnosed with Parkinson's disease and requiring extensive assistance for activities of daily living (ADLs), had severely impaired cognition. The resident's representative reported not receiving any statements regarding the resident's personal funds. Similarly, Resident 23, who has cerebral palsy and intact cognition, also did not receive any personal fund statements. Resident 27, with scoliosis and moderately impaired cognition, required extensive assistance for ADLs, and their representative assumed the funds were used for care, as they had not received any statements. During an interview, the facility's administrator, Staff A, acknowledged the failure to send out personal fund statements, admitting that the facility was behind schedule and had not sent any statements for almost a year. This lapse in procedure placed residents at risk of not having an accurate accounting of their personal funds held in trust by the facility, as required by regulations.
Failure to Resolve Grievances and Inform Residents of Grievance Process
Penalty
Summary
The facility failed to establish an effective system for promptly resolving grievances voiced during Resident Council meetings. Resident 9, who had moderately impaired cognition and was receiving hospice services, reported broken bathroom equipment during a Resident Council meeting. Despite this, the issue was not documented in the meeting minutes or the maintenance book, and no action was taken to resolve the concern. Staff V, the Activities Director, assumed that concerns raised in the meetings were addressed by individual departments but did not follow up to ensure resolution. Additionally, four residents who regularly attended Resident Council meetings were unaware of how to file a grievance or who the facility's Grievance Officer was. The facility's grievance policy stated that grievances should be investigated by the Director of Nursing or the Administrator, with results communicated to the resident or their representative. However, the process for handling concerns raised in Resident Council meetings was informal, with no formal documentation or follow-up to ensure grievances were addressed. Interviews with staff revealed a lack of clarity and communication regarding the grievance process. Staff A, the Administrator, and Staff H, the Grievance Officer, acknowledged that concerns from Resident Council meetings were not treated as formal grievances. The process relied on department heads to address issues based on meeting minutes, but there was no documentation or follow-up to confirm resolution. This lack of a structured grievance process placed residents at risk for unresolved concerns and dissatisfaction.
Failure to Conduct Accurate PASARR Assessments
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) assessments accurately reflected the mental health conditions of two residents, leading to a deficiency in the care provided. Resident 16 was admitted with diagnoses including a stroke and depression, and their comprehensive assessment indicated severe cognitive impairment and symptoms of depression. However, the PASARR assessment, completed by the Resident Care Manager upon admission, incorrectly indicated that a level two evaluation was not required, despite the presence of a mood disorder. Similarly, Resident 8, who was admitted with an anxiety disorder and had moderately impaired cognition, also did not receive the necessary level two evaluation as indicated by their PASARR assessment. The staff responsible for completing the PASARRs, Staff C and Staff D, were unaware of the updated regulations requiring these evaluations to be completed prior to admission, and they had not received training on the changes. The facility administrator, Staff A, was also unaware of the regulatory changes and the need for training, contributing to the oversight.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for three residents who were trauma survivors. Resident 12, who had experienced significant personal losses including the death of their spouse and multiple amputations, expressed feelings of sadness and loss of manhood. Despite these clear indicators of trauma, the resident's care plan did not address their trauma concerns or identify any triggers or interventions to manage their mental health well-being. Staff H, the Social Services Director, was unaware of the recent nature of the resident's losses and did not conduct a thorough assessment to understand the impact on the resident's mental health. Resident 38, who had a history of cataracts, dementia, and multiple falls, expressed feelings of isolation and guilt over the death of their child from alcoholism. Despite these expressed concerns, the psychosocial history did not reflect these issues, and no trauma-based care plan was initiated. Staff DD, the Social Services Assistant, was aware of the resident's regrets but did not ensure that these were documented or addressed in the care plan. Resident 27, diagnosed with PTSD, anxiety, and depression, had specific triggers related to their past experiences of being yelled at by their parents. However, their care plan did not include any trauma-informed interventions or assessments to address these triggers. Staff H acknowledged that the process for trauma-informed care was not followed, and there was no trauma assessment tool available in the electronic health record. The Director of Nursing Services confirmed that no trauma assessments had been completed for the residents.
Kitchen Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the kitchen, which placed residents at risk for infection. Observations revealed several issues, including a broken and missing area of rubberized concrete under the oven's right leg support, making it uncleanable. Additionally, the top of the oven was covered with dusty stainless steel appliances and inserts used for the steam table. The clean sink area had a leaking water faucet, which worsened over time, affecting a second faucet. Despite the Dietary Manager reporting the issue to the Maintenance Director, the problem persisted. Further observations showed that white plastic barrels containing powdered milk, flour, and other dried goods were stored under a steam table, exposing them to constant high temperatures and moisture, potentially affecting their quality. The kitchen also had two dirty vents with black fuzzy dust, and one vent had exposed yellow insulation due to splits in the ceiling. Interviews with staff revealed a lack of maintenance personnel and communication issues, as the Administrator was unaware of the kitchen repair issues until informed by the surveyors.
Failure to Maintain Resident Dignity and Hygiene
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident 12, by not providing adequate care to support their bowel continence and personal hygiene needs. Resident 12, who was readmitted with a fracture of the right lower leg and other significant health issues, required assistance with a mechanical lift for transfers and was continent of bowel. However, the resident was not on a scheduled bowel toileting program, leading to multiple incontinent bowel episodes. The resident expressed dissatisfaction with the care received, particularly the lack of timely assistance to use the bathroom, resulting in accidents. Additionally, the facility did not provide Resident 12 with sufficient opportunities for personal hygiene, as they were only scheduled for one shower per week. The resident expressed a preference for more frequent showers, especially before appointments and family visits, but staff indicated they lacked the time to accommodate this request. The care plan for Resident 12 did not include a specific toileting schedule, and staff acknowledged the difficulty in using the mechanical lift quickly due to the need for two staff members. The Director of Nursing Services recognized the need for reassessment to determine the resident's toileting and showering needs.
Failure to Assess and Monitor Physical Restraints
Penalty
Summary
The facility failed to comprehensively assess and monitor the need for physical restraints for two residents, identified as Resident 30 and Resident 39. Resident 30, who was admitted with a mood disorder and heart failure, had severely impaired cognition and required substantial assistance for bed mobility. Observations revealed that roll bolsters were used to immobilize Resident 30 in bed without a physician's order or proper assessment. Staff interviews indicated that the roll bolsters were used due to insufficient staffing to assist the resident in getting up, and there was no ongoing reassessment or consent obtained for their use. Similarly, Resident 39, who had a history of stroke, dementia, and depression, was observed with roll bolsters that limited their freedom of movement. There were no physician orders or assessments justifying the use of these restraints. Staff interviews revealed that the roll bolsters were used to prevent the resident from turning around in bed, but there was no documentation of an assessment, order, or consent for their use. The facility's failure to assess, document, and obtain necessary consents for the use of physical restraints placed residents at risk for diminished quality of life and other complications.
Failure to Complete Significant Change Assessments for Residents
Penalty
Summary
The facility failed to complete a significant change assessment (SCA) for two residents, Resident 9 and Resident 30, who were reviewed for hospice and end-of-life care. According to the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, an SCA is required when a resident experiences a major decline or improvement in health status, such as when hospice benefits are selected or discontinued. Resident 9 was admitted with hospice care and later discharged from hospice services, but no SCA was completed following this change. Similarly, Resident 30 experienced a significant decline in activities of daily living (ADLs) and was diagnosed with palliative care, yet no SCA was conducted to address these changes. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of MDS assessments. Staff C and Staff D, who shared the task with Staff Y, the MDS Coordinator, were uncertain about who was responsible for completing the SCAs for Residents 9 and 30. Staff B, the Director of Nursing Services, admitted to not being knowledgeable about the timing and frequency of SCAs. This lack of coordination and understanding among staff members contributed to the failure to complete the necessary assessments, placing the residents at risk for unmet care needs.
Failure to Update PASARR for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to update the Pre-Admission Screening and Resident Review (PASARR) Level I form for a resident who was newly diagnosed with mental health concerns. This oversight involved a resident who was admitted with diagnoses including depression and blindness. The resident's medication records indicated that they were prescribed Ativan, a psychotropic medication, for agitation and comfort care without a stop date. The medication was initially ordered in July 2024 and continued into August 2024. Despite these changes in the resident's mental health status and medication regimen, the PASARR assessment from January 2023 was not updated to reflect the new behavioral diagnoses of anxiety, agitation, or delusions. Interviews with facility staff revealed a lack of awareness regarding the requirement to update PASARR forms when a resident is newly diagnosed with mental health issues. The contracted pharmacist noted that the resident was receiving Ativan due to agitation from delusions, yet the resident case managers admitted they were unaware of the need to update the PASARR assessments under such circumstances. This failure to update the PASARR form potentially placed the resident at risk for health and emotional decline due to the absence of a professional evaluation to determine if further mental health interventions were necessary.
Inaccurate and Outdated Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that care plans for two residents were reviewed, revised, and accurately reflected their current care needs. Resident 38, who had been at the facility for over a year, had a care plan that was outdated and did not reflect their current condition. Despite having cognitive impairment, the resident was able to express their needs clearly. The care plan did not account for the resident's interest in activities such as reading newspapers and going on outings, nor did it reflect their worsening vision due to cataracts. Additionally, the care plan did not update the resident's restorative program after a fall that resulted in a clavicle fracture, and there were no new restorative assessments or interventions documented. Resident 39, who was severely cognitively impaired and required substantial assistance for self-care, had a care plan that inaccurately stated they could feed themselves 50% of their meals. Observations showed that the resident was fed 100% of their meals by staff and preferred to remain in bed rather than use a wheelchair, contrary to what was documented in the care plan. Interviews with staff and the resident's representative confirmed that the resident no longer fed themselves due to their dementia. The Director of Nursing Services acknowledged that the care plans did not reflect the current conditions and concerns of the residents.
Failure to Implement Restorative Aide Programs
Penalty
Summary
The facility failed to consistently provide necessary care and services to ensure that Restorative Aide (RA) Nursing programs were implemented for three residents, leading to a risk of avoidable decline in their functional abilities. Resident 21, who had dementia and diabetes, was observed multiple times remaining in bed without participating in their RA programs for dressing/grooming and bed mobility. Staff interviews revealed that the resident was not encouraged to participate due to fatigue and fear of transferring, and the Restorative Assistant responsible for these programs was working as a regular Nursing Assistant (NA) instead. Resident 39, with a history of stroke, dysphagia, and dementia, was also not participating in their RA programs for eating/swallowing and transfer training. Observations showed the resident being fed by staff without any attempt to encourage self-feeding, contrary to their care plan. Interviews with staff and the resident's representative indicated a lack of awareness and implementation of the RA programs, with staff routinely providing total assistance for meals and not facilitating transfer training. Resident 9, diagnosed with ankylosing spondylitis, was not receiving exercises or participating in RA programs for bed mobility, dressing, and walking as outlined in their care plan. Observations and interviews highlighted that the resident struggled with reaching their call light due to stiffness and had not been engaged in the prescribed exercises. The Restorative Director acknowledged the staffing issues, with only one RA available who was also assigned to work as a NA, leading to the delegation of RA program responsibilities to floor NAs without proper training or documentation processes in place.
Failure to Provide Meaningful Activities for a Resident
Penalty
Summary
The facility failed to provide meaningful and engaging activities for a resident who did not participate in group activities due to visual and hearing impairments. The resident, who had a history of cataracts, dementia, and multiple falls, expressed feelings of isolation and dissatisfaction with the facility due to the lack of suitable activities. Despite the resident's interest in political science and news, they were unable to read newspapers or watch television effectively, and their voting ballot remained uncompleted due to a lack of assistance from staff. Interviews with staff revealed that there were no planned or routine one-on-one activities for the resident, and the activities director was unsure how to address the resident's needs. Documentation showed minimal engagement with the resident, with one-on-one activities being limited to brief interactions such as assisting with bedding. The activities staff acknowledged the need for follow-up assessments to better understand and meet the resident's activity preferences, but no specific actions were taken to address the deficiency at the time of the report.
Deficiencies in Skin Assessments and Specialized Services
Penalty
Summary
The facility failed to ensure residents received care and services in accordance with professional standards of practice, particularly regarding ongoing skin assessments and specialized services. For Resident 37, the facility did not conduct proper skin assessments or document the condition of the skin around the urostomy stoma. Despite having a physician's order to change the urostomy bag and monitor for leakage, there was no care plan addressing the potential for skin impairment or the presence of an additional opening on the resident's abdomen that drained fluid. Staff interviews revealed a lack of awareness and documentation regarding the resident's skin condition, which was not communicated to the physician. Resident 8, who had Alzheimer's disease and open wounds on their head, was also not properly monitored. The facility failed to follow a physician's order to document the resident's skin and wound condition weekly. Despite having a chronic skin condition, there was only one documented observation over a 12-week period. The Director of Nursing Services acknowledged that the nurses were responsible for skin and wound treatments but did not follow the physician's orders for Resident 8. The facility also failed to provide timely specialized services for Residents 9 and 20. Resident 9, who had a history of falls and was at risk due to leg weakness, did not receive the ordered physical and occupational therapy services. The facility did not consult the resident, who was capable of making decisions, and instead relied on the family's previous decision to decline therapy. For Resident 20, the facility did not ensure the continuation of Botox injections for hand contractures due to missing power of attorney documentation, resulting in a significant delay in treatment.
Failure to Ensure Safe and Functional Bathroom Equipment
Penalty
Summary
The facility failed to ensure that a resident's bathroom had safe and functional Durable Medical Equipment (DME), which placed the resident at risk for falls and injuries. Resident 9, who was admitted with diagnoses including lower back pain and anxiety, was observed using a wheelchair and self-propelling in their room. The bathroom equipment, specifically a toilet seat riser with handles and portable handrails, was not secured properly. The handrails were unstable, with the right-side handrail being broken, causing it to push outwards when pressure was applied. Resident 9 reported these issues during a group meeting but was informed that nothing could be done. Staff interviews revealed a lack of communication and documentation regarding the broken equipment. Staff M, a Nursing Assistant, did not report the issues to maintenance or document them in the maintenance book. Staff V, the Activities Director, recalled the resident's report but did not ensure it was recorded. The Maintenance Director, Staff I, confirmed no reports were received about the equipment. The Restorative Director, Staff E, was unaware of the equipment issues and had not assessed the bathroom, as the resident attributed their falls to leg weakness. The maintenance book showed no entries for the equipment issues, and the resident experienced two non-injury falls in the bathroom, attributed to leg weakness and deconditioning.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure residents were free from unnecessary psychotropic medications, as evidenced by the cases of two residents. Resident 7 was prescribed Ativan on a PRN basis without a stop date, and the medication was continued for 43 days before being discontinued and reordered without a stop date. Despite a pharmacist's recommendation to add a stop date, the medication was extended for three months without documented rationale. Additionally, behavior monitoring for Resident 7 was inconsistent, with numerous shifts lacking documentation of interventions or outcomes. Resident 16 was prescribed Desvenlafaxine and Remeron for depression, but there were no orders for monitoring targeted behaviors. The Desvenlafaxine dosage was increased without complete documentation of behavior monitoring, and there was no care plan for the resident's depression or use of psychotropic medications. Furthermore, there was no signed consent or education provided for the use of Remeron, and staff reported increased sadness without documentation to support these claims. Interviews with staff revealed a lack of adherence to protocols for obtaining informed consent and monitoring targeted behaviors. The Director of Nursing Services acknowledged the need for consent and documentation of behavior changes to justify medication adjustments. The facility's failure to develop, monitor, and implement individualized care plans and obtain informed consent placed residents at risk for medication-related adverse effects and compromised their ability to make informed decisions.
Failure to Provide Adequate Communication Support for Deaf Resident
Penalty
Summary
The facility failed to provide adequate communication support for a resident who is deaf, resulting in miscommunications and unmet care needs. The resident, who has complete hearing loss and other medical conditions such as heart disease, diabetes, and kidney disease, was observed using a whiteboard and an iPad for communication. Despite these tools, the resident expressed frustration over the staff's inability to communicate effectively, particularly regarding medication information and during personal care activities. The resident's care plan only mentioned the use of a whiteboard for communication, with no additional instructions or interventions. Interviews and observations revealed that staff members did not consistently use the whiteboard to communicate with the resident, and some staff members did not understand sign language. The resident's representative had requested an interpreter due to poor communication, but the facility had not yet provided one, even three months after the resident's admission. During medication administration, a nurse failed to inform the resident about the medications being given, despite the resident's request. Additionally, an incident occurred where a staff member startled the resident by changing their sheets without prior communication. The facility's administrator acknowledged the ongoing search for an interpreter but had not yet secured one.
Failure to Timely Assess Change in Condition and Manage Medication Reaction
Penalty
Summary
The facility failed to assess a change in condition in a timely manner for a resident who complained of abdominal pain and experienced an allergic reaction to a prescribed antibiotic. The resident, who had multiple diagnoses including deaf-nonspeaking, urinary retention with a catheter, chronic UTIs, and heart and kidney failure, communicated their pain through sign language and writing. On the morning of the incident, the resident pointed to their urinary catheter and complained of back pain to a nursing assistant, who did not report the complaint to a nurse. Despite the resident's communication of pain and the need to go to the emergency room, there was a delay in response, with the emergency ambulance arriving three hours after the initial complaint. The resident's medical record indicated a previous urologist visit where excessive sediment was noted in the urine, and an order was given to flush the catheter with acetic acid. However, there was no order to flush the catheter until 12 days later, and staff used normal saline instead. The resident's urinary catheter was leaking, and the resident experienced unmanaged pain due to the delay in assessment and treatment. Additionally, the resident was prescribed Cefdinir for a UTI, which led to a suspected allergic reaction causing throat pain and swelling. The staff failed to assess the resident's mouth or throat and did not notify the resident representative or provider promptly. The resident received a one-time dose of Benadryl for the side effects of Cefdinir, but there was no further direction documented. The staff did not assess the resident's condition, and the resident was not sent to the emergency room despite the suspected allergic reaction. The resident later developed a secondary fungal infection in the mouth, which was attributed to the antibiotic. The facility lacked a written policy for flushing urinary catheters, and staff relied on online resources for guidance, indicating a gap in proper procedural knowledge and communication among staff members.
Unsanitary Flooring Conditions in Resident Rooms
Penalty
Summary
The facility failed to maintain a cleanable and sanitary environment in three of ten resident rooms, as observed during a survey. In room [ROOM NUMBER], a five by four feet area of white tile was discolored to a blackish-brown color, with a black sticky substance between the tiles and multiple indentations that were uncleanable. Resident 1 reported that their room was dirty and the floor could not be cleaned properly. In room [ROOM NUMBER], a three by three feet area of worn tiles with several indentation marks and black sticky substance between the tiles was observed. Similarly, room [ROOM NUMBER] had a four by four feet area of worn, discolored tiles with several indentation marks and black sticky substance between the tiles. During an interview, the Environmental Manager, Staff H, acknowledged that the rooms were not cleanable and that the black sticky substance was glue coming up from the under flooring where the tiles were glued. Staff H admitted awareness of the uncleanable surfaces, which were old and worn. This situation placed staff and residents at an increased risk for infectious diseases and a non-functional resident environment due to the uncleanable flooring surfaces.
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A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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