Crystal Cove Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Lacey, Washington.
- Location
- 1505 Carpenter Road Se, Lacey, Washington 98503
- CMS Provider Number
- 505254
- Inspections on file
- 50
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 50
Citation history
Health deficiencies cited at Crystal Cove Post Acute during CMS and state inspections, most recent first.
The facility failed to follow its bed-hold policy by not providing written bed-hold notices to two residents when they were transferred to the hospital, and by not maintaining signed copies in their medical records. One cognitively intact resident requested hospital transfer, and later hospital staff reported that when the resident was ready for discharge, the facility stated the prior semi-private bed was no longer available and only a four-bed room could be offered, which the resident declined, leading the hospital to find another facility. Another resident with mild cognitive impairment was transferred to the hospital by ambulance without any documented bed-hold notice. The DNS acknowledged that no bed-hold forms were signed or documented for these residents and that nursing staff were responsible for providing such notices when a return was expected.
A resident with a right below-the-knee amputation, mild cognitive impairment, and dependence on staff for ADLs, transfers, and mobility was discharged from PT with a documented recommendation for a Restorative Nursing Program (RNP) and prosthetic follow-up. Facility policy required that residents identified as needing restorative services receive interventions such as ROM, mobility training, and amputation/prosthesis care, and that the discharging therapist or nurse communicate the restorative plan to restorative aides. Record review showed no MD order for RNP services and no documentation that restorative nursing services were provided, which was confirmed by the PT during interview.
The facility changed its dining schedule to create a 15‑hour gap between dinner and breakfast without allowing the resident council to vote on or approve the new mealtimes, although residents were informed via a flyer. A resident council member reported they would have opposed the change, and several residents stated that evening snacks were inconsistent, with some being told there were no snacks or that staff were out of them. Dietary and activities staff described snack trays, an activities cart, and a stocked refrigerator, but acknowledged that residents, including those who were bedbound, often had to request snacks and that staff might not be going room to room. The Administrator reported that CNAs and activities staff were supposed to offer snacks and water in the evening but confirmed there was no documentation of this, and the RD stated she was unaware that a nourishing snack was required when the interval between meals exceeded 14 hours.
The deficiency concerns unsecured smoking materials, incomplete smoking assessment, and inadequate lighting in the smoking area and access path. A resident who was cognitively intact and used tobacco kept cigarettes unsecured in a bedside drawer instead of having them locked in the treatment cart, and the resident’s smoking assessment lacked documentation on medications, behaviors, and nursing safety assessment. Staff acknowledged the assessment was incomplete. In addition, residents accessed a smoking area via a narrow sidewalk with an S-curve and 2–6-inch drop-offs or ruts at the edges, where wheel tracks were visible. Staff and residents reported that management stopped turning on the flood lights after dark due to substance use concerns, yet residents continued to use the area in the dark; one resident reported a fall while returning from the smoking area when it was “pitch black,” and others described the area as dangerous due to uneven surfaces and lack of lighting.
A resident with end stage renal disease, atrial fibrillation, and significant balance deficits was repeatedly left unsupervised at the edge of the bed despite requiring substantial staff assistance for mobility and transfers. The resident experienced multiple unwitnessed falls, including one after returning from dialysis when they were left unattended at the bedside for a meal, resulting in fractures to the right wrist and hospitalization. Staff interviews confirmed awareness of the resident's high fall risk and the need for supervision, but interventions were not consistently implemented.
The facility did not maintain required room temperatures, with multiple resident rooms recorded well below the mandated 71-81°F range. Residents and their families reported persistent cold conditions, and staff confirmed that many room heaters were not activated or maintained. Maintenance acknowledged that the HVAC system was not fully operational and that previous staff had not ensured proper heater upkeep, resulting in ongoing discomfort for residents.
A resident admitted with multiple fractures, a subarachnoid hemorrhage, an external fixator, and an indwelling catheter did not receive timely wound or catheter care as required by physician orders and facility policy. Orders for wound and catheter care were delayed, and documentation showed that care was not provided or recorded for several days after admission, resulting in the resident leaving the facility against medical advice.
A resident with complex medical needs did not have required admission or weekly weights obtained, despite physician orders and care plan directives. The dietician's recommendation for a nutritional supplement was not communicated to the physician, resulting in the resident not receiving the supplement. The DON confirmed these lapses in care.
Two residents with chronic pain conditions missed multiple consecutive doses of their prescribed narcotic pain medications due to the facility not receiving the medications from the pharmacy in a timely manner. Documentation and interviews with residents, an LPN, and the DON confirmed the missed doses and the delay in pharmacy delivery.
A resident with a physician's order for CPR was found unresponsive, but staff failed to initiate CPR or call emergency services, violating the facility's emergency response policy. The resident's POLST indicated full resuscitation, but staff did not follow protocol, leading to the resident's death. The facility's investigation revealed that several staff members lacked current CPR certifications.
The facility failed to provide adequate care for pressure ulcers, resulting in harm to residents. A resident developed an unstageable pressure ulcer due to delayed treatment, while another did not receive necessary equipment to prevent ulcer worsening. Incomplete skin assessments and lack of timely interventions were noted for multiple residents, highlighting significant deficiencies in wound care management.
A resident with a gastrostomy tube was not properly assessed for tube placement before enteral feeding, and the prescribed hydration orders were not followed. The LPN administered 50 ml of water instead of the prescribed 100 ml after feeding, placing the resident at risk for nutritional issues.
The facility failed to monitor and address significant weight loss and fluid restrictions for several residents, leading to potential harm. A resident experienced significant weight loss due to inadequate weight monitoring and lack of communication with the physician. Another resident faced similar issues with supplement intake and dietary interventions. Additionally, fluid restrictions were not consistently documented or communicated, resulting in potential non-adherence.
The facility experienced significant staffing shortages, leading to delays in resident care and unmet needs. Residents reported long wait times for assistance, and staff were overwhelmed with responsibilities, resulting in incomplete tasks and documentation. The facility's management staff were frequently pulled from their duties to cover direct care, further impacting the quality of care provided.
The facility failed to ensure staff competency in infection control practices, particularly in implementing Enhanced Barrier Precautions (EBP) and using personal protective equipment (PPE). Staff lacked understanding of the EBP indicator system, and there was insufficient training for agency staff. Additionally, there was inadequate oversight of the Restorative Nursing Program and management of central venous catheters.
The governing body failed to provide adequate oversight, resulting in insufficient staffing and ineffective Quality Assurance and Performance Improvement (QAPI) programs. This led to unmet resident needs, repeated deficiencies, and inadequate infection control practices. The facility also failed to ensure staff competencies and did not maintain a proper Quality Assessment and Assurance (QAA) committee, placing residents at risk for harm.
The facility's QAPI program failed to identify and address deficiencies, leading to repeated issues in areas such as resident rights, ADL care, and infection control. The Administrator, new to the facility, had not reviewed past reports or attended QAPI meetings, contributing to the ongoing deficiencies.
The facility failed to implement an effective Infection Prevention and Control Program, as staff frequently neglected hand hygiene and PPE use, and did not follow enhanced barrier precautions (EBP) protocols. Observations across all halls showed staff handling food trays and assisting residents without proper hygiene or PPE. The facility's EBP policy was not consistently followed, with staff confused about the orange sticker system indicating residents requiring EBP. During a suspected gastrointestinal outbreak, symptomatic residents were not promptly isolated, and transmission-based precautions were not implemented, compromising infection control.
The facility failed to address and resolve concerns raised by the Resident Council over three months, leading to repeated unresolved issues and resident frustration. Concerns included dietary errors, dirty utensils, missing clothing, and unsatisfactory coffee. Despite consistent reporting, the facility did not provide follow-up or resolutions, leaving residents feeling unheard. The Activities Director admitted to not receiving updates from department heads unless a grievance form was involved, and the Resident Council Response Form was not utilized.
The facility did not provide residents with access to their personal funds during evenings and weekends, affecting all 12 residents reviewed. A resident reported being unable to withdraw money on weekends, and staff confirmed that access was restricted until a recent change allowed the administrator to assist with withdrawals after hours.
The facility did not provide quarterly personal fund statements to residents, affecting three individuals. A resident, who was cognitively intact, reported not receiving statements and requested monthly updates. The Business Office Manager was unsure about past distributions but planned to distribute statements moving forward. The Administrator confirmed that statements were not provided until their recent employment, with plans to start distribution that week.
The facility failed to maintain a safe and clean environment, with issues such as non-functioning lights, dead bugs in fixtures, peeling door coverings, and soiled medical equipment observed across all wings. The Maintenance Director was aware of some issues but had not addressed them, and the Resident Care Manager confirmed the soiling of a resident's tube feeding pole.
The facility failed to log and address grievances raised during Resident Council meetings over three months. Residents reported dietary errors, dirty utensils, missing laundry, and inappropriate staff behavior, but these issues were not logged or resolved. The Activities Director admitted to not following up on these concerns, leaving residents feeling frustrated and unimportant.
The facility failed to document necessary assessments, orders, consents, and care plans for the use of bed rails and mobility bars for four residents. Despite facility policy, these elements were missing from the residents' records, and staff acknowledged the oversight.
The facility failed to provide required transfer/discharge notifications to several residents and their representatives, and did not notify the Ombudsman. One resident's representative was not informed of a hospital transfer, leaving them unaware of the resident's whereabouts. The facility's staff acknowledged these oversights.
The facility failed to provide written bed hold notices to four residents during hospital transfers, as required by policy. The EHRs lacked documentation of these notices, and staff confirmed that notices were only given if residents requested a bed hold, contrary to policy.
A long-term care facility failed to ensure accurate MDS assessments for nine residents, leading to potential risks of unmet care needs. Errors included incorrect documentation of medication dose reductions, missing PASRR processes, and inaccurate recording of restorative programs. Additionally, some residents' MDS assessments did not reflect their current medical conditions or treatments, such as hospice services and central line access for dialysis. These inaccuracies were acknowledged by the MDS Director, indicating a need for improved assessment accuracy.
The facility failed to review and revise comprehensive care plans for several residents, leading to deficiencies in individualized care. Two residents had their beds positioned against the wall without proper documentation. Another resident's care plan lacked dialysis details and mobility bar usage. Additional residents had incomplete care plans, missing specific interventions for dementia, anxiety, and activity preferences. These deficiencies placed residents at risk of receiving inappropriate and inadequate care.
The facility failed to consistently review and revise care plans for several residents, leading to discrepancies and omissions in their care. For example, a resident's care plan inaccurately reflected their medication regimen, while another's did not document the use of two different classes of psychotropic medications. Additionally, care plans for vision, hearing, and dental care were incomplete and not personalized, failing to address specific needs such as outdated prescriptions and missing equipment.
The facility failed to meet professional standards of practice for 13 residents, leading to medication errors and delays in treatment. Nurses did not accurately follow or clarify physicians' orders, resulting in residents receiving incorrect medications or dosages, and there was a lack of documentation for medication administration and monitoring of symptoms. Additionally, stat lab tests and x-rays were not performed in a timely manner, and some residents did not receive necessary consultations or follow-ups.
The facility failed to assist three residents with ADLs, including oral care, shaving, and meal assistance. A resident did not receive oral hygiene supplies for seven days, another was left unshaved and in bed despite needing assistance, and a third resident was unable to eat due to lack of setup help. Staff acknowledged these oversights, highlighting deficiencies in care.
The facility failed to implement bowel management protocols for three residents, resulting in extended periods without bowel movements. Despite the facility's protocol requiring interventions after three days, no medications were administered, and there was no documentation of physician notification. This oversight affected residents with varying cognitive impairments, placing them at risk for discomfort and complications.
The facility failed to provide restorative services at the required frequency for several residents, leading to a deficiency in maintaining or improving their range of motion and mobility. The care plans lacked specific details, and staffing shortages contributed to the issue, as the Restorative Nursing Assistant was unable to complete the necessary restorative programs due to being pulled for direct resident care.
The facility failed to properly assess, maintain, and monitor PICC lines for two residents receiving IV therapy. The IV orders lacked essential details such as infusion rate, duration, and flush instructions. Additionally, there was no documentation of PICC line measurements or regular changing of needleless injection caps, as confirmed by staff interviews.
The facility failed to ensure residents were free from unnecessary medications, affecting four residents. A resident received tramadol despite no reported pain, another continued on tramadol and acetaminophen with zero pain scores, a third was on antibiotics for a healed ulcer, and a fourth had an unadjusted oxygen order despite stable SpO2 levels. Staff acknowledged lapses in assessment and documentation.
The facility failed to ensure proper management of psychotropic medications for several residents, including the absence of target behavior identification, behavior and side effect monitoring, and informed consent. A resident received medications without specific target behaviors identified, while another was given medication without consent and lacked non-pharmacological intervention documentation. Similar issues were noted for other residents, highlighting deficiencies in medication management.
The facility failed to ensure proper medication storage and labeling, with expired medications found in the A and B Medication Nursing Station Room and C Wing Cart. The B Wing Cart had similar issues, including improper documentation of controlled substances and expired medications. The A Wing Cart was left unattended with medication on top. These deficiencies risked resident safety and medication errors.
The facility failed to provide residents with prescribed therapeutic diets, serving meals uniformly without regard to dietary restrictions. Staff admitted to only serving Renal diets and were unaware of other dietary requirements. The Dietary Manager acknowledged the lack of a system for therapeutic diets, confirming non-compliance.
The facility failed to ensure its binding arbitration agreements included necessary resident rights wording and did not adequately explain the agreements to two cognitively intact residents. The agreements lacked information on communication rights with officials, neutral arbitrator selection, and venue convenience. One resident did not recall signing the agreement, while another was unaware of the arbitration process and optional nature of signing. The administrator acknowledged these shortcomings.
The facility's QAA committee meetings lacked required members, including the Infection Preventionist and Medical Director, during several meetings in the past year. This absence was acknowledged by the current Administrator, who had not yet attended a QAPI meeting.
A resident, who was cognitively intact and needed assistance with bathing, was transported down a hallway in a shower chair with inadequate covering, exposing their left side and buttocks. A CNA involved did not notice the exposure, and the DON confirmed that residents should be covered to maintain dignity.
The facility failed to honor and facilitate resident bathing choices for three residents, leading to a deficiency in promoting resident self-determination. A resident reported receiving only one shower in 13 days, despite being scheduled for showers twice a week. Another resident, who had their shower frequency increased, was not offered showers on several scheduled days. A third resident reported infrequent assistance with bathing, with records indicating a lack of documentation for offered or provided showers over several weeks. Staff confirmed that residents were not consistently offered or assisted with bathing according to their schedules.
A facility failed to transfer a deceased resident's trust funds within the required 30-day period, leaving a balance of $314.35 unaddressed. The Business Office Manager confirmed the oversight, and the Administrator was aware and had contacted the Department of Social and Health Services to resolve the issue.
A facility failed to ensure the privacy and confidentiality of a resident's medical information when a laptop displaying personal data was left open and unsecured on a medication cart. Multiple staff members, including an Infection Preventionist and a Resident Care Manager, walked past the open laptop without securing it. The expectation was for staff to lock the computer when stepping away, as confirmed by the Administrator and the Director of Nursing.
A facility failed to provide complete documentation during the transfer of a resident with PTSD, depression, and anxiety to a hospital. The transfer, initiated due to inappropriate behaviors, lacked essential information such as practitioner contact details and care instructions. Staff acknowledged the absence of documentation, placing residents at risk of unmet medical needs.
The facility failed to ensure accurate PASRR documentation for two residents, leading to potential unmet care needs. One resident's PASRR only included PTSD, omitting depression and anxiety diagnoses, while another's PASRR failed to include an anxiety disorder despite medication use. Staff interviews revealed a lack of understanding about updating PASRRs for diagnosis changes.
The facility failed to provide individualized activities for three residents, leading to a deficiency in meeting their engagement needs. A resident with communication deficits was left without activities, another was not provided with music or animal interactions as per their care plan, and a third resident with cognitive impairment lacked personal entertainment options. Staff absences and lack of awareness contributed to these deficiencies.
A resident in a long-term care facility did not receive necessary podiatry care, resulting in long, thick, and untrimmed toenails. Despite the facility's directive for weekly nail care, records showed it was not provided, and the resident was not referred to the podiatrist during their visits. Staff confirmed the oversight, acknowledging the resident should have been referred for podiatry care.
A facility failed to implement fall prevention interventions for a resident with dementia and a history of falls. Observations showed the resident's call light was often out of reach, and the fall mat was improperly positioned. Staff interviews confirmed these lapses, and the DON acknowledged unmet expectations. The resident also required setup assistance with meals, which was not consistently provided.
A resident with an indwelling urinary catheter lacked documented justification for its use, and the facility failed to assess for catheter removal. The resident, with a history of Fournier's gangrene, initially used a condom catheter but switched to an indwelling catheter due to an open sore. Despite the wound's resolution, the catheter remained without justification. Additionally, the catheter tubing was not secured, and a urology referral was not completed due to insurance issues.
Failure to Provide Required Bed-Hold Notices at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide required written bed-hold notices to residents at the time of hospital transfer, as required by its own policy and state regulations. The facility’s undated "Bed Hold Notice" policy stated that in the event of an emergency transfer, written notice of the facility’s bed-hold policies must be provided to the resident and/or resident representative within 24 hours, and a signed and dated copy must be kept in the resident’s record. For one resident who was cognitively intact, the medical record documented that the resident requested transfer to the hospital for treatment and evaluation, but there was no documentation that a bed-hold notice was provided at the time of transfer. For another resident with mild cognitive impairment who was transferred and admitted to the hospital by ambulance, review of the medical record likewise showed no documentation that a bed-hold notice was provided. A hospital staff member reported that the first resident had previously occupied a semi-private room, and when the hospital notified the facility that the resident was ready for discharge, the facility stated only a four-bed room was available because the prior semi-private bed was no longer available; the resident did not want to return to a four-bed room, and the hospital had to locate another facility for discharge. The DNS confirmed that bed-hold forms were not signed and there was no documentation that bed-hold notices were provided to these two residents, and acknowledged that nursing staff were responsible for ensuring bed-hold notices were given when residents were transferred to the hospital with an expected return.
Failure to Implement Recommended Restorative Nursing Program After PT Discharge
Penalty
Summary
The facility failed to provide restorative nursing services as recommended for a resident with a right below-the-knee amputation. Facility policy stated that residents identified through the comprehensive assessment process as needing restorative nursing services would receive them, including interventions such as passive or active ROM, splint or brace assistance, bed mobility, transfer and walking training, dressing and grooming training, eating and swallowing training, amputation/prosthesis care, and communication training. The policy also required the discharging therapist, Restorative Nurse, or designated licensed nurse to communicate the restorative nursing plan to the appropriate restorative aide and provide necessary training. The resident was admitted with a diagnosis including a right below-the-knee amputation and, per a quarterly MDS, had mild cognitive impairment, no behaviors, required staff assistance for ADLs, transfers, and mobility, and used a wheelchair. A PT Discharge Summary covering services from 08/18/2025 through 09/30/2025 documented recommendations for a Restorative Nursing Program and follow-up with a prosthetic company for further fittings. Review of the medical record showed no physician’s order for restorative nursing program services for this resident, and during interview the PT confirmed there was a recommendation for restorative services but no documentation that the resident received them.
Failure to Obtain Resident Input and Provide Consistent Nourishing Bedtime Snacks During 15‑Hour Meal Interval
Penalty
Summary
The facility implemented a new meal schedule that created a 15‑hour interval between the evening and morning meals for all dining locations, with dinner times ranging from 4:30 PM to 6:00 PM and corresponding breakfast times from 7:30 AM to 9:00 AM. Resident Council minutes documented the new schedule and indicated that a flyer explaining the change was distributed by the Activities Director; however, a resident council member reported that residents were only informed of the new mealtimes and were not given the opportunity to vote on or approve the 15‑hour gap. The resident stated they would have voted against the change if given the option and indicated that snacks were put out but residents had to ask for them. Multiple residents reported inconsistent access to evening snacks, with one resident describing snack availability as “hit and miss” and stating staff sometimes said there were no snacks, and another resident reporting they had to ask for snacks but never received them because staff said they were out. The Dietary Manager stated that CNAs and residents could request snacks at the kitchen door and that snack trays were placed out after breakfast and again at night, but acknowledged uncertainty about whether staff went room to room, particularly for bedbound residents. The Activities Director and Activity Aide described snack offerings from an activities cart during the day and evening and mentioned a stocked refrigerator accessible at night, while the Administrator stated that CNAs and activities staff were supposed to offer snacks and water after dinner, with no documentation of the evening snack pass. The Registered Dietician reported she was not informed of the 15‑hour gap between dinner and breakfast and was unaware that a nourishing snack was required when the interval between meals exceeded 14 hours. The facility later indicated its snack policy was under revision.
Unsecured Smoking Materials and Inadequate Lighting in Smoking Area
Penalty
Summary
The deficiency involves the facility’s failure to secure cigarettes and complete a smoking assessment for one resident, and failure to maintain adequate lighting in the smoking area and access pathway. One cognitively intact resident with current tobacco use had cigarettes stored unsecured in the top drawer of the bedside cabinet. The resident stated they kept their cigarettes in the drawer, and the cigarettes were later collected by an LPN, who stated they should have been locked in the treatment cart labeled with the resident’s name. The DON reported that residents were expected to give staff their cigarettes when purchased so they could be locked in the treatment cart. The same resident’s smoking assessment, dated several days prior to the MDS, was incomplete, with blanks under the sections for medications, resident behaviors, and nursing assessment of smoking safety. A Resident Care Manager/RN confirmed that the smoking assessment was not complete and stated they would need to reevaluate the resident. These omissions meant that the resident’s smoking-related risks and safety needs were not fully documented or assessed as required by the facility’s process. The facility also failed to provide adequate lighting for residents using the designated smoking area and the sidewalk leading to it. Residents accessed the smoking area by exiting through the dining room door and proceeding along a concrete area and then a sidewalk with a small S-curve, where there were 2–6-inch drop-offs or ruts between the sidewalk edge and adjacent planters or ground, with visible wheel tracks in the mud. Staff who supervised smoking and multiple residents reported that management had stopped turning on the flood lights after dark due to concerns about residents smoking marijuana and a whiskey bottle found near the area, but residents continued to use the smoking area in the dark. One resident reported falling while walking back from the smoking area when it was “pitch black,” and other residents and staff described the area as dangerous due to the narrow sidewalk, uneven surfaces, and lack of lighting. Observations confirmed that the string of flood lights along the fence was the sole effective light source when on, that solar lights provided only a faint glow, and that ruts along the sidewalk had trapped residents’ electric wheelchairs, sometimes requiring assistance to get back onto the path.
Failure to Supervise High Fall Risk Resident Resulting in Injury
Penalty
Summary
The facility failed to provide adequate supervision and implement effective fall prevention strategies for a resident assessed as high risk for falls. The resident, who had diagnoses including end stage renal disease and atrial fibrillation, was cognitively intact but required substantial to maximal staff assistance for mobility and transfers, and was dependent on staff for chair to bed transfers. Despite documented balance deficits, decreased safety awareness, and a history of multiple unwitnessed falls from bed, the resident was repeatedly left unsupervised at the edge of the bed, contrary to care plan interventions and staff knowledge of the resident's needs. The resident experienced at least four unwitnessed falls, each time being found on the floor after being left at the edge of the bed or in bed without adequate supervision. After each fall, interventions such as ensuring the resident was not left at the edge of the bed, frequent checks, and securing the mattress were documented, but these were not consistently implemented. On one occasion, after returning from dialysis and expressing fatigue, the resident was positioned at the edge of the bed for a meal and left unattended, resulting in a fall that caused multiple fractures to the right wrist and required hospital transfer. Interviews with staff confirmed that the resident required two staff and a mechanical lift for transfers, had significant balance issues, and was not safe to be left at the edge of the bed unattended. Staff acknowledged that the resident was frequently drowsy, especially after dialysis, and that leaving the resident unsupervised at the bedside was unsafe. The Director of Nursing Services also confirmed that the resident was high risk for falls and should not have been left unattended at the edge of the bed, especially given the resident's history and condition at the time.
Failure to Maintain Adequate Room Temperatures for Residents
Penalty
Summary
The facility failed to provide a comfortable and homelike environment by not maintaining adequate heat in resident rooms across three of four hallways reviewed. Facility documentation required ambient temperatures in resident and patient care areas to be maintained between 71 and 81 degrees Fahrenheit, or as required by state or local regulations. However, multiple temperature readings taken in various resident rooms showed temperatures significantly below this range, with some rooms as low as 58.1 degrees Fahrenheit. Residents and their families reported ongoing issues with cold rooms, and several residents confirmed during interviews that their rooms were cold. Staff interviews revealed that the heating system required manual intervention by maintenance to activate heaters in individual rooms, and that many heaters had not been cleaned or turned on. The maintenance director acknowledged that most resident rooms in the affected hallways did not have heaters operating at the time of the survey and that the HVAC system was still awaiting repairs and parts replacement. Staff also reported that there had been heat outages, particularly over weekends, and that residents had complained about the cold. In response, staff provided extra blankets, but residents continued to express discomfort, with one resident stating that it was so cold she did not want to take a shower. The maintenance director further acknowledged that previous maintenance staff had not ensured that resident heaters were properly cleaned and maintained, contributing to the ongoing issue of inadequate room temperatures.
Failure to Provide Timely Wound and Catheter Care
Penalty
Summary
The facility failed to provide wound and indwelling catheter care according to physician orders and facility policy for a resident who was admitted with multiple fractures, a subarachnoid hemorrhage, an external fixator, and an indwelling catheter. Upon admission, the resident required staff assistance for most activities of daily living and had documented needs for surgical wound care and catheter care. However, wound care orders for the external fixator were not obtained until four days after admission, and catheter care orders were not obtained until seven days after admission, coinciding with the resident's discharge. Documentation showed that wound care for the external fixator was not completed for the first four days, and there was no documented catheter care during the resident's stay. Collateral contact reported that the resident's surgical dressing was not changed for extended periods and catheter care was not performed, leading to the resident leaving the facility against medical advice. The Director of Nursing confirmed that although the catheter and external fixator were identified on the care plan and admission assessment, treatment orders were not promptly obtained, and there was no documentation of care provided for the indwelling catheter or the external fixator until several days after admission.
Failure to Obtain Weights and Provide Recommended Nutritional Supplement
Penalty
Summary
The facility failed to obtain required admission weights for a resident with significant medical conditions, including non-traumatic subarachnoid hemorrhage, cerebral aneurysm, hemiplegia/hemiparesis, and dysphagia. Although physician orders specified that admission weights should be taken for three days, only one weight was documented, and no further weights were recorded until nearly two months later. The resident's care plan also called for weekly weights, but these were not completed as required. Additionally, the dietician recommended a nutritional supplement (Benecalorie) three times daily due to the resident's poor intake and risk for weight loss. However, this recommendation was not forwarded to the physician for an order, and the resident did not receive the supplement. Documentation from the nutrition team repeatedly requested updated weights to confirm adequacy of intake, but these requests were not fulfilled. The DON acknowledged these failures during an interview.
Failure to Ensure Timely Receipt of Ordered Pain Medications
Penalty
Summary
The facility failed to ensure the timely acquisition and receipt of ordered medications for two residents with complex medical conditions and ongoing pain management needs. One resident, who was cognitively intact and had spinal stenosis and thoracic vertebrae fractures, had an active order for Morphine ER 30 mg every 12 hours for pain. This resident did not receive three consecutive doses as documented in the Medication Administration Records, with progress notes indicating the medication was pending or awaiting pharmacy delivery. The resident confirmed missing doses of prescribed pain medication due to the facility running out of the medication. Another resident, also cognitively intact and with lumbar stenosis and back pain, had an order for Norco 5-325 mg three times daily for pain. This resident missed four consecutive doses, with progress notes and staff interviews confirming the medication was not available and was awaiting pharmacy delivery. Both residents and staff acknowledged the missed doses, and the Director of Nursing Services confirmed the failures were due to medications not being received from the pharmacy in a timely manner.
Failure to Perform CPR on Unresponsive Resident
Penalty
Summary
The facility failed to ensure that staff performed CPR on a resident who was found unresponsive, despite having a physician's order for CPR. The resident, who was admitted with diagnoses including bladder cancer and diabetes, was alert and oriented according to the Minimum Data Set. The resident's POLST form indicated a preference for full resuscitation, including CPR and other life-sustaining treatments. However, when the resident was found unresponsive, the staff did not initiate CPR or call emergency services, which was a violation of the facility's emergency response policy. The incident began when a CNA found the resident unresponsive and reported it to a Licensed Practical Nurse (LPN), who also found no signs of life. Instead of initiating CPR, the LPN sought assistance from a Registered Nurse (RN), whose CPR certification could not be verified. The RN assessed the resident and concluded that the resident had passed away without attempting resuscitation. The facility's investigation revealed that the staff involved did not follow the emergency response protocol, which required immediate CPR in the absence of a DNR order. Interviews with the facility's Administrator and Director of Nursing confirmed that the staff failed to initiate CPR or notify emergency services, leading to the resident's death. The investigation also uncovered that several staff members did not have current CPR certifications, contributing to the failure to provide the necessary emergency response. This deficiency was identified as an Immediate Jeopardy situation, placing residents at risk for serious harm or death.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services to promote wound healing and prevent the development or worsening of pressure ulcers for four residents. Resident 1 experienced harm due to the lack of timely skin assessments and treatment, resulting in the development of an unstageable pressure ulcer on the left heel. Despite hospice documentation noting a new pressure injury, treatment was not initiated for 12 days. Observations revealed that Resident 1 was often without protective boots, which were intended to relieve pressure on the heels. Resident 2, who was admitted with paraplegia and a fracture, had a care plan that included monitoring and documenting pressure injuries. However, there were significant gaps in skin assessments, and the resident did not receive an air mattress as required. A wound consultant later identified a healing Stage 3 pressure ulcer, indicating a lack of timely intervention and monitoring. Resident 5, at risk for pressure ulcers, also experienced incomplete skin assessments. A skin tear on the upper back was not properly documented or treated, leading to the development of an unstageable pressure ulcer. Resident 6, admitted with cerebral palsy and polyneuropathy, did not receive any skin assessments after the initial admission assessment, despite being at risk for pressure ulcers. The facility's Director of Nursing acknowledged the failure to complete weekly skin assessments for these residents, attributing it to the absence of a wound nurse.
Failure to Verify Gastrostomy Tube Placement and Follow Hydration Orders
Penalty
Summary
The facility failed to properly assess the placement of a gastrostomy tube before initiating enteral feeding for a resident, identified as Resident 7. This resident was admitted with conditions including cerebral infarction, hemiplegia, dysphagia, and severe protein malnutrition, and had a feeding tube in place upon admission. According to the facility's policy, the placement and functioning of the feeding tube should be verified before any feeding, flushing, or medication administration. However, during an observation, a Licensed Practical Nurse (LPN) did not check the placement of the gastrostomy tube before administering 50 ml of water and 250 ml of the prescribed enteral feeding. Additionally, the LPN did not follow the prescribed hydration orders, as she flushed the tube with only 50 ml of water instead of the prescribed 100 ml after the feeding. The LPN acknowledged these oversights during the observation. This failure to adhere to the facility's policy and the physician's orders placed the resident at risk for nutritional alterations and decreased quality of life.
Deficiencies in Monitoring Weight Loss and Fluid Restrictions
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss and fluid restrictions for several residents, leading to potential harm and decreased quality of life. Resident 71 experienced a significant weight loss of 14.41% in 55 days due to the facility's failure to obtain weekly weights as per the care plan, update the physician with the registered dietician's recommendations, and offer supplemental food when the resident consumed less than fifty percent of their meal. The facility did not have orders for weekly weights, and there was a lack of communication with the physician regarding the dietician's recommendations for over five weeks. Resident 65 also experienced harm due to inadequate supplement intake and lack of modification in dietary interventions, resulting in a significant weight loss of 16.64% in 113 days. The facility's documentation showed inconsistencies in meal intake records, with staff failing to offer alternatives or supplements when the resident consumed less than 50% of their meals. Additionally, there were gaps in the medication administration record, indicating a lack of documentation for the resident's liquid nutritional supplement intake. The facility also failed to monitor and implement accurate fluid restrictions for residents with specific medical conditions. For instance, Resident 1 had a fluid restriction order that was not consistently communicated to or documented by staff, leading to incomplete records of fluid intake. Similarly, Resident 6's fluid restriction was inconsistently documented, with discrepancies between the care plan and actual intake records. Resident 12's fluid restriction was not adequately communicated to staff, and there was a lack of documentation to reconcile the resident's total fluid intake, resulting in potential non-adherence to the prescribed fluid restriction.
Staffing Shortages Lead to Delays in Resident Care
Penalty
Summary
The facility failed to ensure sufficient qualified nursing staff were available to provide care and services, as evidenced by interviews with residents and staff. Residents reported long wait times for assistance with activities of daily living, such as bathing and being assisted back into bed. Some residents expressed concerns about not receiving care according to their preferences, such as having a female staff member assist with bathing. Staff interviews revealed that the workload was overwhelming, with Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) responsible for a large number of residents, leading to incomplete tasks and documentation. The facility's staffing issues were further compounded by the removal of aides from the Restorative Nursing Program (RNP) to cover direct care staff absences. This resulted in the RNPs not being completed for several residents. The Director of Nursing Services (DNS) and other management staff were also pulled from their duties to provide direct care, which affected their ability to perform their primary responsibilities, such as oversight and timely assessments. The facility was missing Registered Nurse (RN) coverage on multiple dates, which could potentially delay resident care needs being met. The facility's hiring and retention efforts were inadequate, with open positions being listed on job platforms but no specific retention interventions in place. The staffing coordinator was responsible for determining staffing levels, but the DNS was unaware of how these levels were set. The facility's reliance on management staff to cover staffing shortages further strained the ability to provide consistent and timely care to residents, as evidenced by the delays and incomplete care reported by both residents and staff.
Deficiencies in Staff Competency and Infection Control Practices
Penalty
Summary
The facility failed to ensure that licensed nurses and nursing aides possessed the necessary competencies and skills to provide adequate nursing services, particularly in the implementation of Enhanced Barrier Precautions (EBP) and the correct use of personal protective equipment (PPE). Staff members demonstrated a lack of understanding regarding the facility's orange sticker system, which was intended to indicate residents on EBP. There was no additional signage to support this system, and some residents who required EBP were missing the necessary indicators. Staff members, including the Infection Preventionist and Certified Nursing Assistants, were unclear about the meaning of the orange stickers and the appropriate precautions to take, such as the use of gowns during high-contact care activities. The facility also failed to implement effective orientation and training for agency and contracted staff. Staff members reported that they had only received training during their initial orientation and had not participated in recent training sessions. The facility lacked a written policy or system to orient agency staff to its policies and procedures, as confirmed by the Administrator and Director of Nursing Services. This lack of ongoing training and orientation contributed to the staff's inadequate understanding and implementation of necessary precautions and procedures. Additionally, the facility did not ensure that staff were trained and competent in managing central venous catheters, as evidenced by the absence of training and competency evaluations for staff responsible for central line care. The oversight of the Restorative Nursing Program was also deficient, as the designated Restorative Nurse had left, and the Director of Nursing Services, who assumed the duties, was unaware of the requirements. The Restorative Nursing Assistants had not met with a Restorative Nurse since November 2024, indicating a lack of oversight and evaluation of the program's effectiveness.
Governing Body's Oversight Failures Lead to Multiple Deficiencies
Penalty
Summary
The governing body of the facility failed to ensure adequate oversight and monitoring of the administration and nursing directors, resulting in several deficiencies in care and operations. The facility was not staffed sufficiently to meet the needs of the residents, leading to delays in activities of daily living (ADLs) such as showers, grooming, and nail care. Additionally, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, which resulted in repeated deficiencies over several years. The lack of oversight also extended to infection control practices, intravenous therapy, and restorative nursing, placing residents at risk for injury and unmet needs. The facility's staffing issues were further compounded by the removal of Restorative Nursing Assistants (RNAs) from their duties to cover direct care staff absences, which disrupted the Restorative Nursing Program (RNP). The facility also failed to ensure that licensed nurses and nursing aides had the appropriate competencies and skill sets to provide necessary nursing services, including infection control procedures. The governing body did not implement policies for the orientation of agency staff or provide updated training for licensed staff in managing central venous catheters. The governing body also failed to maintain a Quality Assessment and Assurance (QAA) committee with required members, such as the Infection Preventionist and Medical Director, to conduct necessary QAPI and QAA activities. This lack of a functioning QAPI program led to the facility's inability to self-identify deficiencies and develop effective plans of action. Additionally, the facility did not have systems in place to monitor residents for weight loss or implement timely interventions, resulting in harm to two residents. The facility also failed to track and document staff COVID-19 vaccination status, further highlighting the lack of oversight and effective management.
Repeated Deficiencies Due to Ineffective QAPI Program
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) program effectively identified and addressed deficiencies, leading to repeated and widespread deficiencies. During an interview, the Administrator, who had only been in the facility since January 2025, admitted to not having reviewed the previous deficiency report or attended a QAPI meeting. This lack of engagement with the QAPI process contributed to the facility's inability to sustain corrections for previously identified deficiencies. The report highlights several repeat deficiencies across multiple surveys, including issues related to resident rights, self-determination, treatment requests, activities of daily living (ADL) care, quality of care, unnecessary psychotropic medication use, nutrition, food safety, and infection control. These deficiencies were identified in past surveys and were not effectively addressed, resulting in a pattern of harm and placing residents at risk for unmet needs that could negatively impact their safety, quality of life, and quality of care.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to operationalize an effective Infection Prevention and Control Program (IPCP) as evidenced by multiple instances of staff not adhering to standard precautions, enhanced barrier precautions, and transmission-based precautions. Observations revealed that staff frequently neglected to perform hand hygiene between resident interactions, failed to use personal protective equipment (PPE) appropriately, and did not follow protocols for residents on enhanced barrier precautions (EBP). This was observed across all four halls of the facility, with staff handling food trays, assisting residents, and performing care activities without proper hand hygiene or PPE use. The facility's policy on enhanced barrier precautions was not consistently followed, as evidenced by the lack of clear signage and staff understanding of the orange sticker system meant to indicate residents requiring EBP. Staff interviews revealed confusion about the meaning of the orange stickers and when to implement EBP, leading to inadequate use of gowns and gloves during high-contact resident care activities. Several residents who should have been on EBP due to wounds or indwelling medical devices were not properly identified or managed according to the facility's policy and CDC guidelines. Additionally, during a suspected gastrointestinal outbreak, the facility failed to promptly isolate symptomatic residents and implement transmission-based precautions. Residents exhibiting symptoms such as vomiting and diarrhea were not placed on appropriate precautions, and there was a lack of signage to indicate necessary PPE for staff entering these residents' rooms. Interviews with staff indicated a lack of communication and understanding regarding the outbreak and the necessary infection control measures, further compromising the facility's ability to prevent the spread of infection.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to address and resolve concerns raised by the Resident Council (RC) over a three-month period, leading to repeated unresolved issues and frustration among residents. The RC minutes from October, November, and December 2024 documented recurring issues such as dietary staff errors on meal trays, dirty utensils, missing clothing, and unsatisfactory coffee. Despite these concerns being consistently reported, the facility did not provide follow-up or resolutions, leaving residents feeling unheard and powerless. Interviews with residents and staff revealed a lack of communication and follow-up on the part of the facility. The RC President and other residents confirmed that they had not received any responses or updates on their concerns. The Activities Director, responsible for transcribing RC meeting notes and communicating with department heads, admitted to not receiving updates from department heads unless a grievance form was involved. Additionally, the facility's Resident Council Response Form, intended to track issues and resolutions, was not utilized, further contributing to the lack of resolution and communication.
Lack of Access to Personal Funds During Non-Banking Hours
Penalty
Summary
The facility failed to ensure that residents with personal funds or resident trust accounts had ready access to their accounts during evenings and weekends. This deficiency was identified for all 12 residents reviewed for personal funds accounts. Resident 4, who was cognitively intact as per the quarterly minimum data set assessment, reported being unable to withdraw money from their account on weekends. Staff K, the Business Office Manager, confirmed that residents could not access their funds after hours or on weekends until recently, when a new procedure was implemented allowing a nurse to contact the administrator for assistance with withdrawals. Staff A, the Administrator, corroborated that residents had been unable to withdraw money during non-banking hours until about three weeks prior to the survey.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly personal fund statements to residents with personal fund accounts, affecting three sampled residents. Resident 4, who was cognitively intact, reported not receiving statements and expressed a desire for monthly statements. Staff K, the Business Office Manager, was uncertain if statements were distributed before their employment in October 2024 but indicated that statements would be distributed moving forward. Staff A, the Administrator, confirmed that trust fund account statements were not provided until they began working at the facility three weeks prior, and assured that residents would start receiving statements that week.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment across all four wings, as observed during the survey. Specific deficiencies included overhead lights being out or containing dead bugs, blue decorative coverings peeling off resident doors, and gouges in doorways exposing wood beneath. Additionally, the shower room on C Wing had peeling paint, a moldy smell, and a dust-covered air vent. These conditions were observed over multiple days, indicating a lack of timely maintenance and cleaning. Staff O, the Maintenance Director, acknowledged awareness of some issues, such as the non-functioning overhead light in a resident's room and the peeling blue coverings, but had not yet addressed them. Furthermore, Resident 61's tube feeding pole was heavily soiled with dried feeding solution, which was confirmed by Staff C, the Resident Care Manager. These observations highlight the facility's failure to ensure a clean and well-maintained environment, as required by regulations.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to establish a system to ensure grievances were properly initiated, logged, addressed, and resolved in response to residents' verbal concerns during Resident Council meetings over a three-month period. The Resident Council minutes for October, November, and December 2024 revealed multiple complaints from residents regarding dietary issues, such as errors on meal trays, dirty utensils, and inadequate portion sizes. Additionally, residents reported maintenance and laundry issues, including missing clothing and unreturned laundry items. Despite these recurring complaints, the facility did not initiate or log grievances for these issues, leaving them unaddressed. In October, residents expressed concerns about dietary errors, dirty utensils, and missing laundry items. However, the grievance log for that month showed no initiation or logging of grievances for these issues. In November, similar complaints were raised, including dietary errors, dirty dishware, and delayed call light responses. Again, the grievance log did not reflect any initiation of grievances for these concerns. By December, residents continued to report unresolved issues, such as dietary staff not following tray cards, missing clothing, and inappropriate behavior by nurse aides. Yet, the grievance log remained devoid of any entries addressing these ongoing complaints. The facility's failure to log and address grievances was compounded by the lack of follow-up and investigation into the residents' concerns. The Activities Director, responsible for transcribing Resident Council minutes, admitted to not participating in the follow-up process and acknowledged that grievances should have been initiated on behalf of the residents. This oversight placed residents at risk of feeling frustrated and diminished their quality of life, as their concerns were not being adequately addressed or resolved.
Failure to Document Restraint Use and Alternatives
Penalty
Summary
The facility failed to obtain necessary assessments, orders, consents, and care plans for the use of potential restraints, specifically bed rails and mobility bars, for four residents. Resident 4, who was cognitively intact, had their bed placed against the wall without an evaluation, consent, order, or care plan. Similarly, Resident 1, also cognitively intact, had their bed against the wall without the required documentation. Resident 65, who was moderately cognitively impaired, had their bed against the wall and window without an order, evaluation, consent, or care plan. Staff acknowledged the absence of these documents and the expectation for them to be in place. Resident 6, who was cognitively intact and dependent on staff for lower body mobility, used upper bilateral mobility bars for repositioning in bed. However, there was no safety assessment or care plan for the use of these bars. Staff interviews revealed that the consent form did not include an assessment of safety for the use of mobility bars, and no alternatives were offered before their use. The facility's policy required these elements to be documented, but they were not found in the residents' electronic health records.
Failure to Notify Residents and Representatives of Transfers
Penalty
Summary
The facility failed to provide written transfer or discharge notices to residents and their representatives, as well as notifications to the Ombudsman, for several residents who were transferred to the hospital. Specifically, five residents did not receive the required transfer/discharge notifications, and six residents did not have the Ombudsman notified of their transfers. This lack of communication was confirmed through interviews and record reviews, which showed that the facility did not adhere to its own policy requiring such notifications to be provided in a language and manner understandable to the residents and their representatives. Additionally, the facility failed to update a resident's representative regarding a hospitalization. In the case of one resident with PTSD, depression, and anxiety, the medical and financial power of attorney was not informed of the resident's transfer to the hospital. The representative was unaware of the discharge and was not informed of the resident's whereabouts until later. The resident's belongings were not sent with them, and the representative was only updated on the situation after inquiring about the resident's discharge. This oversight was acknowledged by the facility's staff, who admitted that the expected notifications had not been completed.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their representatives at the time of transfer to the hospital for four out of six sampled residents. This deficiency was identified during a review of hospitalization records for Residents 4, 11, 42, and 57. The facility's policy, titled 'Bed hold Notice Upon Transfer,' requires that written information about bed hold policies be provided to residents or their representatives before a transfer or within 24 hours in the case of an emergency transfer. However, the electronic health records for these residents showed no documentation of bed hold notifications being provided. During an interview with the Administrator and the Director of Nursing Services, it was confirmed that the facility's practice was to offer a bed hold notice only if the resident expressed a desire for it. If the resident did not want a bed hold, no notice was provided. Staff B acknowledged that Residents 4, 11, 42, and 57 should have received bed hold notifications, indicating a lapse in adherence to the facility's policy and state regulations.
Inaccurate MDS Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments were complete and accurate for nine residents, leading to potential risks of unmet and unidentified care needs. For Resident 27, the MDS inaccurately recorded a gradual dose reduction (GDR) date for an antipsychotic medication, which was not supported by the Electronic Health Record (EHR). Similarly, Resident 11's MDS did not reflect a completed Level II Preadmission Screening and Resident Review (PASRR), despite it being present in the EHR. Resident 12's MDS failed to include an active diagnosis of anxiety, despite the resident being prescribed an antianxiety medication for this condition. Resident 42's MDS inaccurately documented participation in restorative programs, which were not individualized or properly documented in the care plan. Residents 1 and 65 had restorative nursing programs incorrectly coded on their MDS, which were acknowledged as errors by the MDS Director. Resident 16's MDS inaccurately marked dialysis instead of hospice services, and Resident 32's MDS failed to update the care plan after hospice services were discontinued, also missing documentation of a right-hand contracture. Resident 57's MDS omitted the presence of a central line and intravenous access, which were necessary for their hemodialysis treatment. These omissions were acknowledged by the MDS Director as affecting the accuracy of the care plan. The report highlights multiple instances where the MDS assessments did not accurately reflect the residents' conditions or care needs, potentially impacting their quality of life.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to review and revise comprehensive care plans for seven residents, leading to deficiencies in individualized care. Resident 65, who was moderately cognitively impaired due to a stroke, and Resident 4, who was cognitively intact, both had their beds positioned against the wall without any care plan, evaluation, consent, or order documented. Staff members confirmed the absence of these necessary documents in the residents' charts, which was against the facility's expectations. Resident 6, who required dialysis for kidney disease, had missing information in their care plan regarding dialysis details, such as the nephrologist's information and goal dialysis weight. Additionally, the care plan lacked documentation on the use of mobility bars, which were necessary for the resident's repositioning. Staff interviews revealed that these omissions were acknowledged, and it was confirmed that such information should have been included in the care plan. Other residents, such as Resident 11, 27, 12, and 61, also had incomplete care plans. Resident 11's care plan did not include Level II PASRR recommendations, while Resident 27's care plan lacked specific interventions for dementia and anxiety management. Resident 12's care plan did not specify the antidepressant medications or target behaviors for monitoring. Lastly, Resident 61's activity care plan failed to incorporate their interests in being around pets and going outside for fresh air, as identified in their MDS. These deficiencies in care planning placed residents at risk of receiving inappropriate and inadequate care.
Inadequate Care Plan Revisions in LTC Facility
Penalty
Summary
The facility failed to ensure care plans were consistently reviewed and revised to meet the current needs of several residents, leading to deficiencies in care. For instance, Resident 65's care plan inaccurately reflected their medication regimen, as it listed an oral analgesic that was not being administered. This discrepancy was identified by the Director of Nursing, who noted that the care plan did not align with the medication administration record. Resident 27's care plan was not updated to reflect the use of two different classes of psychotropic medications, including an antianxiety medication that was not documented. Additionally, the care plan inaccurately stated a negative PASRR status, despite a Level II PASRR referral being made. The Resident Care Manager acknowledged these oversights, indicating that the care plan should have been updated to reflect the current medication regimen and PASRR status. Other residents, such as Resident 58, had care plans that were incomplete and not personalized to their needs. For example, the vision care plan did not address the resident's outdated glasses prescription or provide instructions for staff assistance. Similarly, the hearing care plan failed to address the missing hearing amplifier, and the dental care plan lacked guidance on the resident's oral care needs. These deficiencies were acknowledged by the Resident Care Manager, who stated that the care plans needed to be reviewed and revised to accurately reflect the residents' care needs.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for 13 of 25 sample residents. Nurses did not accurately follow or clarify physicians' orders, leading to medication errors and delays in treatment. For instance, Resident 65 received blood pressure medications despite having a systolic blood pressure below the threshold specified in the physician's order. Similarly, Resident 175 did not receive a cancer medication on two occasions because it was not available, and there was no documentation of the physician being notified. Resident 3 was given acetaminophen for pain without meeting the temperature criteria specified in the physician's order, and the nursing staff failed to contact the physician to provide the medication outside the parameters of the order. Resident 55 received blood pressure medications despite having vital signs that should have prompted the medications to be held. Additionally, Resident 42 received oxygen at a rate higher than ordered, and there was no documentation of the actual rate administered. The facility also failed to perform stat lab tests and x-rays in a timely manner for Resident 42, and there was a lack of documentation for medication administration. Other deficiencies included Resident 12 receiving pain medication outside the ordered parameters, Resident 71 not receiving a stat urinalysis due to a supply shortage, and Resident 7 having incomplete documentation for monitoring symptoms. Resident 40 missed several doses of scheduled medications without documented rationale, and Resident 69 received a pill instead of a liquid multivitamin without notifying the provider. Resident 1's low blood pressure reading was not followed up with a manual check or provider notification, and Resident 27's high blood pressure was not communicated to the provider when medication was held. Lastly, Resident 6 did not receive diabetic diet counseling from a registered dietician as ordered.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for three residents, leading to deficiencies in care. Resident 124, who required extensive assistance with personal hygiene, reported not having their teeth brushed for seven days after admission. Despite requesting a toothbrush multiple times, it was not provided until observed by surveyors. Staff acknowledged that hygiene supplies and assistance should have been provided upon admission. Resident 32, who was moderately cognitively impaired and required substantial assistance, was observed with unshaved scruff and tangled hair. The resident expressed a desire to get out of bed for meals and activities, but was not assisted in doing so. The facility had not provided a haircut despite multiple requests, and there was confusion about the resident's hospice status, affecting their care plan. Staff acknowledged the need for daily personal care and assistance with getting out of bed. Resident 27, with severe cognitive impairment and on hospice care, required supervision and assistance with eating. Observations showed the resident was unable to open food containers and did not receive the necessary setup assistance, resulting in uneaten meals. Staff incorrectly believed the resident was independent in eating, despite care plans indicating the need for supervision and setup assistance. The Director of Nursing Services confirmed the expectation for staff to assist with meal setup and provide alternative food options based on the resident's preferences.
Failure to Implement Bowel Management Protocols
Penalty
Summary
The facility failed to implement bowel management interventions for three residents, leading to prolonged periods without bowel movements. Resident 32, who was moderately cognitively impaired and required significant assistance with activities of daily living, did not have a bowel movement for six days. Despite the facility's bowel protocol, which required interventions after three days without a bowel movement, no PRN medications were administered, and there was no documentation of physician notification. Similarly, Resident 65, also moderately cognitively impaired, experienced two separate four-day periods without bowel movements, yet no bowel management medications were administered as per the protocol. Resident 3, who was cognitively intact, went six days without a bowel movement, and the bowel protocol was not initiated. The facility's Director of Nursing Services acknowledged that pharmacological and non-pharmacological interventions should have been implemented by the third day of no bowel movement. The failure to adhere to the bowel management protocol placed these residents at risk for discomfort and further complications.
Deficiency in Providing Required Restorative Services
Penalty
Summary
The facility failed to provide restorative services at the frequency required for five out of six residents reviewed with restorative nursing programs (RNPs). These residents were assessed to need specific restorative services to maintain or improve their range of motion (ROM) and mobility. However, the facility did not meet the required frequency of these services, as documented in the residents' care plans and medical records. For instance, Resident 1, who had a cerebral infarction affecting their right side, was supposed to receive passive ROM and dressing/grooming services five to seven days a week but did not receive them at the required frequency. The facility's restorative nursing documentation policy required that the need for restorative services be documented in the medical record and indicated on the resident's plan of care. However, the care plans for several residents, including Residents 42, 69, and 61, lacked specific details such as measurable goals, personalized interventions, and the number of repetitions and sets to be performed. Additionally, the facility's staffing issues contributed to the deficiency, as there was a shortage of restorative aides, and the Director of Nursing Services was unaware of their assumed duties as the Restorative Nurse. The facility's inability to provide the required frequency of restorative services was further exacerbated by staffing challenges. The Restorative Nursing Assistant (RNA) reported that they were unable to complete the necessary restorative programs due to being pulled for direct resident care when the facility was short-staffed. This staffing issue resulted in the RNA having insufficient time to complete the approximately 16 hours of restorative programs needed per day, leading to the deficiency in providing adequate restorative care to the residents.
Deficiencies in PICC Line Management for Two Residents
Penalty
Summary
The facility failed to ensure proper assessment, maintenance, and monitoring of Peripherally Inserted Central Catheters (PICC lines) for two residents receiving intravenous (IV) therapy. The deficiencies were identified during a review of the facility's practices and policies, which revealed that the IV orders for both residents did not include essential details such as the rate and duration of infusion, method of delivery, and flush orders. Additionally, there was no documentation of the measurement and monitoring of the PICC line's external length or the regular changing of needleless injection caps. Resident 55, who was admitted with a double lumen PICC line for the treatment of a right hip infection, had incomplete IV orders that lacked flush instructions and details about the infusion process. The facility also failed to document the measurement of the PICC line's external length and the changing of needleless injection caps. Staff interviews confirmed the absence of these critical care components, which are necessary to prevent complications such as infection and loss of vascular access. Similarly, Resident 12, who required IV medication for osteomyelitis, had IV orders that did not specify the rate and duration of infusion or the method of delivery. The facility did not document the performance of PICC flushes before and after medication administration, nor did they measure the PICC line's external length or change the needleless injection caps as required. These omissions were confirmed by staff interviews, highlighting a systemic issue in the facility's management of IV therapy.
Failure to Ensure Freedom from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications, affecting four residents. Resident 1, who was cognitively intact and reported no pain, continued to receive tramadol despite consistently documented pain scores of zero, except for one instance. The Director of Nursing Services acknowledged that a pain assessment should have been completed, and the provider notified when zeros were documented across the board. Resident 27, with severe cognitive impairment and on hospice care, was receiving scheduled tramadol and acetaminophen despite consistently documented pain scores of zero. The resident had an as-needed tramadol order for pain related to falls, which was not updated after the last fall. The Resident Care Manager admitted that the order should have had a stop date and that the necessity for pain medication was only reviewed if there was increased pain or use of as-needed medications. Resident 32 continued to receive Bactrim DS prophylactically for a healed heel ulcer, with no documentation explaining the continued use. Staff members were unaware of the reason for the ongoing antibiotic treatment. Resident 42, who required supplemental oxygen, had an order to decrease the oxygen flow rate that was never transcribed or implemented. The resident's SpO2 levels were consistently above the required threshold, yet the facility failed to document or assess the need for continued supplemental oxygen, as confirmed by the Resident Care Manager.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications had specific target behaviors identified for their use, behavior and adverse side effect monitoring were in place, non-pharmacological interventions were identified and documented, informed consent was obtained prior to administering the medication, and resident-specific care plans and interventions were developed and implemented. This deficiency was observed in four out of five sampled residents reviewed for unnecessary medications. Resident 12, who was cognitively intact and diagnosed with depression, was prescribed multiple psychotropic medications without specific target behaviors identified for each medication. The care plans did not specify the medications or the target behaviors they were intended to treat, and there was no behavior monitoring in place. The Social Services Director acknowledged the lack of identification of target behaviors and monitoring. Resident 27, with severe cognitive impairment and receiving hospice services, was administered psychotropic medications without proper consent and monitoring. The resident received lorazepam before consent was obtained, and there was no documentation of non-pharmacological interventions before administering PRN doses. Additionally, orthostatic blood pressures were not monitored as required. Similar deficiencies were noted for Residents 3 and 40, where target behavior monitoring was absent, and medications were administered without proper consent or documentation.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling practices in the medication room and carts, leading to several deficiencies. In the A and B Medication Nursing Station Room, expired doses of Vancomycin were found in the refrigerator, which were confirmed by the Resident Care Manager (RCM) to be expired and should not have been kept. Additionally, the C Wing Cart contained uncovered medication cups for different residents, improperly stored ear and eye drops, and oral medications mixed with suppositories. Expired medications, such as Bupropion HCL, were also found, and wound care supplies were improperly stored on the medication cart instead of the treatment cart. The B Wing Cart had similar issues, with expired medications like Naloxone and Duloxetine HCL found, and a Symbicort inhaler lacking a complete expiration date. A pill cutter with a white powdery substance was also noted. A controlled substance, Norco, was not properly documented in the controlled substance book, and the medication administration record (MAR) was not updated. The medication was not wasted in a timely manner after a resident refused it, and it was improperly stored in the top drawer without a label. The A Wing Cart was observed unattended with Culturelle tablets left on top, which was confirmed by a Registered Nurse (RN) to be inappropriate. The facility's expectations, as stated by the RCM, were not met in several areas, including the storage of expired medications, proper labeling, and the handling of controlled substances. These deficiencies placed residents at risk for receiving expired medications, cross-contamination, and other medication-related issues.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to ensure that residents prescribed therapeutic diets received the correct foods and drinks as ordered by a physician or dietitian. During an observation, it was noted that the noon meal was plated uniformly for all residents, regardless of dietary needs, unless there was an allergy or dislike noted. Specific instances included a plate labeled 'controlled carbohydrates' and another labeled 'low calorie,' both of which were served without consideration for their dietary restrictions. Staff W, a cook, admitted to only serving Renal diets and was unaware of the requirements for other therapeutic diets. Staff H, the Dietary Manager, who had recently started, acknowledged the absence of a system to prepare and serve therapeutic diets, stating that the previous manager allowed residents to choose any food they wanted. Staff H confirmed that the facility was not in compliance with serving therapeutic diets, although efforts were being made to implement a new system to address this issue.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that its binding arbitration agreements included necessary wording regarding resident rights and did not adequately explain the agreements to residents. The arbitration agreements were missing critical information, such as the right of residents or their representatives to communicate with federal, state, or local officials, the requirement for a mutually agreed-upon neutral arbitrator, and the selection of a convenient venue for both parties. During interviews, staff members acknowledged the absence of this information in the agreements. Two residents, both cognitively intact, were affected by this deficiency. Resident 53 did not recall signing the arbitration agreement and expressed that they would not have signed it had they understood it meant waiving their right to litigation. Resident 18 was aware of signing the agreement but did not understand the arbitration process or that signing was optional. The facility did not explain that the agreement could be terminated or withdrawn within 30 days. The administrator confirmed that the facility's practices did not meet expectations for informing residents of their rights.
QAA Committee Lacks Required Members
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee that included the required members, specifically the Infection Preventionist (IP) and the Medical Director or their designee. This deficiency was identified through interviews and record reviews, which revealed that the QAA committee meetings throughout the past year were missing these key members. Specifically, the IP was absent from meetings on May 24th, 2024, and December 20th, 2024, while both the IP and Medical Director were absent from meetings on August 29th, 2024, and September 11th, 2024. The absence of these members detracted from the effectiveness of the QAA committee, potentially placing residents at risk for quality deficiencies and adverse events. The current Administrator, who joined the facility in January 2025, acknowledged the missing required QAA committee members but had not yet attended a QAPI meeting due to the time frame of their tenure.
Resident Privacy Not Maintained During Transport
Penalty
Summary
The facility failed to uphold the dignity of a resident by not providing adequate privacy during transportation after a shower. Resident 1, who was cognitively intact and required substantial to maximal assistance with bathing, was observed being transported down the hallway in a shower chair with only blankets draped over their abdomen, leaving their left side and buttocks exposed. This incident occurred on January 23, 2025, at 10:23 AM. Staff X, a Certified Nursing Assistant, was questioned about the incident and stated she did not notice the resident's bottom was exposed. The Director of Nursing, Staff B, later confirmed that the expectation was for residents to be covered when not clothed to maintain their dignity during such transport.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate resident bathing choices for three residents, leading to a deficiency in promoting resident self-determination. Resident 124, who required extensive assistance with bathing, reported receiving only one shower in 13 days since admission, despite being scheduled for showers twice a week. The facility's records corroborated the resident's account, showing no documentation of showers being offered or provided on the scheduled days. Similarly, Resident 42, who was cognitively intact and had their shower frequency increased to twice a week, was not offered or provided showers on several scheduled days. Resident 51, also cognitively intact and requiring oversight for safety, reported infrequent assistance with bathing, with records indicating a lack of documentation for offered or provided showers over several weeks. Staff confirmed that residents were not consistently offered or assisted with bathing according to their schedules, violating the residents' rights to self-determination and choice.
Failure to Transfer Resident Trust Funds Timely
Penalty
Summary
The facility failed to ensure the timely transfer of funds from a resident trust account following the discharge of a resident. Specifically, Resident 177, who was deceased, had a remaining account balance of $314.35 that was not transferred within the required 30-day period. This oversight was confirmed by the Business Office Manager, Staff K, who acknowledged that the account had not been closed in the stipulated timeframe. The Administrator, Staff A, was also aware of the issue and had contacted the Department of Social and Health Services to address the closure of the account.
Failure to Secure Resident Medical Information
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' medical information when a laptop on the D Wing Medication cart was left open and unsecured, displaying a resident's personal medical information. This incident involved Resident 60, whose medical information was visible on the laptop screen. Staff L, an Infection Preventionist, was observed talking to a contractor staff seven feet away from the open laptop and subsequently walked away without securing it. Over the next several minutes, multiple staff members, including Staff D, Resident Care Manager, and Staff M, Lead Restorative Nursing Assistant, walked past the open laptop without securing it. Eventually, Staff D noticed the open laptop and locked it. During a later interview, both the Administrator and the Director of Nursing Services confirmed that the expectation was for staff to lock the computer when stepping away from the cart.
Incomplete Documentation During Resident Transfer
Penalty
Summary
The facility failed to ensure complete documentation during the transfer or discharge of residents, specifically for one resident reviewed for closed records. Resident 11, who had been admitted with diagnoses of PTSD, depression, and anxiety, was transferred and discharged to the hospital. This discharge was initiated by the facility, which involved calling the police due to the resident's inappropriate behaviors. However, the facility did not maintain adequate documentation of the information provided to the receiving hospital. The Electronic Health Record (EHR) for Resident 11 lacked essential details such as the contact information of the practitioner responsible for the resident's care, resident representative information, Advance Directive information, special instructions or precautions for ongoing care, and comprehensive care plan goals. During interviews, Staff B, the Director of Nursing Services, acknowledged the absence of documentation and confirmed that communication with the hospital was minimal and undocumented. This deficiency placed residents at risk of unidentified and unmet medical needs.
Inaccurate PASRR Documentation for Two Residents
Penalty
Summary
The facility failed to ensure the completion and accuracy of the Level I Preadmission Screening and Resident Reviews (PASRR) for two residents, leading to potential risks of unmet and unidentified care needs. Resident 11 was admitted with diagnoses of PTSD, depression, and anxiety. However, their Level I PASRR completed prior to admission only included PTSD, and the Level II PASRR completed in 2023 also only addressed PTSD. Despite the addition of depression and anxiety diagnoses upon admission, no updated Level I PASRR was completed to reflect these changes. Interviews with staff revealed a lack of understanding regarding the need to update PASRRs when diagnoses change, not just medications. Resident 12 was admitted with orders for antidepressants and antianxiety medication. Their Level I PASRR indicated a diagnosis of depressive disorder but failed to include an anxiety disorder, despite documentation showing the use of buspirone for anxiety. The Social Services Director acknowledged the inaccuracy and the need to update the PASRR to reflect the resident's anxiety disorder. These deficiencies highlight the facility's failure to maintain accurate and complete PASRR documentation, potentially impacting the residents' quality of life.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to implement individualized activities for three residents, leading to a deficiency in meeting their needs for engagement and stimulation. Resident 69, who does not speak English and has a communication deficit, was observed multiple times in a dark room without any activities or social interaction, despite having a care plan that included music, TV, and one-on-one visits. The facility's activities assistant had quit, and the Activities Director was out sick, resulting in a lack of activities being offered to Resident 69. Resident 61, who is cognitively intact, expressed the importance of listening to music and being around animals. However, observations showed the resident lying in bed without music or TV, and the care plan did not address their interest in fresh air or animals. The Activities Director acknowledged that staff should have provided one-on-one interactions as per the care plan, but this was not done due to the director's absence. Resident 27, with severe cognitive impairment and receiving hospice care, valued having reading materials and music. Observations revealed the resident in bed without any activities or stimulation, often staring at a roommate's TV without sound. Interviews with staff indicated a lack of awareness of the resident's preferences, and the resident did not have their own TV, which was acknowledged as an issue by the Activities Director and DNS.
Failure to Provide Podiatry Care for a Resident
Penalty
Summary
The facility failed to provide necessary podiatry care and services for a resident, identified as Resident 61, who was reviewed for foot care. The resident, who was cognitively intact and required substantial to maximal assistance with hygiene and lower body care, was observed with long, yellow, thick, and untrimmed toenails. Several toenails were starting to curve around the ends of the toes. The resident reported that staff had not offered or provided toenail care since their admission to the facility, despite having received podiatry care prior to hospitalization and placement at the facility. The facility's Treatment Administration Records indicated that nail care was to be provided weekly on the resident's shower day, but documentation showed that this care was consistently not provided. Additionally, the resident was not referred to or seen by the podiatrist during the podiatrist's visits to the facility, despite the need for such care. Staff C, the Resident Care Manager, confirmed that the resident had not been referred or seen by the podiatrist and acknowledged that the resident should have already been referred or seen.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to consistently implement fall prevention interventions for Resident 27, who was admitted with diagnoses of dementia and anxiety and had a history of falls. The resident's care plan included interventions such as a fall mat to the right side of the bed and keeping the call light within reach. However, multiple observations revealed that the call light was often out of reach, draped over the bed, or on the floor, and the fall mat was not properly positioned next to the resident's bed. These lapses in care were noted during several observations, indicating a pattern of neglect in adhering to the resident's care plan. Staff interviews confirmed the deficiencies, with CNAs acknowledging that they had forgotten to place the call light within reach after providing care. The Director of Nursing Services also acknowledged that the expectations were not met regarding the placement of the fall mat and call light. Additionally, the resident required setup assistance with meals, but this was not consistently provided, as evidenced by an unopened food container left at the bedside. These failures placed the resident at risk of falling and injury, as well as a diminished quality of life.
Failure to Ensure Proper Catheter Care and Assessment
Penalty
Summary
The facility failed to ensure proper care and assessment for a resident with an indwelling urinary catheter, leading to a deficiency. Resident 42, who was cognitively intact, had an indwelling catheter without a documented justification for its continued use. The resident had a history of Fournier's gangrene, which required penile grafting, and was initially recommended to use a condom catheter to prevent skin breakdown. However, after developing an open sore from the condom catheter, the resident was switched to an indwelling catheter to keep urine out of the wound. Despite the resolution of the penile wound, there was no documented clinical justification for the continued use of the indwelling catheter, and the resident was not assessed for catheter removal. Additionally, the facility failed to secure the catheter tubing properly, as observed when Resident 42 reported feeling tugging on the catheter due to the absence of a leg strap. The facility also did not follow through with a urology referral for the resident, as the initial attempt to schedule an appointment was unsuccessful due to insurance issues, and no further attempts were documented. These inactions placed the resident at risk for unnecessary catheterization and potential complications.
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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