Eliseo
Inspection history, citations, penalties and survey trends for this long-term care facility in Tacoma, Washington.
- Location
- 1301 N Highlands Parkway, Tacoma, Washington 98406
- CMS Provider Number
- 505435
- Inspections on file
- 34
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Eliseo during CMS and state inspections, most recent first.
A resident with chronic respiratory failure, heart failure, and dementia had no documented bowel movement during their stay despite facility policy and provider orders requiring a stepwise bowel protocol. Admission information showed the last BM occurred prior to arrival, and the EHR contained no BM entries for the entire stay. The eMAR showed MOM was given, but there was no documentation of a digital rectal exam, rectal suppository, enema, or provider notification as required when MOM was ineffective. CNAs and LPNs described expectations to document BMs and follow the constipation protocol, and leadership acknowledged the protocol and orders were not followed. The resident’s family reported the resident was in pain, had no BM while at the facility, and was later found to have a fecal impaction at the hospital with additional complications.
Three residents requiring 15-minute monitoring for suicide risk or post-fall observation did not have complete or accurate documentation of their checks. In one case, a resident at risk for suicide was left unobserved during required intervals, and staff later documented checks they did not perform. For two other residents, monitoring logs were incomplete, with gaps in documentation, while the MARs indicated checks were done. The RCM confirmed that staff failed to follow documentation protocols.
A resident and their representative were not informed of specific charges for services not covered by insurance or private pay agreements. Only the daily room and board rate was disclosed, and additional service costs, such as therapy, were not communicated before the resident incurred them. This resulted in confusion and unmet expectations when services were discontinued and charges were not clearly explained.
The facility did not develop or implement complete care plans for five residents, resulting in unmet needs in areas such as activities, pain management, edema, and personal hygiene. Residents with dementia, chronic pain, edema, and dependence for personal care were observed or reported to have needs that were not addressed in their care plans, and staff confirmed that care planning was incomplete or missing for these issues.
The facility did not provide care as ordered for several residents, including not administering as-needed medications for loose stools, failing to monitor and document edema or apply compression stockings as ordered, and not repositioning a dependent resident as required. These actions were confirmed by staff interviews and direct observations.
Two residents with fluid restrictions were not properly monitored or provided fluids according to provider orders. Staff were unaware of the restrictions, documentation of fluid intake was inaccurate, and meal tickets instructed staff to provide more fluids than allowed. The process for totaling and monitoring fluid intake was not followed, resulting in residents receiving incorrect amounts of fluids.
The facility did not ensure that oxygen tubing and respiratory care equipment were properly dated and changed weekly as required by policy for three residents with significant respiratory and cardiac conditions. Observations found undated and improperly maintained equipment, and staff interviews revealed inconsistent knowledge and adherence to procedures for respiratory care equipment maintenance.
A resident with COPD and muscle weakness was moved between rooms multiple times and was not given the opportunity to view the new room or choose prior to one of the moves. The resident expressed concerns about the new room's size and the placement of personal belongings, and staff confirmed that the expected process of allowing a room viewing and follow-up on concerns did not occur.
The facility did not obtain or maintain required advanced directive (AD) and guardianship documentation for two residents, including one with dementia and another with a history of stroke. In both cases, the electronic health record lacked evidence of a durable power of attorney (DPOA) for healthcare, and care conference reports failed to document or review the residents' decision-making status as required.
A resident with dementia and depression continued to receive Seroquel and Depakote despite documentation that Seroquel was mostly ineffective and the resident had not exhibited behaviors for about a month. Staff observations noted the resident was frequently sleepy, and no dose reduction was attempted after starting Depakote, resulting in the continued use of unnecessary psychotropic medication and potential chemical restraint.
A resident with COPD and muscle weakness was involved in repeated verbal and physical altercations with a roommate, including items being thrown and shouting matches. Despite documentation of these incidents and facility policy requiring immediate investigation and reporting, no incident report was filed and the state was not notified. Staff interviews confirmed the reporting failure.
The facility did not conduct or document timely care conferences for two residents, one with diabetes and hypertension and another with heart failure, arthritis, and depression. Both residents either did not attend or could not recall attending a care conference, and required documentation was missing from the EHR, as confirmed by staff interviews and record review.
A resident with vascular dementia and depression was frequently documented by nursing staff as exhibiting continuous agitation and aggression, despite multiple observations and staff interviews indicating the resident was calm, asleep, or pleasantly conversive. This inconsistency between documentation and actual resident behavior reflects a failure to accurately monitor and record behaviors in line with professional standards.
A resident with diabetes and depression did not receive new glasses as prescribed following a neuro-ophthalmology consultation. Despite staff awareness and the prescription being available, a lack of communication and follow-up between nursing and health information staff led to a delay in obtaining the corrective lenses.
A resident with impaired mobility and a history of declining therapy services later requested to start a restorative therapy program. However, due to a lack of communication and follow-up among staff, the resident's request was not addressed, and no assessment or referral for restorative therapy was completed.
Two residents with chronic pain conditions did not receive appropriate pain assessment and monitoring. One resident on hospice care experienced daily pain but had inconsistent documentation and an improperly discontinued pain monitor. Another resident with multiple pain diagnoses reported ongoing pain and ineffective medication, with no ongoing pain monitoring or documentation in the EHR. Staff confirmed that pain assessments were not consistently performed or recorded as expected.
A resident with vascular dementia and depression did not receive person-centered, individualized interventions for dementia-related behaviors. The care plan included only general strategies and lacked documentation of the resident's preferences or specific approaches, despite ongoing behavioral issues such as aggression and resistance to care. Staff responses were limited to reapproaching, distraction, and redirection, without evidence of tailored interventions.
The facility did not post the required scheduled and actual nursing staff hours for each shift over several days. Staff responsible for staffing postings tracked the information but did not display it, and the Administrator was unaware of the incomplete postings.
A resident's grievances regarding missing property and communication issues were not promptly resolved by the facility. The grievance policy was not followed, as the Personal Possession Record was incomplete, and the investigation into missing items was inadequately documented. The resident's family reported dissatisfaction with a Social Services Assistant's involvement and faced communication challenges with the facility, leading to unresolved grievances and frustration.
A resident at risk for pressure ulcers due to peripheral vascular disease and diabetes mellitus did not receive adequate care to prevent ulcer development. Despite reporting heel pain, the facility failed to identify or treat a pressure ulcer, which was later discovered upon the resident's admission to another facility.
A resident at high risk for falls experienced multiple incidents, including a severe fall resulting in a neck fracture, due to the facility's failure to evaluate and adjust fall prevention interventions. The resident's bed was positioned diagonally, creating a hazardous environment, and staff did not document risk assessments or care deviations despite acknowledging the risks.
A resident with dementia frequently yelled and accused their cognitively intact roommate of theft, leading to verbal altercations. Despite staff interventions like 15-minute checks and redirection, the facility failed to adequately separate the residents or protect the roommate from ongoing verbal abuse, resulting in a deficiency.
The facility failed to properly label insulin pens in a medication cart, as observed during a survey. Two multi-dose insulin pens were found without an open date or expiration date. An LPN confirmed the oversight, and the DON stated that the expectation was for insulins to be dated with both the open and expiration dates.
The facility failed to maintain sanitary food storage in both the kitchen and resident refrigerators, with observations of undated, expired, and spoiled food items. Staff interviews confirmed that these practices did not meet the facility's expectations, posing a risk of contamination.
The facility failed to obtain signed consents for psychotropic medications before administration for three residents. One resident had their risperidone dosage increased without guardian consent, another was prescribed citalopram without consent documentation, and a third received multiple medications without documented consent or education on risks and benefits. Staff interviews revealed that the expectation was for LNs to obtain consents and document them, but this was not followed, risking adverse side effects and diminished quality of life.
The facility failed to maintain a safe environment for three residents. A resident had unsecured medications accessible, another experienced multiple falls without proper reassessment of a transfer pole, and a third had loose bedrails posing a safety risk. Staff interviews highlighted lapses in medication security, fall investigation, and bedrail inspection protocols.
The facility failed to offer, educate, and obtain consent for influenza and pneumococcal vaccinations for five residents, as required by their policy. A review of the EHRs showed no documentation of education or consent for these vaccinations. Interviews with staff revealed a lack of a consistent process for educating and obtaining consent, despite expectations set by the Director of Nursing Services.
The facility failed to offer, educate, and obtain consent for COVID-19 vaccinations for five residents, as required by their policy. A review of the residents' electronic health records showed no documentation of education on the risks and benefits of the vaccine. Interviews revealed that there was no process in place for educating and obtaining consent, as confirmed by the Infection Preventionist/RN and the DON.
The facility failed to maintain a griddle/oven combo unit and a freestanding refrigerator in safe working order. Observations revealed the refrigerator had standing water and condensation, while the griddle/oven unit had leaking grease. Staff interviews indicated the refrigerator was not in working order and should not have been used, and the Maintenance Director was unaware of the issues until later.
The facility did not have a regular maintenance program for inspecting bedrails, leading to potential risks for residents. Staff were expected to notice and report loose bedrails, but there was no formal system in place. The Maintenance Director confirmed this, and the Administrator acknowledged the need for regular inspections.
The facility failed to provide appropriate care for several residents, including delayed wound infection management for a resident with a femur fracture, inadequate monitoring of edema for a resident with CHF, and failure to report respiratory changes for a resident with COPD. Additionally, a resident with edema did not receive prescribed medication, and a resident with Parkinson's disease was improperly positioned without a care plan.
The facility failed to ensure that a resident was free from physical restraints, as evidenced by the use of a tilt in space wheelchair with a pressure alarm. The resident, with diagnoses including Parkinson's disease, was observed leaning in the wheelchair without proper documentation or a restraint assessment. The care plan lacked instructions for the wheelchair's use, and a nurse confirmed improper positioning and absence of markings for the correct tilt angle.
A facility failed to accurately assess a resident's pressure ulcers, which were incorrectly documented as present on admission. The resident, who had Alzheimer's and was unable to communicate needs, developed the ulcers after admission. The MDS Nurse admitted the error, and the DON confirmed the expectation for accurate assessments.
The facility failed to meet professional standards of practice for three residents regarding anticoagulant use and indwelling urinary catheter (IUC) care. A resident on Eliquis had no documentation of monitoring for bleeding, despite visible bruising. Two residents with IUCs had conflicting or unclear provider orders regarding catheter size and change schedules, leading to inadequate care. Staff interviews confirmed these deficiencies in documentation and order clarity.
A resident with Alzheimer's and other conditions did not receive a scheduled dressing change for a pressure ulcer, as observed during a dressing change. The LPN confirmed the missed change, and the treatment record showed missing documentation. The DON stated that nurses are expected to follow dressing change orders.
A facility failed to properly monitor a resident's fluid restriction, leading to the resident receiving more fluid than prescribed. The resident, with pulmonary edema and kidney failure, was supposed to have a 1500 ml fluid limit, but the MAR lacked clear instructions and a method to total daily intake. Staff acknowledged the documentation was confusing and inadequate for accurate monitoring.
A resident with dementia and anxiety was prescribed lorazepam PRN without a stop date, contrary to pharmacy recommendations to limit use to 14 days. The resident received the medication multiple times beyond the recommended period. The DON acknowledged the failure to adhere to pharmacy guidelines.
Failure to Follow Bowel Management Protocol and Provider Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow its bowel management protocol and provider orders for a resident with documented constipation risk. The facility’s undated "Management of Constipation" policy required daily documentation of bowel patterns and initiation of a bowel protocol if no bowel movement (BM) occurred in 48 hours, including administration of Milk of Magnesia (MOM) on the morning of the third day, a digital rectal exam 8–10 hours later if still no BM, a rectal suppository if soft stool was present, and provider notification for enema orders if there was no result within four hours of the suppository. Admission documentation showed the resident’s last BM was on 12/28/2025, and the electronic health record contained no documented BM for the entire facility stay. Provider orders dated 12/29/2025 mirrored the bowel protocol steps. Review of the eMAR showed the resident received MOM on 12/31/2025, and staff later reported an additional MOM dose on 1/2/2026, but there was no documentation of a digital rectal exam, rectal suppository, enema, or provider notification despite the continued absence of a BM. Interviews with CNAs and LPNs confirmed that CNAs were responsible for documenting BMs in the electronic system and notifying nurses if a resident had no BM in three days, and that nurses were expected to administer MOM, then a suppository, and then contact the provider for an enema if needed. The Resident Care Manager and the Director of Nursing acknowledged that the resident did not have a BM during the stay, that no digital exam or further constipation interventions were documented after MOM administration, and that the facility’s bowel protocol and provider orders were not followed. The resident’s daughter reported that the resident was in pain, had no BM during the facility stay, and was later found to have a fecal impaction requiring removal at the hospital, with further health complications noted there.
Incomplete and Inaccurate Documentation of 15-Minute Monitoring Checks
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for three residents who required 15-minute monitoring due to various clinical concerns, including suicide risk and post-fall observation. For one resident with a recent stroke and identified as being at moderate to high risk for suicide, staff failed to perform and document required 15-minute checks during a period when the assigned CNA was on break. Despite this, the monitoring log was later found to have documentation for the missed times, indicating inaccurate recordkeeping. The Resident Care Manager confirmed that staff are expected to document only the tasks they personally complete, and that this expectation was not met. For two other residents, both of whom were placed on 15-minute checks following falls, the monitoring logs showed incomplete documentation for required observation periods. In one case, the log was blank for a significant portion of the day, while the MAR indicated the checks had been completed. In the other case, there was a gap of several hours with no documentation of checks. The Resident Care Manager acknowledged these discrepancies and stated that it was not acceptable to document checks that were not performed or to leave required checks incomplete.
Failure to Disclose Charges for Non-Covered Services
Penalty
Summary
The facility failed to notify a resident and their representative of the specific charges for services not covered under their Medicare Managed Care or private pay agreements. Upon admission, the resident received information about daily room rates and a list of potentially chargeable services, but the actual costs for these services were not provided. Staff confirmed that only the daily room and board charges and beauty salon fees were reviewed with residents, and that costs for medical supplies or therapy were not disclosed. When the resident's insurance coverage ended, an Advance Beneficiary Notice of Non-coverage (ABN) was issued, indicating the resident would be responsible for a daily rate, but did not specify charges for additional services such as therapy or medical supplies. The resident and their financial representative believed all previously received services, including therapy, would continue under private pay, as no separate charges were communicated. However, therapy services were discontinued after insurance authorization ended, and the facility did not provide advance notice of separate charges for these services. Staff interviews confirmed that residents only received information about additional charges after incurring them, and that the ABN did not clarify what was included in the daily rate. This lack of transparency led to confusion and unmet expectations regarding the continuation and cost of services.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for five residents, resulting in unmet needs related to activities, pain management, edema, and personal hygiene. For one resident with dementia, diabetes, and hypertension, the care plan documented preferences for music and reading, but observations showed the resident was left unengaged at the nurses' station, and staff interviews confirmed that appropriate activities were not consistently offered after a unit transfer. Another resident with fibromyalgia, arthritis, and colon cancer reported daily pain, but the care plan lacked specific pain monitoring interventions, and no pain monitoring documentation was found in the electronic health record. A third resident with back pain, sciatica, and arthritis reported severe pain that was not effectively managed, and although pain medication was administered, there was no care plan addressing pain. Staff confirmed that residents with ongoing pain complaints should have individualized pain care plans, but these were missing. For a resident with chronic kidney disease and edema, observations revealed significant swelling in the lower extremities, yet no care plan was initiated to address edema, contrary to staff expectations for accurate care planning. Additionally, a resident with multiple conditions including intracerebral hemorrhage, chronic kidney disease, and hemiplegia was observed with unshaved facial hair and long nails. The care plan did not specify the level of assistance or frequency for shaving and nail care, nor did it include the resident's preferences. Staff interviews indicated the resident was dependent on staff for these tasks and often refused care, but the lack of care planning for personal hygiene needs did not meet facility expectations.
Failure to Provide Ordered Care for Bowel Management, Edema, and Positioning
Penalty
Summary
The facility failed to provide appropriate treatment and care according to provider orders and residents' needs in several areas, including bowel management, edema management, and positioning. For bowel management, a resident with a history of congestive heart failure had provider orders for as-needed medications to address loose stools. Despite multiple documented episodes of loose stools, there was no evidence that the ordered medications were administered on those occasions. Staff interviews confirmed that the resident should have received the medications as ordered, but this did not occur. In the area of edema management, two residents with conditions such as congestive heart failure, respiratory failure, chronic kidney disease, and dependence on dialysis were not properly monitored or treated for edema. One resident had a care plan requiring daily assessment for edema, but there was no documentation of daily monitoring. Another resident had orders for daily use of compression stockings to manage edema, but observations showed the resident was often not wearing the stockings as ordered, and when worn, they were not properly applied. Additionally, nursing documentation did not accurately reflect the presence of edema, despite visible swelling observed during the survey. For positioning, a resident with significant physical impairments, including hemiplegia and dependence on staff for all care, was observed lying on their back in bed for extended periods across multiple observations. Staff interviews indicated the expectation that the resident should be turned every two hours, but there was no evidence this was occurring. The resident was also on hospice care and unable to consistently voice their needs, further emphasizing the importance of staff adherence to positioning protocols.
Failure to Monitor and Provide Fluids per Provider Orders for Residents with Fluid Restrictions
Penalty
Summary
The facility failed to properly monitor and provide fluids according to provider orders for two residents with fluid restrictions. For one resident with a history of spinal fracture, chronic kidney disease, and diabetes, provider orders specified a 1200 cc fluid restriction, with specific amounts to be provided by nursing and dietary staff. Observations revealed that the resident was given more fluids than allowed, and staff were unaware of the fluid restriction. Documentation of fluid intake was inconsistent and inaccurate, with daily totals not matching the amounts provided by nursing and dietary staff. Additionally, required signage indicating the fluid restriction was not posted at the resident's bedside, and meal trays contained more fluid than permitted by the restriction. For the second resident, who had dementia and diabetes, provider orders indicated a 2000 cc fluid restriction. Observations showed a full water pitcher at the bedside, and documentation of fluid intake was again inconsistent and inaccurate, with daily totals not aligning with the actual amounts provided. Meal tickets for both residents instructed staff to provide more fluid than the restrictions allowed, and the registered dietician confirmed that the meal tickets did not reflect the correct fluid restrictions. Interviews with staff, including a CNA, unit manager/LPN, registered dietician, and the DON, revealed a lack of awareness and adherence to the fluid restriction orders. Staff were unclear about which residents were on fluid restrictions, and the process for totaling and monitoring fluid intake was not followed as ordered. The facility did not ensure that residents with fluid restrictions received the correct amount of fluids as prescribed by their providers.
Failure to Date and Change Oxygen Tubing and Equipment as Required
Penalty
Summary
The facility failed to ensure that oxygen tubing and related respiratory care equipment were properly dated and changed according to policy for three residents who required respiratory support. Facility policy required that oxygen tubing, cannulas, masks, and small volume nebulizer (SVN) equipment be changed weekly and appropriately dated by nursing staff. However, observations revealed undated oxygen tubing and equipment in the rooms of all three residents reviewed, and in some cases, equipment was left uncovered or contained unknown liquid residue. One resident with a history of congestive heart failure, asthma, and pleural effusions was observed with uncovered SVN equipment on their bedside table, with undated tubing and a reservoir containing an unknown clear liquid. This resident had orders for SVN treatments as needed for shortness of breath and had received these treatments multiple times in the review period. Another resident with heart failure, dyspnea, and pulmonary hypertension was found with an undated oxygen mask and tubing, which the resident reported having brought from a previous hospital stay. Staff interviews revealed a lack of knowledge or adherence to the facility's policy regarding the dating and changing of oxygen equipment. A third resident with heart failure and acute respiratory failure with hypoxia was observed using an oxygen concentrator with a humidifier, but the tubing was not dated, and the resident was unsure how often the humidifier was changed. Review of this resident's records showed no specific order for changing the oxygen tubing or humidifier. Interviews with facility staff, including the Director of Nursing Services and unit managers, confirmed that the expectation was for weekly changes and dating of equipment, but this was not consistently implemented.
Resident Not Provided Opportunity to View New Room Prior to Move
Penalty
Summary
A resident with chronic obstructive pulmonary disease (COPD) and generalized muscle weakness, who was able to make their needs known, experienced multiple room changes within a few months. The resident reported dissatisfaction with a particular room move, stating they were not given a choice in the move and were not shown the new room prior to relocation. Documentation in the electronic health record confirmed room moves on three separate occasions, and a progress note indicated the resident expressed concerns about the new room being too small and issues with the placement of personal belongings. Social services staff were notified of these concerns. Interviews with facility staff revealed that the move in question was considered an emergency due to ongoing roommate issues, and the resident was not shown the new room beforehand, contrary to facility expectations. The Social Services Director acknowledged that the resident should have been given the opportunity to view the new room and that there should have been follow-up on the resident's concerns. The Administrator also confirmed that the lack of follow-up and failure to offer a room viewing did not meet facility expectations.
Failure to Obtain and Review Advanced Directives and Guardianship Documentation
Penalty
Summary
The facility failed to obtain and maintain appropriate legal documentation regarding advanced directives (AD) and guardianship for two residents. For one resident with a history of dementia, bipolar disorder, and psychotic disorder, the electronic health record (EHR) did not contain documentation of a durable power of attorney (DPOA) for healthcare, despite a physician's statement from several years prior indicating the resident lacked capacity to make their own healthcare decisions. The resident was unable to confirm if the facility had the necessary legal paperwork, and staff interviews confirmed that the AD was not present in the EHR and had not been reviewed as required during care conferences or the previous quarter. For another resident with a history of high blood pressure and stroke, there was no documentation of an AD for healthcare in the EHR, and care conference reports repeatedly indicated that no AD or DPOA was in place, with relevant sections left blank or marked as not applicable. The resident stated they did not have an AD, and staff were unable to locate any such documentation or explain the lack of follow-up. The facility's failure to obtain, document, and periodically review these legal documents did not meet expectations and was confirmed by both the Social Services Director and the Administrator.
Failure to Reduce Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to prevent the use of chemical restraints for one resident with vascular dementia and depression, who was prescribed Seroquel, Depakote, and Mirtazapine. Despite documentation that Seroquel was mostly ineffective and provider notes indicating a goal to discontinue it due to medication class risk, no dose reduction was attempted after Depakote was initiated. Observations over several days showed the resident was often sleepy or had eyes closed, and staff interviews confirmed the resident had not exhibited behaviors for about a month and was redirectable when behaviors had occurred. Staff also reported the resident was frequently sleepy during activities and sometimes did not attend due to this sleepiness. Review of records showed that although monthly psychoactive monitoring summaries documented Seroquel as mostly ineffective, the rationale for not reducing the dose was to continue the current plan of care. Interviews with nursing and social services staff confirmed that no dose reduction was attempted after starting Depakote, and the psychiatric nurse practitioner stated it was clinically contraindicated due to ongoing behaviors, despite staff observations to the contrary. The lack of timely dose reduction and continued use of Seroquel without clear evidence of ongoing behaviors led to the use of unnecessary psychotropic medication and potential chemical restraint.
Failure to Identify and Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to identify and report an allegation of abuse involving a resident who had recently been moved to a new room following an altercation with a roommate. The resident, who had diagnoses including COPD and generalized muscle weakness and was able to communicate needs, reported that their roommate had thrown items at them and that there had been several shouting matches. Despite these incidents, a review of the facility's incident logs showed no abuse allegation was logged for this resident. Progress notes documented verbal altercations and behavioral monitoring, but no formal incident report or state notification was made. Interviews with facility staff confirmed that an incident report should have been completed and the allegation reported to the state, but this did not occur. The facility's policy required immediate investigation and reporting of all alleged violations of abuse, including resident-to-resident altercations, within specified timeframes. The failure to follow these procedures resulted in the deficiency cited by surveyors.
Failure to Document and Conduct Timely Care Conferences
Penalty
Summary
The facility failed to provide and/or maintain timely documentation of care conferences for two of three sampled residents during care planning review. For one resident with diabetes and high blood pressure, there was no evidence in the electronic health record (EHR) that a care conference had occurred following admission, and the resident confirmed not having attended such a meeting. For another resident with heart failure, arthritis, and depression, although a social services progress note indicated a care conference was completed and was to be uploaded to the EHR, there was no documentation in the EHR to confirm this occurred, and the resident did not recall attending a care conference. Interviews with facility staff, including the Social Services Director and the Administrator, confirmed that care conferences had not been conducted or properly documented as required. Staff acknowledged that care conferences should have been held and documented within the initial assessment period and that the lack of documentation did not meet facility expectations. The absence of timely and documented care conferences was verified through both resident interviews and EHR review.
Inaccurate Behavior Monitoring Documentation for Dementia Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not accurately documenting behavior monitoring for a resident with vascular dementia and depression. The resident was assessed as confused and dependent on staff for care. Multiple observations over several days showed the resident was often calm, asleep, or pleasantly conversive, with no signs of agitation or aggression. However, the behavior monitoring documentation by nursing staff indicated continuous behaviors of agitation and aggression on several days and shifts, which was inconsistent with direct observations and staff interviews. Interviews with CNAs, an RN, and Life Enrichment staff confirmed that the resident had not exhibited aggressive or agitated behaviors recently, and was often calm or asleep during their shifts. The Director of Nursing Services stated that it was their expectation that behavior monitoring would be documented accurately. The discrepancy between the documented behaviors and actual observations/interviews demonstrates a failure to maintain accurate records in accordance with professional standards.
Failure to Provide Timely Vision Services
Penalty
Summary
A deficiency occurred when the facility failed to provide prompt vision services to a resident who required new corrective lenses. The resident, who had a history of diabetes and depression, was readmitted to the facility and had a neuro-ophthalmology consultation that resulted in a new prescription for glasses. Despite the prescription being available in early February, the resident reported in May that they had not received the new glasses, and staff were aware of this issue. The resident's electronic health record indicated adequate vision with corrective lenses, but the recommended new glasses were not obtained in a timely manner. Interviews with facility staff revealed a breakdown in communication and follow-up regarding the prescription. The Unit Manager/RN acknowledged that the prescription should have been addressed sooner, and the Health Information Clerk stated they never received the prescription from nursing, which prevented them from processing it with the in-house optometrist. The Director of Nursing Services was also unaware that the prescription had not been filled and noted that proper communication between nursing and health information/medical records was lacking. This failure resulted in the resident not receiving necessary vision services as recommended by their provider.
Failure to Provide Restorative Therapy Services After Resident Request
Penalty
Summary
A resident with chronic obstructive pulmonary disease, generalized muscle weakness, and impaired lower extremity function was admitted to the facility and identified as having an activities of daily living (ADL) self-care performance deficit related to impaired balance. The resident initially refused physical therapy services, expressing a preference to remain in bed and engage in leisure activities, and as a result, no restorative program was recommended at that time. Documentation indicated that the resident limited their own range of motion beyond what they could perform independently. Subsequently, the resident communicated a desire to begin a restorative therapy program during a social services check-in. However, there was no documentation of follow-up with nursing regarding this request, and the unit manager was unaware of the resident's interest in restorative therapy. The director of nursing services confirmed that a referral and assessment should have been completed but were not, due to a lack of communication. This failure resulted in the resident not receiving necessary services to maintain or improve their range of motion and mobility.
Failure to Accurately Assess and Monitor Pain Management
Penalty
Summary
The facility failed to accurately assess and monitor pain for two residents who required pain management services. One resident, with chronic kidney disease, heart failure, and on hospice care, reported daily pain in multiple areas but stated that they only requested pain medication when the pain was unbearable due to staff being too busy. Documentation showed discrepancies in the number of as-needed pain medications administered and a lack of monitoring of pain characteristics as required by the resident's care plan. The pain monitor for this resident was discontinued in error, and there was no documentation of ongoing pain assessment in the electronic health record (EHR). Another resident with multiple chronic pain conditions, including spinal stenosis, degenerative disc disease, and fibromyalgia, reported chronic pain and ineffective pain management, particularly overnight. There was no provider order to monitor this resident's pain level, and no documentation of pain assessment was found in the progress notes. Staff interviews confirmed that pain monitoring was discontinued after seven days, and the DON stated that it was expected for staff to assess and document pain at least daily for residents experiencing pain.
Failure to Provide Individualized Dementia Care Interventions
Penalty
Summary
The facility failed to provide person-centered, individualized interventions for a resident diagnosed with vascular dementia and depression. The resident was admitted with significant cognitive impairment, as evidenced by confusion and dependence on staff for care. The care plan included general interventions such as administering medications, maintaining a consistent routine, and engaging the resident in structured activities, but did not specify resident preferences or individualized approaches. The care plan lacked documentation of specific activities the resident preferred and did not include tailored interventions to address the resident's unique needs and behaviors. Record review and staff interviews revealed that the resident exhibited frequent behavioral disturbances, including aggression and resistance to care, such as becoming combative and striking staff during care. Staff responses to these behaviors included leaving and reapproaching the resident later, as well as attempting distraction and redirection. Despite these efforts, the care plan did not reflect the resident's preferences or document personalized strategies, and staff confirmed that behaviors were ongoing and often triggered during care. The lack of individualized, person-centered interventions placed the resident at risk of unmet care needs and diminished quality of life.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the scheduled and actual hours worked for nursing staff each day during the survey period, as required. Observations over four consecutive days revealed that the posted nurse staffing information did not include the necessary details for each discipline on each shift. Interviews with the Staffing Coordinator confirmed that while the schedule and actual hours were tracked, they were not posted, and once posted, the information was rarely updated for the remainder of the day. The Administrator was unaware that the postings were incomplete and not updated as required, acknowledging that this did not meet expectations.
Failure to Resolve Grievances and Missing Property Issues
Penalty
Summary
The facility failed to promptly resolve grievances for a resident concerning missing property and communication issues. The facility's grievance policy, which requires grievances to be recorded and resolved promptly, was not adequately followed. The resident's missing items, including a belt and glasses, were reported, but the facility did not document a thorough investigation or resolution. The grievance log indicated the issue was referred to environmental services and nursing, but there was no evidence of a satisfactory resolution or communication with the resident or their family. The facility's policies on handling personal belongings were not adhered to, as the Personal Possession Record was not completed for the resident upon admission. This oversight contributed to the inability to resolve the grievance regarding the missing items. Interviews with staff revealed that the inventory list was not completed, and the grievance form's back side, which should have documented the investigation and actions taken, was missing. The Social Services Director acknowledged receiving only one grievance and stated that the missing items were not found, but could not provide documentation of the investigation. Communication issues were also a significant concern, as the resident's family reported multiple grievances that were not addressed. The family expressed dissatisfaction with the involvement of a Social Services Assistant in the resident's care and requested their removal. Despite repeated attempts to communicate with the facility, including emails and phone calls, the family did not receive adequate responses. The facility's responses to the family's inquiries were insufficient, and the grievances remained unresolved, leading to frustration and a diminished quality of life for the resident.
Failure to Prevent and Identify Pressure Ulcer
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of pressure ulcers for a resident who was at risk due to conditions such as peripheral vascular disease and diabetes mellitus. Despite being assessed as at risk for pressure ulcers, the resident did not have any documented pressure ulcers upon admission. The care plan included interventions to keep the feet clean and dry and to monitor and document any skin injuries. However, the facility did not consistently perform skin checks as ordered, with documentation showing a significant gap in performing these checks. The resident began reporting heel pain to staff, but no treatment was provided other than the application of lotion. The resident's family noted the pain, and an alert note later documented swelling and pain in the left heel. Despite these reports, no heel wounds were identified in the resident's records before discharge. Upon admission to another facility, the resident was found to have a Stage II pressure ulcer on the left heel, which was not disclosed by the original facility. This indicates a failure to identify and treat the pressure ulcer, leading to its development and progression.
Failure to Mitigate Fall Risks for High-Risk Resident
Penalty
Summary
The facility failed to evaluate the effectiveness of fall prevention interventions and did not adequately address environmental modifications that posed a risk to Resident 1, who was at high risk for falls. Resident 1, who was cognitively intact and required substantial assistance with mobility and toileting, experienced multiple falls, including two with injuries, over several months. Despite being assessed as high risk for falls, the facility did not implement a toileting program or adequately adjust the resident's environment to mitigate fall risks. Resident 1's bed was positioned diagonally in their room, as per their preference, which created a hazardous environment. This arrangement left limited space between the bed, dresser, and wall, increasing the risk of entrapment and falls. Staff interviews revealed that the resident's preference for bed placement was honored without a documented review of the associated risks and benefits, and no deviation of care was recorded. The resident experienced several falls, including a severe incident where they fell out of bed and sustained a neck fracture, among other injuries. The facility's failure to reassess and adjust the resident's care plan and environment, despite repeated falls and the resident's high-risk status, contributed to the incident. Staff acknowledged the hazardous room setup but did not take corrective action due to the resident's preferences. The lack of proactive measures and failure to document risk assessments and care deviations resulted in harm to Resident 1 and placed them at continued risk for falls and injury.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from mental and verbal abuse, as evidenced by a resident-to-resident altercation involving two residents sharing a room. Resident 1, who was admitted with a diagnosis of dementia and severely impaired cognitive skills, exhibited behaviors of wandering and was noted to yell and scream at Resident 2, accusing them of stealing personal items. Despite staff interventions, Resident 1 continued to display aggressive verbal behavior towards Resident 2, who was cognitively intact and attempted to de-escalate the situation by leaving the room or going to the Bistro. The facility's policy on abuse, neglect, and exploitation required the implementation of procedures to prevent abuse and protect residents from harm. However, the facility's response to the altercation was inadequate, as staff failed to effectively separate the residents or provide a safe environment for Resident 2. Although staff conducted 15-minute checks and attempted to redirect Resident 1, these measures were insufficient in preventing ongoing verbal abuse. Interviews with staff revealed that the altercations were a frequent occurrence, yet no significant actions were taken to protect Resident 2 from the distress caused by Resident 1's behavior. The facility's inaction in addressing the conflict between the residents resulted in a deficiency, as they did not ensure the safety and well-being of Resident 2. Despite being aware of the situation, the facility did not take adequate steps to separate the residents or provide alternative accommodations, such as moving one of the residents to a different room. The failure to implement effective interventions and protect Resident 2 from verbal and mental abuse highlights a significant lapse in the facility's duty to safeguard its residents.
Improper Labeling of Insulin Pens in Medication Cart
Penalty
Summary
The facility failed to ensure proper labeling of insulin medications in one of the medication carts, specifically the 700-hall medication cart. During an observation, two multi-dose insulin pens were found without an open date or expiration date. This was confirmed during an interview with a Licensed Practical Nurse, who acknowledged the presence of two undated insulin pens in the cart. The Director of Nursing Services stated that the expectation was for open insulins to be dated with both the open date and expiration date, which was not adhered to in this instance.
Unsanitary Food Storage Practices
Penalty
Summary
The facility failed to ensure that food was stored and handled in a sanitary manner, as observed in both the kitchen and resident refrigerators. In the kitchen, the walk-in refrigerator contained four bags of raw chicken sitting in bloodied water, undated containers of minced garlic and pudding, a package of bacon with an expired use-by date, and uncovered, undated trays of raw fish. The walk-in freezer had a rack of exposed, dried-out raw meat. Additionally, dry storage contained a container of granola with no date. Staff interviews revealed that these items were recognized as needing disposal, and the storage practices did not meet the facility's expectations. In the resident dining areas, the Narrows, Mountain, and Ocean refrigerators contained various undated and expired food items, some with visible white growth indicating spoilage. The Mountain refrigerator had a Styrofoam container with foul-smelling, unidentifiable food and a bag of raspberries with white growth. The Ocean refrigerator contained a sandwich with an expired use-by date and several plates of food with white growth. Staff interviews confirmed that expired foods should not be present in resident refrigerators, and some items belonged to staff, which was against policy. The facility's adherence to the 2024 Food Code was acknowledged, but the storage of resident foods was not up to standard.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain signed consents for psychotropic medications before administration for three out of five residents reviewed. Resident 40, who was readmitted with multiple diagnoses including heart disease, dementia, anxiety, and a psychotic disorder, had their risperidone dosage increased without obtaining consent from the resident's guardian. Resident 78, admitted with Parkinson's disease, dementia, and depression, was prescribed citalopram for major depressive disorder without any consent documentation upon admission. Resident 119, diagnosed with dementia, was receiving multiple medications including donepezil, olanzapine, mirtazapine, and risperidone without documented consent or education on the risks and benefits provided to the resident or their representative. Interviews with facility staff, including a Registered Nurse/Unit Manager and the Director of Nursing Services, revealed that the expectation was for licensed nurses to obtain consents from residents or their representatives before administering psychotropic medications and to document this in the medical records. However, this procedure was not followed, placing the residents at risk for adverse side effects and diminished quality of life. The facility's document on informed consent, dated December 1998, outlines the necessity for residents to receive appropriate and meaningful information regarding their healthcare decisions, which was not adhered to in these cases.
Failure to Ensure Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for three residents. For Resident 121, medications were not secured properly. A lidocaine patch was found in a refrigerator accessible to residents and on the resident's bedside table, despite the resident not being assessed to self-administer medications. Staff interviews confirmed that medications should be locked away, indicating a lapse in following medication security protocols. Resident 68 experienced multiple falls, yet the facility did not adequately investigate or reassess the use of a transfer pole, which may have contributed to the falls. The resident, who had a history of impulsivity and required substantial assistance for transfers, fell several times while attempting to self-exit the bed. Despite these incidents, the transfer pole's safety was not reassessed, and there was a lack of communication between nursing staff and physical therapy regarding the need for reassessment. For Resident 4, bedrails were observed to be loose, posing a risk of entrapment. Staff interviews revealed that there was no regular system for inspecting bedrails, and maintenance was only notified if staff noticed the issue. This lack of a systematic approach to ensuring bedrail safety resulted in the resident's bedrails being inadequately secured, which did not meet safety expectations.
Failure to Educate and Obtain Consent for Vaccinations
Penalty
Summary
The facility failed to offer, educate, and obtain consent for influenza and pneumococcal vaccinations for five residents, as required by their policy. The policy, dated January 28, 2022, mandates that all residents be offered vaccines to prevent infectious diseases, with prior education on the benefits and potential side effects documented in the resident's medical record. However, a review of the electronic health records (EHR) for Residents 74, 90, 102, 108, and 120 revealed no documentation that staff provided the necessary education or obtained consent for these vaccinations. Interviews with facility staff further highlighted the deficiency. Staff H, the Infection Preventionist/Registered Nurse, admitted to the absence of a consistent process for educating and obtaining consent for the vaccines. Additionally, Staff B, the Director of Nursing Services, confirmed that it was expected for staff to provide education on the risks and benefits before offering and obtaining consent for the vaccines. This lack of adherence to the facility's policy denied residents the opportunity to make informed decisions regarding their immunizations, potentially placing them at risk for communicable diseases.
Failure to Educate and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to offer, educate, and obtain consent for COVID-19 vaccinations for five residents, as identified in the report. The facility's policy, dated January 28, 2022, mandates that all residents be offered vaccines to prevent infectious diseases, with prior education on the benefits and potential side effects documented in the resident's medical record. However, a review of the electronic health records (EHR) for Residents 74, 90, 102, 108, and 120 revealed no documentation indicating that staff had offered or provided education on the risks and benefits of the COVID-19 vaccine. Interviews conducted during the investigation further highlighted the deficiency. Staff H, the Infection Preventionist/Registered Nurse, admitted that there was no process in place for educating and obtaining consent for resident COVID-19 vaccines. Additionally, Staff B, the Director of Nursing Services, stated that it was their expectation for staff to provide education on risks and benefits before offering and obtaining consent for all resident COVID-19 vaccines. This lack of process and documentation denied residents the opportunity to make informed decisions regarding the COVID-19 vaccine.
Failure to Maintain Kitchen Equipment in Safe Working Order
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe working order, specifically a griddle/oven combo unit and one of four freestanding refrigerators. Observations on June 2, 2024, revealed a freestanding refrigerator containing a tray of sandwiches with standing water at the bottom and condensation droplets on the ceiling. A metal container with approximately two inches of water, a small screwdriver, and screws was found inside the refrigerator. Additionally, the griddle/oven combo unit was observed with a grease trap protruding about one and a half inches, with dried grease on the side of the unit and on the ground beneath it. Further observations on June 4, 2024, showed the refrigerator still had water on the floor and droplets on the ceiling, with a rack of resident foods inside. The container with water, screwdriver, and screws remained on the crossbar. The griddle/oven combo unit was observed with brown grease actively leaking down its side, and accumulated grease below the grease trap. Interviews with staff revealed that the refrigerator was not in working order and should not have been used to store resident foods. The Maintenance Director was only made aware of the issues on June 4, 2024, and there were no open work orders for the kitchen at that time.
Lack of Regular Bedrail Inspection Poses Risks
Penalty
Summary
The facility failed to implement a regular maintenance program for inspecting bedrails, which placed residents at risk of falling, entrapment, avoidable injury, and a diminished quality of life. During interviews, it was revealed that there was no established system for regular inspection of bedrails. Staff C, a Registered Nurse/Unit Manager, and Staff B, the Director of Nursing Services, both stated that staff were expected to notice loose bedrails and notify maintenance. Staff M, the Maintenance Director, confirmed the absence of a regular inspection system, indicating that maintenance was only informed of bedrails needing tightening as they were discovered. Staff A, the Administrator, acknowledged that bedrail inspection should be part of a regular preventative maintenance schedule.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for several residents, leading to deficiencies in their care. Resident 42, who was admitted with a fracture of the left femur and subsequent surgical intervention, experienced a delay in the management of a surgical wound infection. Despite obtaining a wound culture, there was a significant delay in receiving the results and initiating antibiotic treatment. The facility's staff did not promptly contact the orthopedic surgeon, resulting in a delay of more than nine days before appropriate treatment was administered. Resident 107, diagnosed with congestive heart failure, did not receive consistent monitoring and documentation of edema as outlined in their care plan. The resident's family expressed concerns about the lack of care, including the failure to elevate the resident's legs and monitor fluid accumulation. An investigation revealed that the licensed nursing staff did not follow the care plan, and there was no documentation of edema assessment in the resident's electronic health record. Resident 2, with chronic obstructive pulmonary disease and congestive heart failure, experienced a change in respiratory status that was not promptly reported to the provider. Despite the resident's complaints of chest congestion and pain, and visible symptoms such as coughing up yellow mucus, the staff failed to notify the provider or document the change in the resident's condition. Additionally, Resident 30, who had edema and acute kidney failure, did not receive prescribed medication for edema management, and there was no care plan addressing this condition. Resident 78, with Parkinson's disease, was observed inappropriately positioned in a wheelchair without a care plan for mobility and positioning, leading to discomfort.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints, as evidenced by the use of a tilt in space wheelchair with a pressure alarm for Resident 78. Resident 78, who was admitted with diagnoses including Parkinson's disease, asthma, and depression, was observed leaning to the front right in the wheelchair, which was then repositioned by a staff member. There was no documentation of a restraint assessment or provider order for the use of the tilt in space wheelchair in Resident 78's electronic health record. Additionally, the care plan initiated in March 2023 did not include instructions regarding the use of the tilt in space wheelchair or the positioning of Resident 78. During an interview and observation, a registered nurse confirmed that Resident 78 was not positioned appropriately and that there were no markings on the wheelchair to indicate the correct angle of tilt as per the provider order and care plan.
Inaccurate Assessment of Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess a pressure ulcer/skin condition for one resident, identified as Resident 7, who was reviewed for pressure injury. Resident 7 was admitted with multiple diagnoses, including Alzheimer's disease, adult failure to thrive, and abnormal weight loss, and was unable to communicate needs. A quarterly Minimum Data Set (MDS) assessment dated May 20, 2024, inaccurately recorded that Resident 7 had two unstageable pressure ulcers present on admission. However, during an interview on June 5, 2024, the MDS Nurse, Staff K, acknowledged that the pressure ulcers developed after the resident's admission to the facility. The Director of Nursing Services, Staff B, confirmed that the expectation was for the MDS assessment to accurately reflect the resident's condition.
Deficiencies in Anticoagulant Monitoring and Catheter Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for three residents concerning anticoagulant use and indwelling urinary catheter (IUC) care. Resident 2, who was admitted with atrial fibrillation, was receiving Eliquis to prevent blood clots. Despite having bruising on their arms and legs, there was no documentation in the electronic health record (EHR) regarding monitoring for abnormal bleeding or bruising, which was expected as part of the care plan. Interviews with staff revealed that there was no order in the medication administration record (MAR) to monitor for adverse side effects of the anticoagulant medication, which was acknowledged as an oversight by the Director of Nursing Services. For Residents 88 and 28, the facility failed to ensure accurate and clear provider orders for IUC care. Resident 88, who had diagnoses including Parkinson's disease and benign prostate hypertrophy, experienced severe lower abdominal pain due to the catheter. The EHR contained conflicting orders regarding the IUC size and change schedule, and the care plan lacked specific details about the catheter type and size. Similarly, Resident 28 had conflicting provider orders regarding the IUC size and type, which needed clarification. Staff interviews confirmed that the orders did not meet expectations for clarity and accuracy, which are necessary for proper catheter management.
Failure to Follow Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to provide necessary treatment to heal pressure injuries for a resident, identified as Resident 7, who was reviewed for pressure injuries. Resident 7 was admitted to the facility with multiple diagnoses, including Alzheimer's disease, adult failure to thrive, and abnormal weight loss, and was unable to communicate needs. During an observation and interview on June 5, 2024, it was noted that a dressing on Resident 7's right outer ankle, dated May 31, 2024, had not been changed as ordered on June 3, 2024. Staff L, an LPN, confirmed the dressing change was missed. A review of the treatment administration record for June 2024 showed missing documentation for multiple orders on June 3, 2024, during the day shift. During an interview, Staff B, the Director of Nursing Services, stated that the expectation was for nurses to follow orders for dressing changes.
Failure to Monitor Fluid Restriction
Penalty
Summary
The facility failed to ensure proper fluid restriction for Resident 54, who was admitted with pulmonary edema and kidney failure. The provider's orders specified a fluid restriction of 1500 ml, with 600 ml to be provided by nursing and 900 ml by dietary. However, the medication administration record (MAR) lacked a clear method to total daily fluid intake and did not specify how much liquid to give per section. This resulted in Resident 54 receiving more than the prescribed 1500 ml of fluid on multiple days in May and June 2024. Interviews with staff revealed that the documentation was confusing and did not allow for accurate monitoring of fluid intake, which did not meet the facility's expectations.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medications were limited to 14 days for one of the sampled residents, identified as Resident 6. Resident 6, who was admitted with multiple diagnoses including dementia, anxiety, and congestive heart failure, had an order for lorazepam, an antianxiety medication, to be administered every 2 hours as needed, starting on May 4, 2024, without a specified stop date. Despite pharmacy recommendations on May 14, 2024, to discontinue the lorazepam PRN after 14 days, the medication administration record showed that Resident 6 received lorazepam nine times in May 2024 and once in June 2024. During an interview, the Director of Nursing Services acknowledged that the expectation was for staff to follow pharmacy recommendations, which was not met in this case.
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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