Emerald Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Wapato, Washington.
- Location
- 209 North Ahtanum Avenue, Wapato, Washington 98951
- CMS Provider Number
- 505265
- Inspections on file
- 33
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Emerald Care during CMS and state inspections, most recent first.
A resident with quadriplegia, intact cognition, and decreased lower-extremity sensation, who required set-up assistance for eating, sustained burn injuries with redness and fluid-filled blisters on the thigh after hot coffee spilled in their lap. Dietary staff reported targeting coffee temperatures of 155°F and logging only one of four pots before sending a coffee cart to common areas, and the DON later measured coffee from the cart at 168.8°F with visible steam. The resident stated someone else obtained the coffee from a front station, and there was no established assessment or process to ensure residents could safely handle hot liquids, despite facility policy requiring risk identification and mitigation for accident prevention.
Surveyors found that the facility did not follow its abuse/neglect policy when multiple grievances involving potential abuse and neglect were logged only as staff concerns and not treated as reportable incidents. A resident reported lack of assistance and care from an LPN, another resident experienced a verbal confrontation with a CNA, and a third resident was observed by a representative to have a soiled face and clothing and a urine-saturated brief dripping down the hallway. These events were not entered into the incident reporting log, were not promptly or thoroughly investigated as abuse/neglect allegations, and the residents were not protected from possible ongoing abuse or neglect, as confirmed by the administrator and DON.
The facility failed to report multiple potential allegations of abuse and neglect to the State Agency. One cognitively intact resident with ALS alleged a staff member withheld their eyeglasses and reported feeling unsafe and poorly cared for, including concerns about staff’s ability to manage choking and positioning. Another resident with dementia and Parkinson’s was found by their representative with dried toothpaste on their clothing and face and so wet with urine that it left a trail down the hallway, prompting concerns about dignity and care. A third resident reported that a NA spoke to them in an unprofessional and unnecessary manner regarding a locked bathroom door, constituting a potential allegation of verbal abuse. These concerns were handled as internal grievances, were not entered into the reporting log as abuse/neglect allegations, and were not reported to the State Agency, with the DON stating they did not view the incidents as purposeful or willful abuse or neglect.
The facility failed to thoroughly investigate multiple allegations of abuse and neglect involving three cognitively intact residents with significant care needs. One resident with ALS reported that an LPN ignored a request for help with eyeglasses and left without assisting or communicating. Another resident with dementia and incontinence was reportedly found by a representative with dried toothpaste on their face and clothing and a urine-soaked brief that leaked down the hallway, yet no staff statements, additional resident interviews, skin checks, or care plan changes were documented. A third resident with heart and lung disease reported that a NA spoke to them in an unprofessional, scolding manner about a locked shared bathroom door and then left while the resident was speaking, but the investigation lacked root cause analysis, interviews with other residents, or monitoring for adverse effects. None of these allegations appeared on the incident reporting log, and documentation did not show complete analyses to rule out abuse or neglect.
The facility failed to discard expired foods and did not consistently monitor refrigerator temperatures, increasing the risk of food-borne illnesses. Expired tortillas were served, and temperature logs were missing for two refrigerators. Staff acknowledged these lapses, with the Dietary Manager noting the small black refrigerator was not in use.
A resident with a history of dementia and neurogenic bladder was at risk for UTIs due to inadequate catheter care. The facility failed to implement physician orders for regular catheter changes and monitoring, resulting in compromised catheter integrity and increased infection risk. Staff interviews confirmed the oversight in managing the resident's IUC, highlighting a deficiency in care protocols.
The facility failed to secure the medication room, allowing unauthorized access by the Maintenance Director, who used a key obtained from a predecessor to enter the room monthly for air conditioner checks. This was against the facility's policy, which restricts access to licensed nursing personnel and authorized staff.
The facility failed to ensure the Director of Nursing (DNS) maintained an active RN license, as required by their job description. The DNS, identified as Staff R, worked for 17 days after their license expired. The Administrator, Staff A, was informed by Staff R that the license was believed to be renewed but later found it was expired.
The facility failed to implement proper infection control practices for urinary catheters, as observed with two residents whose catheter bags were seen touching the floor, contrary to facility policy and CDC guidelines. This oversight placed the residents at risk for infections, as confirmed by staff interviews.
The facility failed to thoroughly investigate and address resident-to-resident altercations involving four residents, lacking root cause analysis, witness statements, and care plan updates. Staff were unaware of incidents, and responsibilities for follow-up were unclear, leaving residents at risk for further altercations.
The facility failed to maintain proper infection control practices during hydration passes and resident care. Staff did not change gloves or perform hand hygiene between dirty and clean tasks, increasing the risk of cross-contamination for two residents. The Infection Preventionist and Director of Nursing Services acknowledged the deficiencies and emphasized the need to follow infection control policies and physician orders.
The facility failed to update care plans for two residents, leading to discrepancies in their documented care needs. One resident's dental care and dietary refusals were not reflected, while another's transfer and meal assistance needs were outdated. Staff acknowledged the need for updates but had not made the necessary revisions.
The facility failed to ensure ongoing communication and collaboration with the dialysis center for three residents requiring dialysis services, leading to risks of unnoticed health changes and delays in care. Despite multiple dialysis sessions, there was minimal documented communication with the dialysis center, and staff acknowledged the lack of a proper communication system.
Burn Injury from Overheated Coffee and Lack of Hot-Liquid Safety Process
Penalty
Summary
The deficiency involves the facility’s failure to ensure hot liquids were provided at a safe drinking temperature, resulting in a resident sustaining burn injuries. The facility’s policy titled “Free of Hazards/Supervision and Devices” required an interdisciplinary approach to identify, evaluate, and mitigate risks to maintain resident safety. Washington State Department of Labor and Industries guidance indicated that water at 155°F can cause a third-degree burn in one second. Despite this, dietary staff reported they ensured brewed coffee was at 155°F before taking the coffee cart to resident areas and kept logs to make sure it was not over 155°F. Resident 1, who had quadriplegia, heart failure, anxiety, intact cognition, and required set-up assistance for eating and dependence for other ADLs, reported spilling hot coffee on their lap. Due to decreased sensation in their legs, the resident did not feel the burn and did not report the incident immediately. A nursing progress note documented an area of redness on the right thigh measuring 4.5 cm by 13.0 cm with multiple fluid-filled blisters, and the facility’s investigation noted a red area with blisters after the resident stated they had spilled a hot beverage earlier in the day and forgotten about it until nighttime care. Surveyor observation showed the resident seated in a common area with a cup of coffee with a lid on the table and a sweatshirt over their lap, and the resident stated they had obtained coffee from the front coffee station with assistance from someone else. During the survey, the DON measured coffee from a pot on the coffee cart in the common area and found it to be 168.8°F, with visible steam rising from the cup. The dietary manager later confirmed that staff were only checking the temperature of one of four coffee pots before leaving the kitchen and were unsure whether temperatures were taken directly from the pot or from a pitcher. The DON and administrator acknowledged that there was no process or assessments in place to ensure residents were safe in handling hot liquids, and that staff were expected to check coffee temperatures before sending and before serving, but this was not being carried out as described.
Failure to Identify and Investigate Allegations of Abuse and Neglect
Penalty
Summary
Surveyors identified that the facility failed to implement its abuse, neglect, and exploitation policy for three residents when allegations were documented but not treated as reportable abuse/neglect events. The written policy dated 01/2026 required the facility to prohibit and prevent abuse, neglect, and exploitation of residents with ongoing oversight and supervision of staff to ensure policies were implemented. Review of the grievance log from 07/01/2025 through 01/25/2026 showed multiple entries that involved potential abuse or neglect concerns, but these were only logged as staff concerns or grievances and not identified, reported, or investigated as allegations of abuse or neglect. For one resident, a staff concern was logged regarding lack of assistance and care from an LPN when asked. For another resident, a staff concern was logged regarding a verbal confrontation with a nursing assistant. For a third resident, the resident’s representative reported the resident was left with a soiled face and clothing and a brief so saturated with urine that it dripped down the hallway. Record review showed that none of these three incidents were entered into the facility’s reporting log, which is used to document incidents that may involve abuse, neglect, or mistreatment of residents, and there was no evidence of thorough investigation to rule out abuse or neglect. Completion dates on the grievance log, when present, were several days after the concerns were reported, and one concern had no completion date at all. During interviews, the administrator and DON acknowledged confusion among staff about which concerns should be placed on the grievance log versus the reporting log and confirmed that the concerns involving these three residents were not identified as allegations of abuse or neglect and were not investigated as such, meaning the residents were not provided protection from the possibility of ongoing abuse or neglect.
Failure to Report Allegations of Abuse and Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report potential allegations of abuse and neglect to the State Agency (SA) for three residents whose cases were reviewed. For one resident with ALS who was cognitively intact and dependent on staff for all ADLs, a grievance log and incident reports showed that the resident alleged a staff member did not place their eyeglasses on as requested, instead holding them out of reach for a couple of minutes before setting them on a table and leaving the room. The resident expressed concerns about how the staff member treated them and requested that this staff member no longer provide their care. The Social Services Director later learned, via an email from a community health reporter, that the resident had complained that staff did not know how to care for a person with ALS, did not feel cared for or safe, and felt staff did not know how to manage episodes of choking or position their head upright. Although this concern was investigated internally, the facility’s reporting log showed that this potential allegation of abuse and/or neglect was not entered into the reporting log and was not reported to the SA. A second deficiency component involved another resident with dementia and Parkinson’s disease, who was cognitively intact and required substantial to maximum assistance with toileting and dressing and was frequently incontinent of urine. A grievance form documented that the resident’s representative reported finding the resident in their wheelchair with dried toothpaste on their shirt, pants, and face, and that when they assisted the resident to the dayroom, the resident was so wet with urine that a trail of urine was left down the hallway. The representative stated they wanted the resident treated with dignity. This concern, which constituted a potential allegation of neglect, was handled as a grievance within the facility. Review of the reporting log showed that this potential allegation of neglect was not reported to the SA. The third component of the deficiency involved a resident with heart failure and depression, who was cognitively intact, independent with toilet transfers, and required substantial to maximum assistance with toileting hygiene. A grievance form documented that the resident reported being upset with the way a nursing assistant spoke to them, blaming them for locking a shared bathroom door and saying, “Would you stop locking the dang door?” The resident stated that the way they were spoken to was unprofessional and unnecessary. This concern, a potential allegation of verbal abuse, was investigated as a grievance rather than as an allegation of abuse. Review of the reporting log showed that no potential allegation of abuse for this resident was reported to the SA. In an interview, the DON stated they did not report the concerns for two of the residents as allegations of abuse or neglect because they did not believe the staff actions were purposeful or willful.
Failure to Thoroughly Investigate Multiple Abuse and Neglect Allegations
Penalty
Summary
The facility failed to conduct complete and thorough investigations into multiple reported allegations of abuse and neglect. For one resident with ALS, intact cognition, and total dependence on staff for all ADLs, a grievance was filed after the resident reported that an LPN did not respond to their request to have their glasses put on, instead holding the glasses out silently for several minutes, then placing them down and leaving the room without assisting or explaining. The resident reported feeling unsupported and mistreated and requested that this staff member no longer enter their room or provide care. Although the concern was reported to the DNS, the investigation as documented focused on educating the staff member, without evidence of a root cause analysis, contributing factors review, or measures to rule out abuse or neglect. For another resident with dementia, heart failure, urge incontinence, intact cognition, and frequent urinary incontinence, the resident’s representative reported finding the resident with dried toothpaste on their face, shirt, and pants and with a brief so saturated with urine that it leaked down the hallway when the representative assisted the resident to the day room. The grievance documentation showed the resident was interviewed and reported no concerns, and the DNS concluded that lack of dignity and timely care could not be substantiated and that abuse and neglect were ruled out. However, the grievance file contained no interviews with other residents, no identification of the staff involved in the incident, no staff statements, no care plan changes, no alert charting, and no skin checks to assess the resident after sitting in urine. The investigation lacked any documented root cause or analysis explaining why the resident was soaked with urine or why personal hygiene needs were not met. For a third resident with heart failure, lung disease, intact cognition, and frequent urinary incontinence, a grievance was filed after the resident reported that a nursing assistant entered their room and told them to stop locking the “dang” door, blaming them for locking a shared bathroom door. The resident reported being upset by the unprofessional tone, feeling as if they were being scolded and accused of lying when they tried to explain they had not used the restroom that day, and described the staff member throwing their hands up and leaving the room while the resident was talking. The grievance conclusion documented removal of the staff member from the room and unit and referenced education about sharing information on other residents, but there was no documented root cause or analysis to rule out abuse or neglect, no interviews with other residents about the staff member’s interactions, no care plan changes, and no alert charting to monitor for adverse reactions. Additionally, the facility’s reporting incident log contained no entries for these allegations, and the administrator and DNS acknowledged staff confusion about what should be entered on the grievance log versus the reporting log.
Expired Foods and Inadequate Temperature Monitoring in Facility
Penalty
Summary
The facility failed to ensure expired foods were discarded and did not consistently monitor refrigerator temperatures, which increased the risk of food-borne illnesses for residents. During an observation, expired food items, including spinach wraps, white corn tortillas, and flour tortillas, were found in the dry storage area. Staff K, a cook, confirmed that the expired flour tortillas had been served during a lunch meal, mistakenly assuming they were fresh. The Dietary Manager later disposed of the expired items. The facility's policy required food items to be rotated, labeled, dated, and discarded on the expiration date, but this was not adhered to. Additionally, the facility did not maintain temperature logs for two refrigerators. The kitchen snack refrigerator, which stored salads, snacks, juices, and milk, lacked a temperature log. A small black refrigerator, containing nutritional shakes, had only one temperature recorded for the entire month. Staff L, the Dietary Manager, acknowledged the lapse in maintaining temperature logs and stated that the small black refrigerator was not in use. Staff A, the Administrator, was aware of these issues and confirmed the expectation for dietary staff to rotate food items and discard expired food.
Inadequate Catheter Care Leads to Increased UTI Risk
Penalty
Summary
The facility failed to provide adequate care for a resident with an indwelling urinary catheter (IUC), which placed the resident at risk for urinary tract infections (UTIs). The resident, who had a history of dementia and neurogenic bladder, was readmitted to the facility with an IUC following a hospital stay for septic shock due to a complicated UTI. Despite physician orders to change the catheter every four weeks and follow up with a urologist, the facility did not implement these orders in a timely manner. Observations revealed that the resident's catheter bag was improperly positioned on the floor, causing tension on the drainage tube and compromising the integrity of the closed drainage system. The resident's medical records lacked specific orders regarding the type, size, and maintenance schedule for the IUC, and there was no documentation of monitoring for signs of infection or complications. Interviews with facility staff confirmed that the necessary orders for catheter care were not placed in the resident's chart until much later, and the catheter was not changed as required. The deficiency was further highlighted by staff interviews, where it was acknowledged that the correct process for managing the resident's IUC was not followed. Staff members admitted that the oversight in placing the necessary orders contributed to the increased risk of UTIs for the resident. The facility's failure to adhere to proper catheter management protocols and physician orders resulted in inadequate care for the resident, as evidenced by the lack of timely catheter changes and monitoring for potential infections.
Unauthorized Access to Medication Room
Penalty
Summary
The facility failed to secure all medications in the locked medication room and did not limit access to authorized personnel, which is inconsistent with professional practice. This deficiency was identified when an unauthorized staff member, the Maintenance Director (Staff E), accessed the medication storage room. The facility's policy, dated July 2021, stated that medication should only be accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications, and that medication rooms should be locked when not attended by authorized persons. During an observation and interview, it was noted that Staff H, a Registered Nurse/Resident Care Manager, used their key to open the medication room, stating that only nursing staff had keys and that no controlled medications were stored there. However, Staff E, the Maintenance Director, was observed using a key to open the locked medication room door to allow the State Fire Marshal access. Staff E stated they had obtained the key from the previous Maintenance Director and were unaware they should not have it, using it monthly to check the air conditioner unit. The facility Administrator, Staff A, confirmed they were unaware that Staff E had a key and acknowledged that Staff E should not have access to the medication storage room.
Director of Nursing Worked with Expired License
Penalty
Summary
The facility failed to ensure that the Director of Nursing Services (DNS), identified as Staff R, maintained an active nursing license while providing care to residents. The facility's job description for the DNS position required a current unrestricted license as a Registered Nurse (RN). However, a review of Staff R's personnel records revealed that their RN license had expired, and they continued to work for 17 days after the expiration. During an interview, the facility's Administrator, Staff A, acknowledged that Staff R had informed them of the license renewal prior to its expiration but later discovered it was expired. Consequently, Staff R should not have worked those 17 days without an active license.
Inadequate Infection Control for Urinary Catheters
Penalty
Summary
The facility failed to implement proper infection control practices for indwelling urinary catheter equipment for two residents, leading to a risk of infections. Resident 29, who has a history of urinary tract infections and is cognitively impaired, was observed multiple times with their urinary catheter bag and tubing dragging on the floor while being moved in a wheelchair. The facility's policy and CDC guidelines clearly state that catheter bags should not touch the floor to prevent infection, yet these practices were not followed by the staff, as evidenced by observations and staff interviews. Similarly, Resident 52, who is cognitively intact and has a history of UTIs, was also observed with their catheter bag touching the floor while seated in a wheelchair. Despite holding the catheter tubing to prevent it from dragging, the bag still made contact with the floor. Staff interviews confirmed that catheter bags and tubing should not touch the floor, yet this practice was not adhered to, placing the residents at risk for infections.
Inadequate Investigation of Resident Altercations
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into resident-to-resident altercations, which involved four residents. The incidents included verbal and physical altercations between Residents 4 and 5, and Residents 6 and 7. The investigation reports lacked essential details such as root cause analysis, witness statements, and interventions to prevent further incidents. Additionally, there were no updates or changes made to the care plans of the involved residents to address the altercations. Resident 4 and Resident 5 were involved in a verbal altercation that escalated to a physical confrontation. The incident report did not provide a comprehensive description of the event, including which resident initiated the name-calling or which shoulder was hit. Furthermore, there were no documented interventions or care plan changes to prevent future altercations between these residents, despite their history of issues. Staff interviews revealed a lack of awareness and communication regarding the incident, with responsibilities for follow-up and care plan updates being unclear. Similarly, Residents 6 and 7 were involved in a physical altercation during lunch. The report failed to include a root cause analysis or details about the residents' injuries and did not document any interventions or care plan changes. Staff interviews indicated a lack of awareness of the incident and insufficient monitoring of Resident 7's known aggressive behaviors. The Social Services Director and nursing staff did not collaborate effectively to implement appropriate interventions, leaving the residents at risk for further altercations.
Infection Control Deficiencies in Hydration Pass and Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for two residents by not performing hand hygiene and glove changes between dirty and clean tasks. Staff E, during hydration passes, repeatedly used the same gloves to handle contaminated resident cups, fill them with ice, and return them to the residents' bedside tables. This practice was observed multiple times, with water from the contaminated cups splashing into the ice chest, further increasing the risk of cross-contamination. Staff E admitted to being trained by a former employee and stated that resident cups were only changed if visibly dirty or during night shifts, contrary to the facility's policy on hand hygiene and glove use. Additionally, the Registered Dietician confirmed that the hydration cart was set up by kitchen staff and that cups were supposed to be changed twice a day, which was not consistently followed by Staff E. The Infection Preventionist acknowledged that the smoking assistants had received hand hygiene training but admitted that the hydration pass was not performed correctly. The Director of Nursing Services emphasized that all staff were expected to follow physician orders and basic hand hygiene procedures when providing care to residents. For Resident 26, who had diagnoses including dementia and required substantial assistance with personal hygiene, Staff K failed to change gloves after cleaning the resident's groin area during incontinent care. Instead, Staff K used the same contaminated gloves to grab clean wipes and continue the care, acknowledging the mistake during the observation. This failure to change gloves between dirty and clean tasks was a direct violation of the facility's infection control policy and increased the risk of cross-contamination for the resident. For Resident 21, who had diagnoses including dementia, localized swelling, and cellulitis, Staff H did not follow proper wound care procedures during a dressing change. Staff H removed the soiled dressing from the resident's right leg without changing gloves or cleaning the wound before applying new ointment and dressing. The same contaminated gloves were used to handle both legs, and hand hygiene was not performed between glove changes. The Infection Preventionist confirmed that the wound care was done incorrectly and that the nurse should have followed the physician's orders, which included cleansing the wound and changing gloves during the dressing change. The Director of Nursing Services reiterated the importance of following physician orders and infection control policies.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure resident care plans were reviewed and revised to accurately reflect care needs for two residents. Resident 40, who had all their teeth removed and received dentures, did not have their care plan updated to reflect these changes. Despite the resident's refusal to follow a physician-ordered fluid restriction and ground meat diet, these refusals were not documented in the care plan. Staff responsible for updating the care plan admitted they had not had time to make the necessary updates. Resident 66, who required assistance for transfers and meal assistance, had an outdated care plan that did not reflect their current needs. The care plan indicated one-person assistance for transfers, but staff were using two-person assistance and an underarm lift technique, which was not recommended. Additionally, the care plan stated the resident required one-to-one assistance for eating, but observations showed the resident eating independently without staff assistance. Staff interviews confirmed the care plan was not accurate and needed updating. The facility's policy required care plans to be updated with any changes in the resident's condition or needs. However, the failure to revise the care plans for these residents placed them at risk for inadequate or unsafe care. Staff acknowledged the discrepancies and the need for care plan updates, but the necessary revisions had not been made in a timely manner.
Failure to Ensure Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis center for three residents (Resident 40, 44, and 38) who required dialysis services. This failure placed the residents at risk for unnoticed significant changes in their health status, delay in care, and potential death. The facility's policy required communication regarding medication administration, physician orders, laboratory values, vital signs, advance directives, nutritional management, dialysis treatment responses, adverse reactions, and changes in condition. However, the facility did not adhere to this policy, as evidenced by the lack of documented communication with the dialysis center for the residents in question. Resident 40, who had diagnoses including diabetes and end-stage renal disease, received dialysis treatments three times a week. Despite having 13 dialysis sessions each month from December 2023 to February 2024, the medical record showed communication from the dialysis center for only three sessions. Additionally, there was no documentation of communication when the resident refused a dialysis session on January 23, 2024. Similarly, Resident 44, who had end-stage renal disease and fluid overload, also had 13 dialysis sessions each month but only one documented communication from the dialysis center during the same period. An adverse reaction involving blood-saturated dressings at the vascular access site was not communicated to the dialysis center. Resident 38, with end-stage renal disease and dependence on dialysis, had 13 dialysis sessions each month from December 2023 to February 2024. The medical record showed limited communication from the dialysis center, with only a few documented instances. Interviews with staff revealed that there was no system in place for communication with the dialysis center, and the facility did not send any paperwork or communication with the residents when they went to their dialysis sessions. The Director of Nursing Services and other staff acknowledged the lack of a proper communication system and the need for improvement in this area.
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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