Enumclaw Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Enumclaw, Washington.
- Location
- 2323 Jensen Street, Enumclaw, Washington 98022
- CMS Provider Number
- 505400
- Inspections on file
- 26
- Latest survey
- September 23, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Enumclaw Health And Rehabilitation during CMS and state inspections, most recent first.
Several residents submitted grievances regarding issues such as equipment malfunction, staff behavior, and inadequate hygiene assistance, but these grievances were not entered into the facility's log, investigated, or resolved according to policy. Staff interviews and record reviews confirmed that the grievance log was not current, and residents did not receive timely responses or notifications about their complaints.
A resident who was dependent on staff for bathing and personal hygiene did not consistently receive scheduled showers and grooming assistance as outlined in their care plan. Observations and interviews revealed the resident often had unkempt hair and reported irregular shower schedules, while staff confirmed that shower aides were sometimes reassigned, leading to missed care. Documentation showed only two bed baths and three refusals over an 18-day period, with incomplete records for the rest of the month.
A resident with complex medical needs did not consistently receive the physician-ordered frequency of OT and PT sessions. Therapy staff missed sessions without proper documentation or explanation, and staff could not provide records of refusals or reasons for missed treatments.
Surveyors observed expired and unlabeled food items, improper storage of chemicals near food, and staff failing to follow hand hygiene and sanitation protocols during food preparation and service. Cold foods were held above safe temperatures, and utensils were not properly sanitized between uses. These deficiencies in food storage, preparation, and service practices increased the risk of food-borne illness for residents.
Surveyors found that the facility failed to maintain a clean and homelike environment, with observations of stained carpets, broken and missing window blinds, and debris buildup on air vents in multiple areas. Staff interviews confirmed expectations for prompt housekeeping and maintenance, but documentation of regular facility reviews was not available.
Several residents with complex medical needs and a history of falls experienced incidents where the facility failed to complete thorough investigations and documentation. Incident reports lacked details on environmental factors, timely assistance, and required assessments such as neurological and skin checks. Staff interviews confirmed that important sections of reports were left incomplete and necessary evaluations were not performed, resulting in incomplete investigations for multiple residents.
Surveyors found that staff failed to document required transfer reports to hospitals, did not provide written discharge notices to residents or their representatives, and did not notify the LTCO as required. Additionally, the facility did not offer or document bed holds for residents transferred to hospitals, with staff interviews confirming these omissions and confusion over departmental responsibilities.
The facility did not ensure that care conferences included the resident, their representative, and all required IDT members. Instead, only limited staff attended, and care conferences were not completed collaboratively or within required timeframes. Residents with complex needs were not included in their care planning, and their representatives were not invited, contrary to facility policy.
Three residents receiving IV antibiotics did not have their central IV dressings changed as ordered by physicians and as documented in the TARs. Observations showed the dressings had not been changed since an earlier date, despite records indicating otherwise. The Regional Director of Clinical Operations confirmed the discrepancy and the expectation for weekly dressing changes.
The facility did not ensure accurate reconciliation of controlled substances, as required by policy, resulting in missing medication cards and incomplete documentation in Narcotic Ledgers. Nursing staff failed to verify each page of the ledger and did not obtain the required signatures during medication transfers, leading to discrepancies in the accounting of narcotics.
Surveyors observed that staff failed to properly administer 5 out of 28 medications for two residents, resulting in a medication error rate of 17.86%. Errors included administering a pain patch to the wrong site, giving a chewable instead of an enteric-coated medication, incorrect dosages of blood pressure and antidepressant medications, and failing to apply a prescribed pain gel. The DON confirmed staff are expected to follow the seven rights of medication administration and physician orders.
Staff failed to properly store and label medications and supplies, with multiple instances of undated or expired medications found in medication carts and the medication room. Several residents had medications and medical supplies left unsecured at their bedsides without physician orders, and some items were not labeled as required. Nursing staff and leadership confirmed these actions did not follow facility policy or professional standards.
Staff did not consistently provide or document required assistance with ADLs such as bathing, shaving, nail care, and grooming for several dependent residents. Multiple residents were observed with poor hygiene, including untrimmed facial hair, dirty nails, and matted hair, and reported not receiving scheduled showers or grooming. Staff interviews confirmed expectations for care and documentation were not met.
Two residents experienced a lack of dignity when an LPN administered medications in a public hallway and when staff had to use towels or pillowcases for personal hygiene care due to a prolonged shortage of washcloths. Staff and residents reported ongoing issues with supply availability, and the DON acknowledged that these practices did not meet facility expectations for resident dignity.
The facility did not transfer trust fund balances for two residents to the state Office of Financial Recovery within the required 30-day period after discharge or death. One resident's funds were delayed by over three months, while another's were transferred four days late, contrary to facility policy and state regulations.
Multiple residents had inaccurate MDS assessments, including errors in documenting dental status, medication use, mental health diagnoses, bowel continence for a resident with a colostomy, and discharge status. Staff confirmed these inaccuracies after reviewing clinical records and resident interviews.
The facility did not ensure that Level II PASRR evaluation recommendations were incorporated into the care plans for two residents with serious mental health needs. Despite receiving notifications and recommendations for specialized behavioral health services, the required evaluations and care plan updates were not completed as per policy.
Staff did not administer antihypertensive medications according to prescribed parameters for two residents, failed to follow proper resident identification and medication labeling procedures during med pass, and did not complete or clarify physician orders for weights, pain management, and bowel protocols. These actions were not in line with facility policy or professional standards.
A resident with bilateral hearing loss and a history of using hearing aids was left without a replacement after one device broke. Despite documentation of the incident and notification of nursing leadership, there was no evidence of follow-up or assistance to obtain a new hearing aid, and staff interviews revealed a lack of awareness regarding the resident's needs.
Multiple residents with known fall risks experienced repeated falls due to the facility's failure to update and implement individualized fall prevention interventions. For example, a resident with complex medical needs was left alone in their room despite care plan instructions, and another resident's bed was not positioned as directed for safety. Additional residents did not have new interventions added after actual falls, and staff confirmed that care plans were not revised as required.
A resident with severe right-sided weakness and cognitive impairment did not receive required therapy evaluations or treatments as ordered by a physician. Despite facility policy mandating timely therapy evaluation and confirmation from the business office that no insurance pre-authorization was needed, the therapy department failed to evaluate or treat the resident, resulting in a lack of specialized rehabilitative services.
Nursing staff left nurse run sheets containing PHI, including names, room numbers, and diagnoses, unattended and visible on medication carts in two units. Staff confirmed these documents should have been protected and not visible to unauthorized individuals, in accordance with facility policy and resident rights.
Staff failed to consistently perform hand hygiene, use appropriate PPE, and follow posted transmission-based precautions when caring for residents with infectious diseases. Observations included a CNA delivering meal trays and a nurse administering medications without performing hand hygiene, as well as staff entering isolation rooms without required PPE or proper glove use. These actions were not in accordance with facility policy or posted instructions.
A resident with a seizure disorder and brain damage was injured during a transfer due to the use of an incorrect sling. The care plan lacked documentation on the appropriate sling type, and two new CNAs used a split sling instead of the required medium whole-body sling. The resident fell and sustained spinal fractures after the wheelchair bumped the lift, highlighting confusion over sling assessment responsibilities.
The facility failed to provide adequate nutrition and hydration for three residents, resulting in significant weight loss. A resident with severe memory impairment experienced over 11% weight loss in 21 days due to inconsistent meal documentation and lack of assistance. Another resident with diabetes and dementia lost 10 pounds, with meals often out of reach and unrecorded. A third resident with cancer and heart failure also faced significant weight loss, with meals left out of reach and weights not monitored. These issues indicate a systemic failure in supporting residents' nutritional needs.
The facility failed to serve meals within the posted timeframes for residents eating in their rooms on the 100 and 200 Hall Dining Carts. Observations showed significant delays in meal delivery, with breakfast and lunch trays arriving late. Staff interviews revealed no process to address late deliveries, and residents expressed dissatisfaction with the delays affecting their meal schedules and digestion. The Dietary Manager expected timely service, but this was not consistently achieved.
The facility failed to maintain food safety standards, with staff not wearing hairnets, uncovered and undated food in the kitchen, incomplete temperature logs, and uncovered desserts being delivered through hallways, posing risks of contamination.
The facility failed to maintain dignity during meal assistance for three residents. A resident with complex medical needs experienced delays in receiving help with meals, while another was fed by a CNA standing in protective gear. A third resident was assisted by a CNA standing at their bedside, contrary to the facility's expectations for promoting dignity.
A resident with complex medical diagnoses, including a hip fracture and dementia, was observed multiple times with their feet pressed against the footboard of their bed, unable to straighten their legs. Staff confirmed the bed was too short, failing to accommodate the resident's needs.
The facility failed to provide required written transfer notices to two residents during hospitalizations. One resident, with severely impaired memory, was hospitalized multiple times without receiving the necessary notices. Another resident was transferred for medical reasons without receiving a written notification or information about their rights. Staff confirmed the absence of a process for issuing these notices.
A resident with complex medical conditions experienced significant weight loss and developed a new pressure injury, but the facility failed to complete a Significant Change in Status Assessment (SCSA) within the required timeframe. Despite the resident's deteriorating condition, the necessary assessment to address care needs was not conducted, as acknowledged by the MDS Coordinator.
The facility failed to ensure accurate and timely PASRR assessments for two residents. One resident's PASRR Level 1 was not obtained until over two months after admission, while another resident's PASRR Level 1 was incomplete, missing key diagnoses such as dementia and a psychotic disorder. Staff acknowledged the deficiencies and the need for accurate and updated assessments.
The facility failed to develop comprehensive care plans for three residents, leading to unmet care needs. A resident with a spinal cord injury lacked an updated smoking safety evaluation, another on antipsychotic medication had an incomplete care plan, and a third resident did not have a care plan for recommended range of motion exercises.
The facility failed to update CPs for four residents, leading to discrepancies between documented care needs and actual resident conditions. A resident with dementia had no medications ordered despite CP instructions, while another resident's CP inaccurately required moderate assistance with meals despite their independence. Additionally, a resident's discontinued restorative program was not reflected in their CP, and another resident's ability to self-feed was not updated in their CP. The DON acknowledged the need for CP revisions.
The facility failed to follow POs and ensure accurate documentation for several residents. A resident received narcotic pain medication outside ordered parameters, while another used an ace bandage instead of a prescribed compression stocking without order clarification. Additionally, staff inaccurately documented the use of a moon boot and knee splint, which were not worn as ordered.
The facility failed to assist three residents with ADLs, including personal hygiene, dressing, and meal setup. One resident had long, untrimmed nails despite orders for weekly care. Another resident remained in a hospital gown for days and struggled to eat due to improper meal tray positioning. A third resident wore the same gown for multiple days and did not receive needed dressing assistance.
A facility failed to follow its BG monitoring protocol for a diabetic resident, leading to the administration of insulin despite a low BG reading of 70 mg/dl. The resident, with multiple health diagnoses, was not monitored for three days due to a leave of absence, increasing their risk. The DON confirmed the protocol breach and the associated risk.
A resident with hearing impairment was not consistently assisted with their hearing aids, leading to ineffective communication. Observations showed the resident without hearing aids and, when worn, they were not charged. The care plan lacked specific instructions for hearing aid use, and staff failed to ensure proper maintenance and assistance.
The facility failed to provide restorative programs for residents with mobility limitations, including a resident with a progressive neurological condition and another with severe obesity. Despite therapy recommendations, programs were not initiated timely or documented properly, placing residents at risk for declines in ROM and mobility.
The facility failed to document a failed Gradual Dose Reduction (GDR) for a resident's antianxiety medication and did not obtain informed consent for another resident's antidepressant medication. Despite no documented anxious behaviors, the GDR was discontinued without justification, and the medication was increased. Additionally, informed consent was not obtained for an antidepressant, and target behavior monitoring was not established.
The facility failed to dispose of expired medications timely and ensure secure storage, as observed in two medication carts and the central supply room. Expired medications were found on the 100 and 500 Hall medication carts and in the central supply room. Additionally, a treatment cart on the 500 Hall was left unlocked, containing various medical supplies. Staff interviews confirmed these deficiencies.
The facility failed to provide timely dental services for two residents, leading to unmet dental needs. One resident had not seen a dentist for many years despite having broken teeth, and staff did not facilitate a dental appointment until much later. Another resident was without dentures for over 19 months, with staff failing to document the issue or follow up on recommendations for new dentures. Interviews revealed that staff did not meet expectations for timely dental consultations and follow-ups.
The facility failed to accommodate the food preferences of three residents, leading to dissatisfaction and potential risks. One resident with dental issues was served meals they couldn't chew, another received incorrect meal orders despite filling out a weekly menu, and a third was served a disliked vegetable. Staff acknowledged these errors, indicating a lapse in following documented preferences.
The facility failed to maintain comprehensive medical records for three residents, leading to incomplete documentation and potential delays in treatment. A resident's medication change recommendation was delayed over three months, hospice notes for another resident were not updated for several months, and a third resident's pharmacy recommendation was found unscanned. Staff interviews revealed inconsistencies in following the facility's policy for timely document uploads.
The facility failed to maintain infection control practices, with staff not wearing PPE when entering rooms of residents under contact precautions, such as a resident with antibiotic-resistant bacteria and another with a severe intestinal infection. Additionally, urinals were improperly stored next to food trays for two residents, and a cracked floor mat was noted for another resident, posing infection risks.
Failure to Initiate, Investigate, and Resolve Resident Grievances
Penalty
Summary
The facility failed to initiate, investigate, and resolve grievances for six of twelve sampled residents, as required by its grievance policy. The Administrator, who is designated as the Grievance Official, did not maintain an up-to-date grievance log, and several grievances submitted by residents were not entered into the log or followed up with complete documentation of resolution, actions, recommendations, or notification to the residents. For example, one resident reported a malfunctioning mechanical lift that caused pain and submitted two grievances, but did not receive a timely response, and the grievance was not logged or resolved. Another resident filed a grievance about staff behavior that triggered their anxiety, but there was no entry in the log or evidence of resolution or notification. Additional residents reported grievances related to inadequate hygiene assistance and other concerns, which were similarly not documented or resolved according to policy. Interviews with staff confirmed that the grievance log was not current and that grievances were not being tracked or managed as required. The Maintenance Director also stated there was no log for mechanical lift inspections. Review of the grievance forms for the affected residents showed incomplete documentation and lack of follow-up. The facility's failure to follow its own grievance procedures resulted in unresolved grievances and lack of communication with residents regarding the status or outcome of their complaints.
Failure to Provide Consistent ADL Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide required assistance with Activities of Daily Living (ADLs) for a resident who was dependent on staff for bathing, personal hygiene, and grooming. According to the resident's most recent MDS and Baseline Plan of Care, the resident required substantial to maximum support for bathing and was dependent on staff for hair care and personal hygiene, with a care plan specifying showers twice weekly. However, observations on multiple occasions found the resident in bed with unkempt hair, and the resident reported that scheduled showers were not consistently provided as planned, with shower days appearing random and hair becoming so matted that it had to be cut. Interviews with staff revealed that shower aides were sometimes reassigned to other duties, resulting in missed showers. Review of shower task sheets over an 18-day period showed only two bed baths and three documented refusals, with no additional refusals or completed showers documented for the remainder of the 30-day period. Requested documentation for the remaining days was not provided. The lack of consistent ADL assistance was confirmed by both staff and documentation review.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services as ordered by the physician for one resident who required assistance with position and mobility. The resident, who had multiple medically complex conditions, was dependent on staff for all mobility and required substantial to maximal assistance with daily activities such as dressing, transfers, and wheelchair mobility. Physician orders specified occupational therapy (OT) five times per week and physical therapy (PT) three times per week. However, therapy calendars and documentation showed that the resident did not consistently receive the ordered frequency of therapy sessions, with some weeks showing reduced numbers of sessions for both OT and PT. During interviews and observations, the resident reported missing therapy sessions, sometimes due to dialysis appointments, but also noted that therapists occasionally did not show up without explanation. The Therapy Director confirmed that missed therapy sessions should have been documented with reasons for absence or refusal, but such documentation was not available. Staff were unable to provide records of refusals or explanations for the missed sessions, indicating a lack of adherence to the prescribed therapy regimen.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
The facility failed to store, prepare, and serve food under sanitary conditions as required by policy and professional standards. During multiple observations, surveyors found expired and improperly labeled food items in the walk-in refrigerator, including a bag of cut carrots past its use-by date, unsealed and undated packages of cheese, chicken, pork, ham loaf, and boiled eggs, as well as sealed roast beef without a use-by date. Staff interviews confirmed that food should be sealed and labeled with open and use-by dates, but staff were unable to determine how long some items had been stored. Additionally, chemicals such as surface sanitizer were stored next to food products, and staff were observed entering the kitchen without appropriate hair coverings beyond designated areas. Food preparation practices were also found to be unsanitary. Staff were observed handling food and food-contact surfaces with soiled hands or gloves, failing to wash hands after touching their faces or other potentially contaminated surfaces, and placing raw meat near clean trays, resulting in cross-contamination. Staff did not consistently sanitize surfaces or utensils after contact with raw meat, and food was sometimes placed next to dirty items on counters. Staff interviews confirmed that these actions were not in line with facility expectations for food safety and sanitation. During food service, cold foods were repeatedly found to be held at temperatures above the facility's policy of 41°F or lower, with milk, juice, desserts, and salads measured at unsafe temperatures. Staff failed to properly sanitize thermometers between uses, and utensils previously touched with soiled hands were placed back into food containers. Staff also entered the kitchen and handled food without washing hands or donning hairnets as required. These actions and inactions placed residents at risk for consuming expired or contaminated foods and potential exposure to food-borne illness.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's maintenance and housekeeping practices across three units and the main dining room. Over several days, a large carpet stain was noted in the hallway across from a resident room, and staff interviews confirmed that housekeeping was expected to address such stains promptly. Additionally, missing and broken window blinds were observed at the ends of two hallways, with broken blinds found on the floor. Staff acknowledged the need for repairs and replacements to maintain a clean and functional environment for residents. Further observations revealed a buildup of debris on ceiling air vents in the main dining room, as well as on bathroom ceiling vents in several resident rooms and on a wall-mounted heater vent. The maintenance supervisor confirmed that these vents required cleaning and emphasized the importance of a clean, homelike environment. However, the facility was unable to provide documentation of regular facility reviews as required by their own policies. These findings indicate a failure to maintain the environment in a safe, clean, and comfortable condition as outlined in facility policies and resident rights documentation.
Failure to Conduct Thorough Fall Investigations and Assessments
Penalty
Summary
The facility failed to conduct thorough and complete investigations for multiple residents who experienced falls. For several residents with complex medical histories and high fall risk, incident reports and investigations were incomplete. Specifically, documentation was missing regarding environmental factors such as room clutter, wheelchair safety, and whether residents had their needs met or received timely assistance prior to the falls. In some cases, there was no information about when the last assistance was provided or if care plan interventions, such as toileting schedules, were followed. Incident reports for residents who sustained injuries from falls did not consistently include required assessments. For example, neurological assessments were initiated but not documented, and skin assessments for injuries were not completed or lacked details such as measurements and descriptions. Environmental assessments were often left blank, failing to identify potential causes like wet floors, inappropriate footwear, or room hazards. Additionally, there was a lack of documentation regarding whether staff assessed blood sugar levels for residents with diabetes after a fall, as required by their care plans. Interviews with staff, including the DON and regional clinical leadership, confirmed that incident reports and investigations were not thorough and did not meet facility policy expectations. Staff acknowledged that important sections of the incident reports were left incomplete, and necessary assessments were not performed or documented. These deficiencies were observed for multiple residents, including those with a history of falls, complex medical needs, and those dependent on staff for transfers and toileting.
Failure to Provide Required Transfer Documentation and Notifications
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to provide required documentation and notifications during resident transfers and discharges. Specifically, staff did not document that reports were given to receiving hospitals regarding residents' conditions at the time of transfer, and e-interact forms were not completed for several residents transferred to acute care hospitals. Additionally, there was no evidence that written notifications of discharge were provided to residents or their representatives as required by facility policy and regulatory standards. The review also found that the facility did not notify the Office of the State Long Term Care Ombudsman (LTCO) when residents were transferred to hospitals or discharged to the community. Staff interviews revealed confusion regarding departmental responsibilities for LTCO notification, with both nursing and social services staff indicating the other was responsible. In several cases, staff were unable to provide documentation that notifications or reports had been completed, despite facility policies requiring these actions. Furthermore, the facility failed to offer or document the offer of bed holds to residents or their representatives upon transfer to the hospital, as required by the facility's bed hold policy. This deficiency was noted for at least one resident, with staff unable to produce documentation of the offer. The lack of documentation and communication was confirmed through record reviews and staff interviews, which consistently showed that required notifications and reports were not completed or documented for multiple residents during the review period.
Failure to Conduct Interdisciplinary Care Conferences with Resident and Representative Involvement
Penalty
Summary
The facility failed to conduct care conferences with the required participation of the resident, their representative, and the full interdisciplinary team (IDT) for multiple residents. Documentation and interviews revealed that care conferences were routinely attended only by the Resident Care Manager (RCM) and Social Services staff, with other vital IDT members such as nursing, therapy, dietary, and activities staff not present. In several instances, care conference forms were completed by different staff members on separate dates, rather than as a collaborative team meeting with the resident and their representative. Residents reported not being included in their care planning process and not receiving care conferences that involved all relevant departments. For example, one resident stated they had not had a care conference with nursing, therapy, social services, dietary, and activities, and had not received a copy of their care plan. Another resident expressed that their power of attorney or representative was not involved in their care planning, despite being listed in their records. These findings were corroborated by staff interviews, which confirmed that only limited staff attended care conferences and that other departments, though invited, did not participate. Record reviews showed that care conferences were not completed within the required timeframes, such as within 72 hours of admission, and that resident representatives were not invited as required by facility policy and admission agreements. The lack of full IDT participation and resident or representative involvement in care conferences was observed for several residents, including those with complex medical needs such as tube feeding, neurological disorders, and recent admissions requiring therapy services.
Failure to Change Central IV Dressings as Ordered and Documented
Penalty
Summary
The facility failed to ensure that intravenous (IV) dressings for three residents receiving IV antibiotic therapy were changed as ordered by physicians and as documented by staff. For each resident, physician orders and facility policy required central IV dressings to be changed every seven days and as needed. Treatment Administration Records (TARs) indicated that the dressings were signed as changed on specific dates; however, direct observation revealed that the actual last changed date on the dressings was earlier than documented, indicating that the dressings had not been changed according to orders or documentation. Specifically, one resident with a bone infection, another with sepsis, and a third with an infection of the heart chambers and valves all had central IV access and were receiving IV antibiotics. Despite TARs showing that dressings were changed on two occasions, observations showed the dressings had not been changed since an earlier date. The Regional Director of Clinical Operations confirmed the discrepancy between the documented and observed dressing change dates and acknowledged the expectation for weekly dressing changes as per policy and physician orders.
Failure to Accurately Account for Controlled Substances in Narcotic Ledgers
Penalty
Summary
The facility failed to ensure the accuracy of Narcotic Ledgers for two medication carts, resulting in discrepancies in the accounting of controlled substances. According to facility policy, a physical inventory of controlled medications was to be conducted by two licensed staff at each shift change, with documentation on the record and immediate reporting of any discrepancies to the Director of Nursing. However, observations and record reviews revealed that the required procedures were not consistently followed. On one cart, a review of the Narcotic Ledger showed 21 tablets remaining on a page, but the corresponding medication card was missing from the cart. A registered nurse admitted to not catching the missing card during the shift count and stated that only the physical cards in the lock box were counted, rather than verifying each page of the ledger as required. On another cart, multiple pages in the Narcotic Ledger showed transfers of controlled medications to other units with only one nurse's initials, rather than the required signatures of both the releasing and receiving nurse. Several pages also lacked medication names, prescription numbers, or proper identification of the medication form, and some pages had no nurse signature for medication card transfers. Interviews with nursing staff confirmed that the expected process of going page by page in the Narcotic Ledger to ensure all controlled medications were accounted for was not followed. Staff acknowledged the importance of this process in preventing narcotic diversion and ensuring accurate accounting of controlled substances, but admitted to not adhering to the established procedures. The Director of Nursing also confirmed the expectation for both nurses to sign the ledger during transfers and for staff to verify each page during counts.
Medication Error Rate Exceeds 5% Due to Multiple Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by policy and regulation. During observed medication passes, staff administered 5 out of 28 medications incorrectly for two residents. For one resident, a pain medication patch was applied to the left hip instead of the right shoulder as ordered by the physician. The nurse involved acknowledged not clarifying the order before administering the medication to a different site than prescribed. For another resident, multiple errors were observed: a chewable form of a medication was given instead of the prescribed enteric-coated form, a blood pressure medication was administered at 25 mg instead of the ordered 75 mg, and an antidepressant was given at 30 mg instead of the prescribed 60 mg. Additionally, a pain medication gel was not applied as required, despite being documented as administered. The DON confirmed that staff are expected to follow the seven rights of medication administration and adhere to physician orders.
Improper Storage and Labeling of Medications and Supplies
Penalty
Summary
Facility staff failed to ensure proper storage and labeling of medications and biologicals across multiple units, medication carts, and the medication room. Observations revealed that medications, including nasal sprays and insulin pens, were not dated upon opening, and expired medications and supplies were not removed from storage areas. For example, one medication cart contained nasal sprays and an insulin pen without documented open dates, and another cart had expired blood pressure medications and medicated creams stored alongside inhaled medications. The medication room also contained expired vitamins, syringes, needles, and an intravenous device stabilizer. Additionally, staff did not follow facility policy or physician orders regarding the storage of medications at residents' bedsides. Several residents were observed with medications and medical supplies, such as topical pain-relieving patches, anti-fungal creams, powders, and tube feeding formula, left unsecured in their rooms or on their nightstands. In these cases, there were no physician orders permitting bedside storage, and some items were not labeled with the resident's name or the date and time of opening, as required by policy. Interviews with nursing staff and facility leadership confirmed that these practices were inconsistent with facility policies and professional standards. Staff acknowledged that medications and supplies should be dated, stored in locked carts or rooms, and removed upon expiration. They also stated that wound care supplies and medications should not be left in resident rooms to prevent contamination and ensure resident safety.
Failure to Provide Assistance with ADLs and Personal Hygiene
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs), including bathing, shaving, nail care, and grooming, for seven dependent residents. Multiple residents who required substantial or total staff assistance for personal hygiene were observed with untrimmed facial hair, long and dirty fingernails, and uncombed or matted hair. Documentation revealed that scheduled showers and personal hygiene care were frequently missed, with staff either not offering care, not documenting refusals, or leaving records blank or marked as 'Not Applicable.' Several residents reported not receiving showers or assistance with grooming as care planned, despite expressing preferences for more frequent bathing and personal hygiene. For example, one resident stated they had not been shaved or had their nails trimmed for weeks, and another reported only receiving bed baths once a week despite preferring more frequent bathing. Other residents, including those with cognitive or physical impairments, were not offered showers as scheduled, and documentation did not reflect refusals or alternative care provided. In some cases, residents were given baby wipes and told to clean themselves, contrary to their care plans requiring staff assistance. Interviews with staff, including the Director of Nursing and Resident Care Managers, confirmed that the expectation was for staff to follow care plans, offer and assist with ADLs as scheduled, and document any refusals or care provided. However, observations and record reviews demonstrated that these expectations were not consistently met, resulting in unmet care needs and poor hygiene for the affected residents.
Failure to Promote Resident Dignity During Medication Administration and Personal Care
Penalty
Summary
The facility failed to provide care in a manner that promoted dignity for two residents. For one resident, a Licensed Practical Nurse (LPN) administered medications, including eye drops and an inhaler, in the hallway while other residents were present. The Director of Nursing (DON) confirmed that it was the facility's expectation that medication administration should not occur in the hallway and should be offered in private to promote resident dignity. Another resident reported frustration and embarrassment due to the facility frequently running out of washcloths, resulting in staff using pillowcases or towels for personal hygiene care. Multiple observations confirmed that washcloths were not available in various linen closets and the laundry department over several days. Staff interviews corroborated the ongoing shortage, with staff expressing difficulty in providing care and residents voicing concerns about the lack of appropriate supplies for personal hygiene.
Delayed Transfer of Resident Trust Funds After Discharge
Penalty
Summary
The facility failed to ensure that resident trust fund balances were reimbursed to the state Office of Financial Recovery (OFR) within 30 days of discharge or death, as required by policy and regulation. Specifically, one resident's trust fund balance of $229.61 was not transferred to the OFR until over three months after discharge, and another resident's balance of $55.84 was transferred four days past the 30-day requirement. These delays were confirmed by the Business Office Manager during an interview and were identified through record review. The facility's policy states that resident personal funds must be returned to the resident, responsible party, or as directed by state regulation upon discharge or death.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the clinical status and care needs of multiple residents. For one resident, the annual MDS indicated no dental concerns, despite the resident reporting broken teeth and documentation showing decayed and broken teeth requiring dental intervention. Another resident's significant change MDS failed to indicate the use of diuretic and antipsychotic medications, even though medication records confirmed daily administration of both. A third resident's MDS did not reflect a serious mental illness diagnosis, despite behavioral health documentation supporting the presence of such a condition and the need for specialized services. Additional deficiencies included a resident with a colostomy being incorrectly coded as occasionally incontinent of bowel on the MDS, rather than indicating the presence of an ostomy. Another resident's discharge MDS was inaccurately coded, failing to reflect that the resident left the facility against medical advice. In each case, staff interviews confirmed the inaccuracies in the MDS coding, and the need for modifications to ensure accurate assessments as required by facility policy and regulatory standards.
Failure to Incorporate PASRR Level II Recommendations into Care Plans
Penalty
Summary
The facility failed to ensure that recommendations from Level II Preadmission Screening and Resident Review (PASRR) evaluations were incorporated into the care plans for two of five sampled residents. For one resident with multiple complex diagnoses, including anxiety, depression, and a mental health condition related to trauma, staff completed a Level I PASRR indicating the need for a Level II evaluation. Although a Notice of Determination was received confirming the need for specialized behavioral health services, the Level II evaluation was not found in the resident's records, and its recommendations were not integrated into the care plan. The Social Services Director confirmed that the evaluation and its recommendations were received via email but were not implemented as required by facility policy. Similarly, another resident with dementia and depression, who was receiving antipsychotic, antianxiety, and antidepressant medications, was identified as needing a Level II PASRR evaluation following a Level I screen. However, no Level II evaluation was found in this resident's records. The Social Services Director acknowledged that such evaluations should be obtained and included in the resident's records when a serious mental illness is identified. These omissions were in direct violation of the facility's policy and state regulations.
Failure to Follow Medication Administration Parameters and Physician Orders
Penalty
Summary
Staff failed to administer antihypertensive medications according to prescribed parameters for two residents with complex medical histories, including hypertension. For one resident, medications were given on multiple occasions despite blood pressure readings below the ordered threshold. Similarly, another resident received blood pressure medications outside of the specified heart rate and systolic blood pressure parameters on several occasions across two months. These actions were not in accordance with the medication administration records and physician orders. During medication pass observations, an agency LPN did not follow facility policy for resident identification, administering medications without confirming the resident’s identity using two identifiers. The same LPN was also observed storing pre-poured, unlabeled medication cups in the medication cart, and was unable to identify the contents of one of the cups. Facility policy required medications to be administered at the time they are prepared and for medication cups to be labeled if not immediately administered. Additionally, staff did not follow or clarify physician orders for two residents. One resident’s order for monthly weights was not completed for two consecutive months, with documentation either missing or incomplete. Another resident had conflicting as-needed pain medication orders and unclear bowel protocol orders, with no clarification provided to guide staff on which medications to administer first. These failures were confirmed by interviews with facility leadership, who stated that staff were expected to follow physician orders and facility policies.
Failure to Assist Resident in Obtaining Replacement Hearing Aid
Penalty
Summary
The facility failed to ensure that a resident received proper assistance in obtaining a replacement hearing aid after their original device was broken. The resident, who had a history of being hard of hearing in both ears and used hearing aids for both ears, reported that their right hearing aid broke after falling out and being stepped on. Although the incident was documented by social services, and both the resident care manager and director of nursing were notified, there was no further documentation or evidence that an appointment was set up or assistance was provided to replace the broken hearing aid. Interviews with facility staff revealed a lack of awareness and follow-up regarding the resident's need for hearing aid services. The Social Services Director was unaware of any residents requiring referrals for broken hearing aids and did not believe the resident wore hearing aids. Similarly, the Resident Care Manager was unaware of any referrals for the resident's hearing aids, and the Regional Director of Clinical Operations stated that it was their expectation that appointment referrals be followed up on by staff. Observations confirmed that the resident was only wearing a hearing aid in one ear, and records did not show any further action taken to address the broken device.
Failure to Update and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and update appropriate interventions to prevent continued falls among multiple residents with known fall risks and histories of previous falls. For one resident with multiple complex diagnoses and a history of falls, staff were instructed not to leave the resident alone in their room and to keep them near the nurse's station, but the resident experienced repeated falls in their room, indicating that interventions were not consistently followed or updated. Another resident with a history of repeated falls and a recent fall with injury was observed with their bed positioned away from the wall, contrary to their care plan instructions for safety, and staff acknowledged that the care plan interventions needed revision. Additional residents with fall histories did not have new interventions added to their care plans after experiencing actual falls. One resident fell after attempting to close window blinds without staff assistance, despite being at moderate risk for falls and requiring appropriate footwear. Another resident, dependent on staff for transfers and with paralysis, fell after being placed incorrectly in a wheelchair, resulting in the wheelchair tipping over. In both cases, staff confirmed that no new interventions were documented following the falls, contrary to facility policy requiring evaluation and modification of plans after such incidents.
Failure to Provide Timely Rehabilitative Services per Physician Orders
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required by physician orders for one resident who was reviewed for position and mobility needs. The resident, who had a diagnosis of a brain bleed and severe right-sided weakness, was admitted with moderate cognitive impairment and required significant assistance with activities of daily living. Despite a physician's order for physical, occupational, and speech therapy evaluation and treatment, there was no documentation that the resident was evaluated or treated by the therapy department. The facility's policy required therapy evaluations to occur within 48 hours of receiving a physician's order, but this was not followed. Observations and interviews revealed that the resident did not receive any therapy or exercise program and expressed concerns about not being able to improve mobility. Staff interviews indicated a misunderstanding regarding insurance pre-authorization requirements, which led to a delay in therapy evaluation. The business office confirmed that pre-authorization was not needed and that the resident was eligible for therapy evaluation since admission, but the therapy department did not act on this information, resulting in the resident not receiving the ordered rehabilitative services.
Failure to Protect Resident PHI on Medication Carts
Penalty
Summary
Nursing staff on two separate units failed to safeguard resident-identifiable information by leaving nurse run sheets containing protected health information (PHI) unattended and visible on medication carts. On Unit 500, a nurse run sheet listing residents' names, room numbers, and diagnoses was observed left in plain view on the medication cart without staff present. Staff interviews confirmed that the run sheet should have been protected and not visible to unauthorized individuals, and staff acknowledged the importance of maintaining PHI confidentiality for resident rights. Similarly, on Units 200 and 300, a printed nurse run sheet with full names, room numbers, and diagnoses for 15 residents was left unattended and visible on a medication cart, with no nursing staff nearby. Staff confirmed the document was left unattended and agreed that PHI should not be visible to unauthorized individuals. Facility policy and admission agreements reviewed indicated an expectation to protect and maintain the confidentiality of all residents' PHI.
Failure to Follow Infection Control Protocols and Transmission-Based Precautions
Penalty
Summary
Multiple staff members failed to adhere to infection prevention and control protocols, including hand hygiene (HH), use of personal protective equipment (PPE), and proper medication handling. During meal tray delivery, a staff member was observed touching items in resident rooms, wiping their face, and delivering trays to multiple residents, including one on transmission-based precautions (TBP), without performing HH at any point. Similarly, during a medication pass, a nurse handled medications with bare hands, touched various surfaces, administered medications, and used personal items such as a cell phone, all without performing HH between tasks or after glove removal. The nurse also failed to follow the facility's policy of placing medications directly into cups and not handling them directly. Staff also failed to follow posted TBP signage and PPE requirements for residents on isolation precautions. For example, two staff members entered a room with a posted Contact Precautions sign without donning the required gown and gloves, despite the signage instructing all entrants to do so. Another staff member entered a room requiring Special Droplet/Contact Precautions without wearing the required eye protection. Additional observations showed staff not performing HH before donning gloves, wearing damaged gloves during resident care, and failing to perform HH after glove removal and before exiting isolation rooms. The facility's policies required strict adherence to HH before and after resident contact, after glove removal, and when entering or exiting isolation rooms, as well as the use of appropriate PPE as indicated by posted signage. Staff interviews confirmed that expectations for HH and PPE use were known, but staff did not consistently follow these protocols. These lapses were observed in the care of residents with active infectious diseases who were on TBP, as well as during routine care and medication administration.
Incorrect Sling Use Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the correct type of sling was used for a resident during mechanical lift transfers, resulting in harm. The resident, who had a history of brain damage, seizure disorder, and was totally dependent on staff for transfers, was transferred using an incorrect sling type. The care plan did not specify the size or type of sling required, and there was no documented assessment to determine the appropriate sling for the resident. During a transfer, the resident fell from the sling and sustained a spinal injury. The incident occurred when two newly hired CNAs used a split sling instead of the medium whole-body sling that the resident was assessed to require. The resident experienced discomfort and felt the sling was not applied correctly. During the transfer, the resident began to have tremors and slid through the sling after the wheelchair bumped the lift, resulting in a fall to the floor. The resident was later diagnosed with compression fractures to the T4 and T5 vertebrae. Interviews revealed confusion regarding the responsibility for assessing and documenting the appropriate sling type. The Director of Nursing believed the therapy department was responsible, while the Director of Rehabilitation stated that the therapy department did not handle sling assessments. This lack of clarity and documentation contributed to the use of an incorrect sling, leading to the resident's injury.
Failure to Ensure Adequate Nutrition and Hydration
Penalty
Summary
The facility failed to ensure adequate nutrition and hydration for three residents, leading to significant weight loss and potential health risks. Resident 218, who had severe memory impairment and required a pureed diet, experienced a weight loss of over 11% within 21 days. The facility did not consistently document meal intake, and observations showed that meals were often left out of reach, preventing the resident from eating. Staff were unaware of the resident's need for mealtime assistance, and inaccurate meal intake documentation was noted. Resident 15, with complex medical diagnoses including diabetes and dementia, was not weighed upon admission as per facility policy and experienced a 10-pound weight loss. Observations revealed that meals were not positioned to facilitate eating, and the resident struggled to access food. Meal intake documentation was inconsistent, with several meals unrecorded, indicating a lack of monitoring and support for the resident's nutritional needs. Resident 57, with diagnoses including cancer and heart failure, also experienced significant weight loss. The facility failed to document meal intake on numerous occasions, and observations showed meals were left out of reach. Staff did not obtain weekly weights despite the resident's weight loss, and there was a lack of communication and documentation regarding the resident's nutritional status. These deficiencies highlight a systemic failure in monitoring and supporting residents' nutritional needs.
Delayed Meal Service in Resident Rooms
Penalty
Summary
The facility failed to consistently serve meals within the posted timeframes for residents who ate in their rooms on the 100 and 200 Hall Dining Carts. Observations showed that breakfast trays on the 200 Hall were delayed by 74 minutes, and lunch trays on the 100 Hall were delayed by up to 63 minutes. Staff interviews revealed a lack of a process to address late meal deliveries, and some staff trusted the kitchen to resolve delays without inquiry. Residents expressed dissatisfaction with the late meal deliveries, noting that it affected their meal schedules and digestion. The Dietary Manager stated that meals were expected to be served at the posted times and trays should be passed out within five minutes of the carts arriving on the hall. However, observations indicated that this expectation was not met, as meal carts were often delayed, and trays were not delivered promptly. This inconsistency in meal service times placed residents at risk of receiving meals at undesired temperatures and experiencing hunger due to delayed meal delivery.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food safety in its kitchen and unit refrigerators, leading to potential risks of food contamination and foodborne illnesses. Observations revealed that dietary staff, including the Dietary Manager and a Cook, were not wearing hairnets as required by the facility's Personal Hygiene Standards policy. Additionally, the kitchen freezer contained uncovered bowls of ice cream without any date labels, and the refrigerator had opened jugs of milk that were not marked with a date to indicate when they were opened or should be used by. These lapses in food safety practices were acknowledged by the Dietary Manager, who admitted that the items were stored incorrectly and needed to be discarded. Further deficiencies were noted in the unit refrigerators, where temperature logs were incomplete, and the cleanliness of the refrigerators was compromised by sticky stains. The 500 Hall resident snack refrigerator had not been monitored for temperature for several days, and a container of food brought by a visitor was not dated, leading to its disposal. Additionally, staff were observed delivering lunch trays with uncovered desserts through hallways, increasing the risk of food contamination. The Dietary Manager expressed frustration over these practices, emphasizing the importance of maintaining food safety standards.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to provide care and services that maintained and promoted dignity during meal assistance for three residents. Resident 29, who had complex medical diagnoses including cancer, anxiety, depression, and weakness, required substantial assistance with eating. However, during multiple meal services, staff delayed assisting Resident 29, leaving the resident to watch others eat and wait for extended periods before receiving help. On one occasion, Resident 29 had to use the call light twice before receiving assistance, highlighting a lack of timely support. Resident 5, who was dependent on staff for eating due to the loss of ability to move their arms and legs, was fed by a CNA who stood while wearing a protective gown and gloves, which did not align with the facility's expectations for promoting dignity. Similarly, Resident 12, who required setup help with eating, was fed by a CNA standing at their bedside. The Director of Nursing stated that staff were expected to sit next to residents while assisting with feeding, indicating a deviation from the facility's standards during these observations.
Inadequate Bed Accommodation for Resident
Penalty
Summary
The facility failed to provide a comfortable and appropriately sized bed for a resident, identified as Resident 15, who was reviewed for accommodation of needs. Resident 15 had multiple medically complex diagnoses, including a hip fracture and dementia, and was assessed to have functional limitations in their range of motion in both arms and legs, requiring substantial assistance from staff to roll or sit up in bed. Observations on multiple occasions showed Resident 15 lying in bed with both feet pushed up against the footboard, unable to straighten their legs, which was confirmed by the resident's complaint of sore knees. Staff confirmed that the bed was not long enough for the resident to straighten their legs, indicating a failure to accommodate the resident's needs appropriately.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide required written notices to residents at the time of transfer or discharge, as evidenced by the cases of two residents. Resident 23, who had severely impaired memory and was dependent on staff for daily activities, was hospitalized on three occasions due to medical conditions such as seizures and a urinary tract infection. However, there was no record of the facility providing the necessary written transfer notices for any of these hospitalizations. The Director of Nursing confirmed the absence of these notices during an interview. Similarly, Resident 28 was transferred to the hospital for low blood pressure and low blood-oxygen levels, but neither the resident nor their representative received a written notification explaining the reason for the transfer, contact information for the State Long-Term Care Ombudsman, or an explanation of the resident's rights regarding the transfer. Staff confirmed that there was no process in place for providing such written notices at the time of the incident.
Failure to Complete SCSA for Resident with Decline in Condition
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days for a resident who experienced a decline in nutritional intake and a change in skin integrity. The resident, who had complex medical diagnoses including cancer, heart failure, and kidney failure, was admitted with no significant weight loss or pressure injuries. However, the resident later reported weight loss and a wound on their foot, which was observed during an interview. Documentation showed a weight loss of 6.79% between February and March, and a new deep tissue injury was identified on the resident's left heel. Despite these changes, the facility did not complete the required SCSA. The Nutrition Hydration Skin Committee reviewed the resident's condition due to significant weight loss and a new pressure injury, and a wound care consult noted the deteriorating condition of the pressure injury with poor healing potential. The MDS Coordinator acknowledged that a SCSA should have been completed to address the resident's changing condition, but it was not done as required, placing the resident at risk for unmet care needs.
Failure to Ensure Accurate and Timely PASRR Assessments
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening and Resident Review (PASRR) assessment was obtained, accurate, and available in the records for two residents, which is a requirement to determine if residents have mental health or intellectual disability needs that require further assessment or treatment. For Resident 61, the PASRR Level 1 assessment was not available in the records upon admission, and it was only located and added to the records over two months later. Staff M confirmed the absence of the PASRR Level 1 in the records and acknowledged that it should have been obtained at the time of admission. The Divisional Director of Social Services stated that the expectation was for the PASRR Level 1 to be obtained prior to admission. For Resident 29, the PASRR Level 1 assessment was initially incomplete, failing to identify the resident's dementia and psychotic disorder, despite the resident having multiple medically complex diagnoses, including psychosis, anxiety, and depression, and requiring the use of related medications. The PASRR Level 1 was later updated to include the psychotic disorder but still did not reflect the dementia diagnosis. Staff R, the Social Services Director, acknowledged that the PASRR Level 1 forms should be updated and accurate to reflect the resident's current condition and should be readily available in the resident's records.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in meeting their care needs. Resident 5, who had a traumatic spinal cord injury and was dependent on staff for all self-care and mobility, had a care plan for smoking safety that was not updated with a recent evaluation. The last smoking safety evaluation was completed several months prior, and staff could not confirm if a more recent evaluation had been conducted. This lack of updated assessment placed Resident 5 at risk for injuries related to smoking. Resident 34, diagnosed with anxiety and depression, exhibited physical behavior towards others and was on antipsychotic medication. However, the care plan did not specify the medication or the symptoms it was intended to treat, nor did it include resident-specific goals. The care plan was developed over five months after the medication was first prescribed, rather than at the time of administration. Additionally, Resident 8, who was discharged from occupational therapy with a recommendation for a restorative nursing program, did not have a care plan developed to address the recommended range of motion exercises. This oversight meant that staff did not identify the need for assistance with these exercises.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that Care Plans (CPs) were updated and revised as needed to reflect person-centered care for four residents. Resident 34, who had severe memory impairment and dementia, had a CP that included administering and monitoring dementia medications. However, the Medication Administration Record showed no medications were ordered for dementia, and no monitoring was conducted. The Director of Nursing acknowledged that the CP needed revision. Resident 53, who had no memory impairment and required minimal assistance with meals, had a CP indicating moderate assistance was needed. Observations showed the resident feeding themselves independently, and the Director of Nursing confirmed the CP was outdated. Resident 9, with moderate memory loss, had a CP that included a restorative nursing program, which was discontinued due to the resident's refusal to participate. The CP was not updated to reflect this change, and observations showed the resident eating in bed, contrary to CP instructions. The Director of Nursing confirmed the CP was outdated. Resident 28's CP required substantial assistance with meals, but progress notes indicated the resident could feed themselves. Staff confirmed the resident's ability to eat independently, but the CP was not updated. The Director of Nursing emphasized the importance of keeping CPs current to ensure appropriate care.
Failure to Follow Physician's Orders and Inaccurate Documentation
Penalty
Summary
The facility failed to ensure that physician's orders (POs) were followed and/or clarified for several residents, leading to potential risks for unmet care needs and unnecessary treatments. For Resident 50, the facility administered narcotic pain medication outside the ordered parameters, providing the medication for pain levels lower than specified in the order. This was confirmed by the Director of Nursing, who acknowledged the medication was given outside the ordered parameters. Resident 19, who had end-stage kidney failure, was supposed to have a specialty compression stocking applied to their left lower leg daily. However, observations and interviews revealed that the resident was using an ace bandage wrap instead, and staff had not clarified or updated the order to reflect this change in practice. Staff interviews indicated that the resident sometimes refused the stocking, but no clarification of the order was sought. Additionally, the facility failed to ensure that nurses signed only for tasks completed. For Resident 57, staff documented that a moon boot was worn as ordered, but observations showed the resident was not wearing it. Similarly, Resident 29 had orders for a knee splint that was not being worn, yet staff documented monitoring of the splint. Interviews confirmed these discrepancies, indicating that staff signed for tasks that were not completed.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for three residents who were dependent on staff for such care. Resident 25, who had complex medical diagnoses including kidney failure and Alzheimer's disease, was observed with long, jagged fingernails despite physician orders for weekly nail care. Staff confirmed that the required nail care was not provided as ordered. Resident 15, with a history of hip fracture and dementia, required substantial assistance for personal hygiene, dressing, and meal setup. Observations showed that Resident 15 remained in a hospital gown over several days, and staff failed to assist with dressing or provide appropriate meal setup, leaving the resident struggling to eat. Staff confirmed that Resident 15's fingernails were not trimmed as ordered, and the resident's meal tray was not positioned correctly to facilitate eating. Resident 218, who had impaired memory and medical conditions including facial paralysis and a recent knee fracture, required substantial assistance with dressing. Observations revealed that Resident 218 wore the same gown for multiple days and expressed a need for assistance with changing clothes. Staff acknowledged the expectation to assist Resident 218 with dressing due to their limited mobility, but this assistance was not provided as required.
Failure to Follow Blood Glucose Monitoring Protocol for Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with Diabetes Mellitus by not adhering to the established blood glucose (BG) monitoring protocol. The resident, who had intact memory and diagnoses including heart failure, diabetes, high cholesterol, and a heart blockage, was receiving daily insulin injections. On May 10, 2024, the resident's BG was documented at 70 mg/dl, which was below the threshold requiring physician notification and withholding of insulin as per the facility's protocol. However, the fast-acting insulin was administered at noon without notifying the physician, contrary to the protocol. Additionally, the resident took a leave of absence from the facility four hours after the low BG was recorded and three hours after the insulin was administered, leaving the facility unable to monitor or provide necessary care for three days. The Director of Nursing acknowledged that the nurses should have notified the physician and held the insulin, recognizing that the resident was placed at risk during their absence. The facility's failure to follow the medication administration parameters contributed to the deficiency.
Failure to Assist Resident with Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident with hearing deficits was provided the necessary assistance with their hearing aids, as assessed. Resident 218, who had a hearing impairment and used hearing aids, was observed multiple times without their hearing aids in place. The resident's Care Area Assessment indicated that staff should ensure the use of hearing aids for effective communication, yet the care plan did not specify this need. Observations showed that the resident was unable to understand questions from staff when not wearing the hearing aids, indicating a lack of effective communication. Further observations revealed that when Resident 218 did wear their hearing aids, they were not functioning properly due to not being charged. Staff K confirmed that the hearing aids were not charged and found the charger under the resident's bed, suggesting a lack of proper maintenance and assistance with the hearing aids. The Director of Nursing acknowledged that care staff should assist the resident with their hearing aids during morning routines, but this was not consistently done, leading to the deficiency.
Failure to Provide Restorative Programs for Residents with Mobility Limitations
Penalty
Summary
The facility failed to provide a restorative program for four residents with mobility limitations, as identified by staff and reviewed for Range of Motion (ROM). Resident 1, with a progressive neurological condition and functional limitations in both legs, was supposed to receive lower extremity ROM exercises three times a week. However, documentation showed that the program was only provided on 5 out of 10 opportunities, with no records of the program being offered or refused. Resident 22, with multiple complex diagnoses including lymphedema and severe obesity, was assessed to require moderate assistance for mobility. Despite a physician's order for therapy evaluation and treatment, and the resident's agreement to participate in a restorative program, no interventions were established in the care plan. The restorative program was initiated over two weeks after recommendations were made, contrary to the facility's expectations for timely initiation. Resident 8, who was referred for a restorative therapy program for shoulder exercises five times a week, only received assistance on 14 out of 22 opportunities. The sole restorative aide was unable to complete the program as scheduled due to workload. Resident 29, with a diagnosis of weakness, was recommended for an arm ROM program, but the care plan was not updated to reflect this, and no program was established. The facility's failure to provide these restorative programs as directed placed residents at risk for declines in ROM and mobility.
Failure to Document GDR and Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic drugs, as evidenced by the lack of documentation and informed consent. For Resident 9, the facility did not document the rationale for discontinuing a Gradual Dose Reduction (GDR) of an antianxiety medication. Despite the absence of documented anxious behaviors in June, July, and August 2023, the GDR was discontinued in September 2023, and the medication was increased back to the original dose without justification from the physician or documentation of the failed GDR. Interviews with staff confirmed the lack of documentation regarding the resident's behaviors and the decision to revert to the original medication dosage. For Resident 118, the facility failed to obtain informed consent before administering an antidepressant medication. The resident, who was oriented and had intact memory, was prescribed the medication without evidence of a discussion about the risks and benefits. Additionally, there was no monitoring of target behaviors at the start of the antidepressant treatment. The Director of Nursing acknowledged the failure to obtain informed consent and establish behavior monitoring for the medication.
Expired Medications and Unsecured Treatment Cart
Penalty
Summary
The facility failed to ensure the timely disposal of expired medications and secure storage of medications, as observed in two medication carts and the central supply room. On the 100 Hall medication cart, an opened bottle of non-narcotic pain medication was found with an expiration date of the previous month. Similarly, the 500 Hall medication cart contained expired liquid calcium, Vitamin E, and non-narcotic pain medications. In the central supply room, numerous expired medications, including iron medication, non-steroidal anti-inflammatory medication, Vitamin E, digestion enzyme supplements, liquid calcium, calcium tablets, fiber liquid, and protein powder, were found. Staff interviews confirmed that these medications were expired and should have been removed from stock. Additionally, the facility failed to secure a treatment cart on the 500 Hall. The treatment cart was observed unlocked while a nurse prepared medication at a separate medication cart across the hallway. The unlocked cart contained dressings, hydrocortisone cream, iodine, and an antiseptic solution. Staff interviews indicated that the treatment cart should have been locked, and it was the responsibility of the nurses to ensure the security of treatment carts.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide prompt dental services for two residents, leading to unmet dental needs and a diminished quality of life. Resident 45, who had no memory impairment and was able to communicate effectively, had not seen a dentist for many years despite having broken and rotting teeth. Although a dental consult was ordered in December 2022, staff did not facilitate a dental appointment until May 2024, nearly a year and a half later. During this period, Resident 45's dental issues were not addressed in care conferences, and staff failed to document any assistance provided to the resident for dental services. Resident 35, who had severe cognitive impairment and no natural teeth, was observed without dentures and reported waiting for new ones. Despite receiving dentures in September 2022, staff did not document the missing dentures for over 19 months. The facility's records showed that staff did not follow up on dental provider recommendations for new dentures, and no grievance form was filled out when the dentures were first noted missing. Staff failed to complete a referral for new dentures within the required three days. Interviews with facility staff revealed expectations for timely dental consultations and follow-ups, which were not met in these cases. Staff G, the Resident Care Manager, acknowledged the lack of documentation and assistance for Resident 45, while Staff O and Staff R confirmed the failure to provide timely assistance for Resident 35. These deficiencies highlight the facility's failure to adhere to its own policies and state regulations regarding dental care for residents.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to provide meals that accommodated the food preferences of three residents, leading to dissatisfaction and potential risks to their well-being. Resident 8, who was admitted to the facility with no memory impairment, expressed dissatisfaction with the meals provided, as they were unable to chew certain foods due to dental issues. Despite a grievance filed by Resident 8 indicating their need for softer foods and a dislike for meat and seafood, the facility continued to serve meals that did not align with these preferences. The dietary manager, Staff F, acknowledged that the food preference form was not completed within the required timeframe and could not provide documentation of follow-ups with Resident 8. Resident 45, who also had no memory loss, reported that their food preferences were not being followed. Despite filling out a weekly menu, Resident 45 received meals that did not match their requests, such as being served fried eggs instead of scrambled eggs and not receiving cottage cheese as ordered. The facility's records did not document any preference for poached eggs, contradicting the meal served. Staff J confirmed that Resident 45 did not receive the requested cottage cheese and had to rectify the situation. Resident 55, who was understood and able to communicate, was served a meal containing zucchini, despite having a documented dislike for it. The tray card clearly highlighted Resident 55's dislike for zucchini, yet the meal was prepared and delivered with the disliked vegetable. Staff BB acknowledged the error and returned the meal to the kitchen. The dietary manager, Staff F, stated that the expectation was for dietary staff to adhere to the information on the resident's tray card, which was not followed in this instance.
Failure to Maintain Comprehensive Medical Records
Penalty
Summary
The facility failed to maintain comprehensive medical records for three residents, leading to incomplete documentation and potential delays in treatment. For Resident 50, a recommendation from the facility's consultant pharmacist to consider a medication change was not added to the medical record until over three months after the recommendation was made. This delay in updating the medical record could have impacted the resident's treatment plan, as the recommendation involved the use of two beta blockers for heart conditions. Resident 25's hospice notes from February, March, and April were not scanned into the resident's records until May, leaving a gap in the documentation of hospice care. Additionally, Resident 29's February pharmacy recommendation was found in a stack of papers waiting to be uploaded, indicating a delay in updating the resident's medical records. Interviews with staff revealed that the facility's policy required documents to be uploaded timely, but this was not consistently followed, resulting in incomplete and outdated records.
Infection Control Deficiencies in PPE Use and Equipment Storage
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by staff not adhering to the posted instructions for wearing Personal Protective Equipment (PPE) when entering rooms of residents under contact precautions. Specifically, Resident 36, who was on contact precautions due to an infection with antibiotic-resistant bacteria, had multiple instances where staff entered their room without donning the required PPE. Staff V, a Housekeeping Supervisor, and Staff W, a Certified Nursing Assistant (CNA), both entered Resident 36's room without PPE, despite the clear instructions on the door. Additionally, Staff X attempted to enter without PPE but was stopped by another staff member, and Staff Y was similarly stopped by a colleague before entering without PPE. Another deficiency was observed with Resident 16, who was on contact precautions for a severe intestinal infection. A provider was seen in Resident 16's room without wearing a gown or gloves, contrary to the facility's policy and expectations for infection control. The Infection Control Preventionist, Staff D, confirmed that staff were expected to don PPE before entering rooms with contact precautions and emphasized the importance of this practice to prevent the transmission of infections. The facility also failed to properly store resident urinals, as observed with Residents 46 and 57. Resident 46 had a urinal placed next to their breakfast tray on the overbed table while eating, and Resident 57 had a similar situation with a urinal next to their lunch tray. Staff G acknowledged that placing food next to urinals posed an infection control risk. Additionally, Resident 29 had a floor mat that was cracked and peeling, making it uncleanable, which was noted by Staff G as needing replacement.
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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