Fir Lane Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Shelton, Washington.
- Location
- 2430 North 13th Street, Shelton, Washington 98584
- CMS Provider Number
- 505230
- Inspections on file
- 55
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Fir Lane Care during CMS and state inspections, most recent first.
A resident with an ankle infection, mood disorder, substance abuse history, and recent NWB status was discharged to a homeless shelter without an effectively developed discharge plan or sufficient time and orientation. Care plans and managed care discharge plans identified barriers such as non‑weight‑bearing status, lack of housing, and need for placement, with LTC listed as a back‑up, but placement with DSHS was not pursued before the resident was told they had to leave. Staff reported escalating verbally aggressive behavior and suspected alcohol use, yet behavior care plans were not updated until the day police were called, and no documented behavioral health or substance abuse referrals were made. The resident stated they believed they were going to another facility or transitional housing with a bed, but was instead transported by facility van to a street‑level shelter where no bed was available, while staff and the administrator gave conflicting reasons for the discharge and acknowledged that placement options should have been explored earlier.
A cognitively intact resident with an ankle infection, mood disorder, and substance abuse history was issued an involuntary discharge notice after a verbal altercation and concerns about aggression and alcohol use, and was discharged to a homeless shelter. The resident reported being told by the Social Service Director that they had to leave, believed the discharge was not optional, and thought they were going to another facility or senior housing, only to be dropped at a shelter with no available beds. Record review showed no documentation that the LTC Ombudsman was notified of the discharge, and the Social Service Director stated they had not sent the transfer and discharge notice to the Ombudsman, instead sending such notices at the end of the month.
A resident with Alzheimer’s dementia, quadriplegia, severe cognitive impairment, and an existing hospital POLST indicating DNR and selective treatment, as well as a documented DPOA-HC, was admitted with these documents uploaded into the EMR. Facility staff did not recognize or use the existing POLST and instead completed a new POLST with the resident, changing the status to full code/CPR and full treatment, despite the resident’s severe cognitive impairment and reported inability to sign legibly. Later, another nurse completed yet another POLST by phone with the resident’s POA, again unaware of the prior forms, and documentation from a care conference reflected full code without disclosure to the POA that a new POLST had been executed. The DNS acknowledged staff failed to adequately review hospital records and involve the resident’s representative in CPR and POLST decisions as required by policy.
A resident with severe cognitive impairment, paraplegia, dementia, and cancer had a care plan identifying nutritional risk and requiring monitoring of mealtime circumstances, analysis of causes of low intake, and implementation of diet modifications including minced and moist food, mildly thick (MT2) liquids, no straws, upright positioning, and 1:1 assist for PO. Despite repeated 0–25% meal intakes and documented low intake with weight loss, the record showed no documentation that staff attempted to determine patterns or causes of poor intake. After SLP changed the resident to thickened liquids and instructed nursing to remove thin liquids, staff continued to provide family-supplied Ensure without thickening in a sippy cup, sometimes with a straw, and the RD did not direct staff to track intake from home snacks or supplements. CNAs and an LPN reported the resident was fully dependent for eating and that staffing limitations made providing needed assistance difficult, while the DON confirmed that Ensure as given was not MT2 and that staff were expected to follow the care plan.
A resident with paraplegia, dementia, and severe cognitive impairment was admitted with a documented Stage 2 coccyx/sacral pressure ulcer and orders to be repositioned and have skin integrity monitored, but no wound care orders or weekly skin assessments were documented for nearly two weeks. Later notes described a Stage 2 sacral pressure ulcer and referenced a healed Stage 4 ulcer in the same area, while a wound consultant subsequently assessed a separate buttock wound as MASD and was unaware of any coccyx/sacral wound or prior Stage 4 history. Staff interviews confirmed missed weekly skin assessments, unclear documentation about whether the sacral and buttock wounds were the same, and that the resident had an open wound on the bottom since admission and often refused repositioning.
The facility failed to maintain accurate clinical documentation for a resident with severe cognitive impairment and multiple comorbidities. Despite an order for a suprapubic catheter, nursing assistant records and the MDS coded the resident as always incontinent of urine, and a wound consultant note also documented urinary incontinence based on assumption rather than confirmed information. Provider notes repeatedly listed PEG tube feeds as part of SNF recommendations even though the resident did not receive PEG feeds; these entries were carried over from hospital records via AI and not corrected. Wound records were inconsistent, with differing descriptions of a Stage 2 pressure ulcer on the coccyx/sacrum and a partial-thickness MASD wound on the buttocks, and staff were unable to clearly determine whether these referred to the same wound, reflecting unclear and inaccurate wound documentation.
A resident with severe cognitive impairment and hemiplegia experienced multiple falls, but the resident's representative was only notified of one incident. Incident reports showed inconsistent or delayed documentation of family and physician notifications, and staff relied on assumptions rather than direct communication to confirm notifications had occurred.
Two residents experienced failures in the accurate documentation and reconciliation of controlled substances, including missing entries, incomplete records, and improper shift change counts. Staff did not consistently follow procedures for logging medication administration and counting controlled substances, resulting in discrepancies in the Controlled Substance Record Book.
Staff failed to perform hand hygiene during medication administration, including before and after resident contact, after glove removal, and after touching the resident's environment. A nurse administered medications and handled personal and medical equipment without cleaning their hands, while another nurse did not perform hand hygiene after removing protective equipment and before accessing the medication cart. A family member also reported that nurses did not wash their hands or use gloves when administering eye drops.
The facility did not consistently inform or provide documentation to residents about their right to formulate an advance directive, including a POA for health care. Several cognitively intact and impaired residents were not offered this information upon admission, and staff interviews confirmed that the process for offering and documenting advance directives was not followed as required.
The facility did not ensure that grievances voiced by residents during Resident Council meetings were properly logged, investigated, or resolved, despite repeated complaints about issues such as missing beverages with meals, delayed call light response, loud TVs, and privacy concerns. Residents reported that staff failed to follow up or communicate actions taken, and the DON confirmed that required grievance procedures were not followed.
The facility did not notify the State Long-Term Care Ombudsman when two residents were transferred to the hospital on multiple occasions. Staff interviews confirmed that required notifications had not been sent for these hospitalizations, and the Social Services Director acknowledged that no notifications had been made for several months.
The facility did not consistently complete or update PASRR screenings to accurately reflect residents' mental health diagnoses, resulting in several residents with conditions such as anxiety, schizophrenia, delusional disorder, and psychosis not being properly identified or referred for further evaluation. Staff interviews confirmed that PASRR forms were often inaccurate or not updated when new diagnoses were made, and required referrals for Level II evaluations were not always documented or completed.
The facility did not follow physician orders or facility protocols for bowel management, failed to maintain and document coordinated hospice plans of care, and did not routinely assess or monitor non-pressure skin conditions. Several residents went extended periods without bowel movements without receiving ordered PRN medications, hospice documentation was missing for two residents, and a resident with self-inflicted abrasions did not receive recommended treatments or monitoring.
Staff failed to consistently and accurately document and calculate fluid intake for a resident on a fluid restriction, with incomplete and inaccurate records over a two-week period. Additionally, significant weight loss in another resident went unrecognized, and no further nutritional interventions were implemented or evaluated, despite care plan requirements. These failures placed residents at risk for adverse health outcomes.
Two residents with cognitive impairment and limited range of motion did not receive restorative nursing services, despite therapy recommendations and referrals, because the facility lacked sufficient qualified staff. Therapy and nursing staff confirmed that restorative programs were not implemented or initiated, resulting in unmet care needs for these residents.
The facility did not ensure that binding arbitration agreements were clearly explained to three residents or their legal representatives, including two who were cognitively intact and one with a POA due to severe cognitive impairment. Residents and a POA reported not understanding the agreement, the rights being waived, or the voluntary nature of signing. Staff interviews revealed inconsistent explanations, with key information such as the 30-day revocation period and the fact that signing was not a condition of admission not being communicated.
A resident who was cognitively intact missed a scheduled neurology appointment for diagnostic testing after facility staff failed to arrange transportation, leading to the appointment's cancellation. The resident was not informed by the facility and only learned of the cancellation through their own email, resulting in emotional distress and a delay in care. The DON confirmed this did not meet expectations.
Two residents received psychotropic medications before proper consent was obtained. One cognitively intact resident was given an antidepressant prior to signing a consent form, and another resident with a court-appointed guardian was administered multiple psychotropic medications before the guardian was notified and consented. Staff confirmed that consent should have been secured before medication administration.
Two residents receiving psychotropic medications did not have required monitoring or documentation of side effects and behaviors, and pharmacist recommendations for monitoring were not acted upon in a timely manner. Staff confirmed that these monitoring and documentation practices did not meet expectations.
A resident with severe cognitive impairment reported being hit, and the facility did not notify the State Agency of the abuse allegation within the required timeframe, instead reporting it three days later. The DON confirmed this delay did not meet expectations for timely reporting.
The facility did not ensure that care plans were fully developed and updated for three residents, including one with pressure injuries and an indwelling catheter, another with nutritional risk, and a third with anemia and visual impairment. Care plans lacked documentation of catheter justification, nutritional interventions, anemia management, transfusion history, and vision needs, as confirmed by staff interviews.
Multiple residents experienced deficiencies in medication administration, including late administration of thyroid medication, lack of provider follow-up for a resident's blood pressure medication concerns, improper handling of a chewable medication, and failure to promptly waste a controlled substance. Nursing staff did not consistently follow professional standards or physician orders, leading to deviations in medication timing, form, and documentation.
A resident with multiple pressure injuries was not consistently assessed, and ordered pressure redistribution equipment was not functional for several days. The resident reported discomfort and the need for pillows due to a malfunctioning low air loss mattress, which staff did not address promptly. Documentation and wound care consults failed to consistently assess or monitor a pressure injury on the resident's right heel, despite ongoing wound care and previous documentation of the wound.
A resident with a history of Stage 3 and 4 pressure injuries was admitted with an indwelling urinary catheter, initially justified by the presence of these wounds. After the wounds had healed, staff did not reassess or seek provider orders for catheter removal, and no ongoing medical justification for continued catheter use was documented, contrary to facility policy.
Several residents received pain medications, including opioids and acetaminophen, without documented attempts to use non-pharmacological interventions (NPIs) as required by facility policy. In one case, a resident was also given a medication for GERD without an active diagnosis, and staff did not reassess the necessity of this medication on admission. Staff interviews confirmed that NPIs should have been offered and documented, but this was not done.
Surveyors found that two medication carts contained expired medications, unlabeled creams, and multiple bottles of nystatin powder without resident identifiers. An LPN and RN confirmed that medications were left unattended, expired, or lacked proper labeling, which did not meet facility expectations.
The facility did not consistently document refrigerator and freezer temperatures for multiple food storage units, as required by professional standards. Numerous dates were missing from temperature logs, and the Dietary Manager confirmed that staff were responsible for daily checks but acknowledged the gaps in records.
Staff did not consistently follow infection control protocols during wound care, as a nurse failed to perform hand hygiene before donning gloves and did not change gloves after direct contact with a resident's leg. During meal tray delivery, a CNA did not perform hand hygiene between resident rooms or after assisting residents, despite facility expectations. Additionally, laundry staff did not consistently document washer temperature checks, resulting in incomplete records necessary for ensuring proper sanitation.
A resident with severe cognitive impairment, multiple sclerosis, diabetes, and a stage III pressure ulcer did not receive care as outlined in their plan, including frequent repositioning, assistance with meals, and personal hygiene. The resident was repeatedly observed in uncomfortable positions in bed, unable to access meals, and without proper grooming or clothing, while staff interviews and documentation indicated inconsistent adherence to the care plan.
A resident with dementia and a seizure disorder did not receive prescribed seizure medications due to unavailability and refusals, and the facility failed to notify the physician or the resident's representative. This led to the resident becoming unresponsive, requiring CPR, and hospitalization. Hospital records showed subtherapeutic levels of anticonvulsant medications, likely causing a seizure.
Three staff members failed to adhere to CDC guidelines for PPE use when caring for residents with COVID-19. An LPN and two CNAs did not remove their N95 respirators and eye protection after exiting rooms of COVID-19 positive residents, continuing to interact with others in the facility. The Acting DON confirmed that staff did not follow infection control procedures, placing residents and staff at risk.
Two residents in an LTC facility did not receive adequate assistance with daily living activities, such as bathing and dressing, despite being cognitively intact and requiring substantial help. One resident received only one shower 11 days after admission, while the other was left in bed for extended periods without regular hygiene care. Staff were too busy to provide the necessary assistance, contrary to the care plans.
A facility failed to ensure residents were free from physical restraints, using Velcro straps and tilt-in-space wheelchairs improperly. A resident's arm was secured to a wheelchair without proper documentation, while two residents were tilted back excessively in wheelchairs to prevent movement, contrary to care plans. Staff were unaware of the need for proper documentation and the correct use of these devices.
A resident with a history of pressure ulcers and at risk due to developmental delay, diabetes, and morbid obesity developed severe pressure ulcers on both heels, leading to hospitalization and a below-the-knee amputation. The facility failed to accurately assess and document the resident's condition, resulting in a lack of timely intervention. Staff interviews revealed poor communication and awareness of the resident's deteriorating condition, contributing to the delay in treatment.
The facility failed to implement care plan interventions for two residents, leading to deficiencies in their care. One resident, with dementia and depression, was not provided with hearing aids or TED hose as per their care plan and remained in bed without proper hygiene assistance. Another resident, who required assistance with bathing, did not receive a shower or bed bath during their first week of admission. The Director of Nursing acknowledged the inconsistency in implementing care plans.
A resident in a dementia unit sustained a second-degree burn after being found unsupervised on a baseboard heater. The resident, with cognitive impairments and wandering behaviors, was able to access the heater due to inadequate supervision. Staff reported difficulty regulating heater temperatures, and the facility's thermometer was malfunctioning, contributing to the unsafe environment.
A resident with cognitive impairment and a history of elopement left the facility unattended, highlighting a failure to follow the elopement prevention policy. The resident's care plan did not indicate a risk for elopement, and there was no physician's order for a wander guard, which was applied after the initial incident. The facility's logs lacked documentation of the elopement, and the wander guard alarm was not functioning properly.
A resident admitted with a fractured femur and on a pain medication regimen did not receive prescribed medications due to a new LPN's lack of access to the Omnicell and insufficient training on admissions. The resident experienced significant pain overnight without relief, as the LPN was unaware of the procedure to obtain medication or whom to contact for assistance.
A resident was transferred to the hospital from a scheduled appointment without receiving the required written notice of transfer. The facility did not notify the resident, their representative, or the Office of the State Long-Term Care Ombudsman, as the transfer did not occur directly from the facility. The resident, who required moderate to total dependence on staff, was admitted to the ICU without proper notification.
A resident with chronic inflammatory demyelinating polyneuritis was not re-admitted to the facility after hospitalization due to the facility's inability to provide necessary care. The resident required infusions and mobility assistance, but the facility failed to communicate or document discharge plans, leaving the resident without proper support.
The facility did not provide quarterly personal fund statements to residents, including a resident with a neurological condition. The Business Office Manager admitted to inconsistencies in issuing these statements, and the Administrator was unaware of the issue, despite expectations for quarterly distribution.
The facility failed to meet professional standards for two residents. One resident received incorrect pain medication orders and unauthorized oxygen therapy due to transcription errors. Another resident missed doses of an antibiotic because the nurse couldn't locate it, and alert charting was not completed. The DON acknowledged these issues.
The facility failed to provide timely vision services for two residents, leading to a deficiency in maintaining their vision. One resident with diabetes and kidney failure waited several months for an eye appointment that was not scheduled. Another resident with depression and a recent MI experienced vision issues and did not receive a timely eye exam due to poor communication and scheduling issues.
The facility experienced staffing shortages, resulting in unmet resident needs for ADLs such as showers and nail care. Residents reported long wait times for assistance and pain medication, while staff confirmed the inability to complete tasks due to insufficient staffing. The Director of Nursing and Administrator acknowledged the ongoing staffing issues and lack of RN coverage.
The facility failed to record refrigerator temperatures for one of the two refrigerators in the locked medication rooms. An RN and the DNS were unable to locate the temperature log, which should have been recorded by the night shift staff. The DNS confirmed that the log is usually placed on top of the refrigerator and should be started anew if missing.
The facility failed to store and serve food under safe and sanitary conditions, with uncovered food items exposed to dust and debris, and improperly sealed and dated items in the refrigerator and freezer. The Dietary Manager acknowledged the issues, and the Administrator confirmed the expectation for compliance with guidelines.
The facility failed to honor the bathing preferences of a resident with a neurological condition, missing scheduled showers without proper documentation. Additionally, another resident with anxiety, depression, and PTSD was not returned to their original room post-quarantine, despite expressing dissatisfaction and staff acknowledgment.
A facility failed to notify a Medicaid recipient when their personal fund balance exceeded the $2,000 resource limit, risking their Medicaid coverage. The resident's balance had been over the limit for several months, and staff did not consistently provide quarterly fund statements or address the issue in a timely manner.
A resident with anxiety, depression, and PTSD expressed dissatisfaction with a room change after quarantine, desiring to return to their original room with a private shower. Despite repeated complaints, the facility failed to initiate a grievance, as confirmed by staff interviews and grievance logs. The Director of Nursing and Administrator acknowledged the oversight.
Inadequate Discharge Planning and Orientation Prior to Shelter Discharge
Penalty
Summary
The deficiency involves the facility’s failure to communicate, develop, and implement an effective discharge plan and to provide sufficient time and orientation prior to discharge for one resident. The resident was admitted with an ankle infection, mood disorder, and substance abuse, and had limited mobility with non‑weight‑bearing restrictions on the right lower extremity for six weeks. The Discharge Care Plan noted that the resident wished to return to placement options and that there was potential for complications related to discharge planning, including health literacy and the possibility that the prior living environment was not available because the resident did not have a home. Early discharge evaluations documented that the discharge plan was unknown, and subsequent managed care discharge plans identified barriers such as placement needs and the foot injury, with a back‑up plan of LTC if preferred discharge locations were not attainable. Over the course of several weeks, managed care discharge plans projected discharge dates and contemplated discharge to home with the resident’s mother versus placement, while continuing to list barriers of non‑weight‑bearing status and placement. The facility’s social services staff reported they were waiting to explore placement with DSHS until the resident was able to bear weight, and acknowledged they did not have time to plan for placement with DSHS when the resident was later required to leave immediately. Although the resident’s behavior reportedly escalated in the two weeks prior to discharge, including derogatory comments toward other residents, a verbal altercation with a roommate, and threats to physically harm a nurse, the care plan related to these behaviors was not updated until the day police were called. Staff also reported suspected alcohol use, but there was no documentation of referrals to behavioral health or substance abuse programs, and the behavioral consultant was not re‑engaged when behavior escalated. The resident stated that the Social Service Director told them they had to leave after a verbal altercation with a nurse and that they did not believe remaining at the facility was an option. The resident reported being told they would be discharged to a shelter and believed this would be a transitional housing setting with a bed, not a street‑level homeless shelter. The Transfer and Discharge notice cited endangerment to the safety of others as the reason for discharge and listed a specific shelter as the discharge location, with only two days between notice and discharge. The resident reported being surprised when the facility van dropped them off outside a homeless shelter, finding the doors locked and no bed available for the night, and having to travel a distance using a knee scooter to contact family. Facility leadership later stated that the resident was discharged because they no longer needed services and were independent with ADLs, and that they believed the resident wanted to go to a homeless shelter, while also acknowledging that exploring placement options should have occurred prior to discharge and that they were unaware at the time that the shelter did not guarantee overnight beds. Documentation on the day before and day of discharge showed the resident was on behavior alert but did not record significant behaviors other than talking loudly, and staff described the resident as anxious about discharge and attempting to delay the process, while also indicating they had been told the resident was leaving that day and did not know what would happen if the resident refused to leave.
Failure to Notify Long-Term Care Ombudsman of Involuntary Discharge
Penalty
Summary
Surveyors identified a deficiency when the facility failed to notify the Long-Term Care Ombudsman of a resident’s discharge. The resident was admitted with diagnoses including an ankle infection, mood disorder, and substance abuse, and a Minimum Data Set dated 01/04/2026 documented that the resident was cognitively intact. Following a verbal altercation with a nurse and concerns about aggression, verbal abuse toward staff, and the smell of alcohol on the resident, the facility issued a Transfer and Discharge Notice dated 02/18/2026, citing endangerment to the safety of others due to the resident’s clinical or behavioral status. The notice indicated it was given to the resident on 02/17/2026 with a discharge date of 02/19/2026, and the Recapitulation of Stay documented that the resident was being discharged to a shelter. During interview, the resident reported being told by the Social Service Director that they had to leave after the altercation and believed the discharge was not optional. The resident stated they did not know where to go, and the Social Service Director said they would work on a location, later providing a pamphlet that led the resident to believe they were going to another facility or senior housing, rather than a homeless shelter. The resident described being dropped off by the facility van at a homeless shelter, finding the doors locked, and learning there were no beds available for the night, after which they sought help from family. Record review on 02/25/2026 showed no documentation that the Long-Term Care Ombudsman had been notified of the discharge, and the Social Service Director acknowledged in interview that they had not sent the Transfer and Discharge Notice to the Ombudsman, stating they send such notices at the end of the month. This failure was cited under WAC 388-97-0120(5)(b).
Failure to Honor Existing POLST and Involve Representative in CPR Decision-Making
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representative were fully informed and involved in decisions regarding cardiopulmonary resuscitation (CPR) and POLST orders. The facility’s policy required staff on admission to determine whether a resident had an advance directive, identify the primary decision-maker, and place a copy of any advance directive, including POLST and DPOA-HC, in the permanent medical record. For one resident with Alzheimer’s dementia, paraplegia/functional quadriplegia, cancer, severe cognitive impairment, and dependence in activities of daily living, hospital records and transfer orders documented an existing POLST indicating Do Not Resuscitate (DNR) and selective medical treatment, as well as a verified medical DPOA-HC designating a collateral contact as the decision-maker. Despite the existing POLST and DPOA-HC, facility staff completed a new POLST with the resident that changed the code status to attempt resuscitation/CPR and full treatment, and the form bore a legible resident signature even though the collateral contact reported the resident could not sign legibly due to quadriplegia. The Resident Care Manager/LPN who reviewed and signed this POLST stated they were likely given a note that the resident needed a POLST and that they typically spoke with residents and, if they seemed "withit," completed the POLST with them. This staff member acknowledged they were unaware that a prior POLST from the hospital had been uploaded into the electronic medical record. The resident’s care plan documented severe cognitive impairment (BIMS score of 7), and speech therapy notes indicated the resident lacked insight into their condition and risk factors and had reduced health literacy. Later, another Resident Care Manager completed yet another POLST with the collateral contact by phone, documenting DNR and selective medical intervention and indicating the discussion was with the POA, with no documentation that the resident was involved. This staff member reported they initiated the new POLST because a medical provider told them the resident did not have a POLST on file and stated they were unaware of the existing POLST. The collateral contact reported attending a care conference where the facility documented CPR full code and that the spouse stated he was POA, and also reported that the facility did not disclose that a new full-code POLST had been completed with the resident. The DNS stated staff were expected to review hospital records on admission, verify any existing POLST and DPOA-HC, assess cognitive status, and involve the resident representative in decision-making when there was an active DPOA-HC and/or cognitive issues, and acknowledged that staff likely did not see or were not aware of the hospital POLST.
Failure to Implement Nutrition Care Plan and Diet Modifications
Penalty
Summary
The deficiency involves the facility’s failure to implement care plan interventions for low meal intake and diet modifications for a resident with severe cognitive impairment, paraplegia/functional quadriplegia, dementia, and cancer. The resident’s MDS showed dependence on staff for eating, transfers, and bed mobility. A nutrition care plan dated 12/16/2025 identified the resident as at risk for nutritional problems related to a new environment, altered diet, poor appetite, and varied intake, with interventions to monitor and document circumstances around mealtimes and refusals, determine patterns or causes of low intake, alter or remove causes when possible, and monitor and report situations leading to decreased food consumption. Despite this, review of the medical record showed no documentation that staff attempted to determine circumstances, patterns, or causes of the resident’s limited meal intake. Meal intake records from mid- to late December showed the resident repeatedly consumed only 0–25% of multiple meals across many days, while a progress note on 12/23/2025 documented that the resident was on alert for low meal intake, triggering for skin conditions, low intake, and low fluid intake, with weight decreased from 201 to 195 pounds. The note indicated staff would encourage oral intake, assist with meals, and monitor weights, but there was no evidence that the specific care plan interventions to analyze mealtime circumstances and causes of poor intake were carried out. A speech therapy note on 12/23/2025 documented that the resident tolerated mildly thick (MT2) liquids better than thin liquids, that nursing staff were instructed on the diet change, and that no thin liquids should be accessible during meals. Corresponding physician orders and care plan updates specified a minced and moist diet with mildly thick liquids, no straws, upright positioning, and 1:1 assistance for oral intake. Despite these orders and care plan interventions, interviews and record review showed that staff did not consistently follow the diet modification and feeding instructions. The medical provider note on 12/24/2025 stated that all thin liquids had not been removed from the resident’s tray after the change to thickened liquids. The resident’s family brought Ensure from home, which staff poured directly into a sippy cup without thickening, and staff reported that the resident sometimes used a straw with this cup, contrary to the no-straw order. The RD acknowledged knowing about home snacks and Ensure but did not request staff to document or track what the resident consumed from these items and did not know what was in the resident’s sippy cup. CNAs and an LPN confirmed that they poured the family-provided supplement into the sippy cup, sometimes with a straw, and that the resident was dependent for eating and sometimes did not go to the dining room, with limited aides making it hard to provide the needed assistance. The DON stated that Ensure straight from the container is not mildly thick, that the resident required 1:1 assistance and no straws per the care plan, and that staff were expected to follow the care plan interventions.
Failure to Timely Assess and Clarify Pressure Ulcer Versus MASD
Penalty
Summary
The deficiency involves the facility’s failure to accurately and timely assess, monitor, and treat a pressure ulcer for one resident with significant impairments. The resident was admitted with paraplegia/functional quadriplegia, dementia, cancer, severe cognitive impairment, and total dependence for ADLs, transfers, and bed mobility. On admission, documentation showed a Stage 2 pressure ulcer on the coccyx/sacrum area measuring approximately 2.5 inches by 0.1 inch, with a horizontal open area noted on the skin assessment. Provider notes from the SNF recommended repositioning every two hours and monitoring skin integrity, especially the sacral area. However, from admission through 12/27/2025, the medical record contained no wound care orders for the documented Stage 2 pressure ulcer. Further record review showed no weekly skin assessment documentation between 12/15/2025 and 12/28/2025, despite facility policy requiring weekly wound monitoring and documentation. On 12/27/2025, a nurse progress note indicated a sacral wound was present after CNA notification during ADL care. A weekly skin evaluation on 12/28/2025 documented a Stage 2 pressure ulcer on the sacrum, and a 12/29/2025 note described a new Stage 2 pressure area and referenced a healed Stage 4 pressure area in the same region. On 12/30/2025, the wound consultant assessed a wound on the left buttock, diagnosed as MASD and non-pressure related, located on the fleshy part of the buttock extending from left to right, and reported being unaware of any coccyx/sacral wound or prior healed Stage 4 ulcer. Staff interviews confirmed that weekly skin assessments were expected but not completed in the week after admission, that the record was unclear whether the sacral and buttock wounds were the same, and that the resident had an open wound on the bottom since admission, with frequent refusals to reposition.
Inaccurate Clinical Documentation for Continence, Tube Feeding, and Wounds
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and consistent clinical documentation for a resident with paraplegia/functional quadriplegia, dementia, and cancer. The resident had a physician order for a suprapubic catheter, but nursing assistant documentation repeatedly recorded the resident as incontinent of urine on multiple dates in December. The MDS assessment also coded the resident as always incontinent of urine. The DON later stated this documentation was incorrect because the resident was not incontinent of urine, and the MDS coordinator confirmed the MDS was coded incorrectly. Additionally, the wound consultant’s note documented urinary incontinence based on an assumption related to bowel incontinence, and the wound consultant stated they were unaware the resident had a suprapubic catheter. Further documentation discrepancies involved PEG tube feeding and wound assessments. Medical provider notes on several dates listed SNF recommendations that included PEG tube feeds, but the physician assistant later stated the resident did not have PEG tube feeds and that these recommendations were erroneously pulled from hospital records using artificial intelligence and not corrected on proofreading. Wound documentation was also inconsistent: the admission evaluation identified a Stage 2 pressure ulcer on the coccyx, a later weekly skin evaluation documented a Stage 2 pressure ulcer on the sacrum, and the wound consultant’s initial assessment described a partial-thickness MASD wound on the left buttock extending across both buttocks. The resident care manager/LPN could not determine from the record whether these were the same wound, and the wound consultant reported being unaware of a coccyx/sacral wound or a healed Stage 4 pressure ulcer on the sacrum, indicating unclear and inaccurate wound documentation in the medical record.
Failure to Notify Resident Representative of Multiple Falls
Penalty
Summary
The facility failed to notify the resident representative of multiple falls experienced by a resident who had a history of stroke with hemiplegia and severe cognitive impairment. The resident required substantial assistance for bed mobility and transfers. According to interviews and record reviews, the resident's representative was only informed of one fall, despite the resident having experienced five falls during their stay. The representative stated they were present daily and were unaware of the additional incidents until a discharge meeting with staff. Review of incident reports revealed that notifications to the family and physician were inconsistently documented. In some cases, the reports indicated that notifications were made after a delay, while in others, there was no evidence of notification at all. Staff responsible for reviewing the incident reports acknowledged that they did not personally contact the family and relied on assumptions or secondhand information regarding whether notifications had occurred, particularly for falls that happened during night shifts.
Failure to Accurately Document and Reconcile Controlled Substances
Penalty
Summary
The facility failed to accurately document and reconcile controlled substances for two residents, resulting in incomplete and inconsistent records in the Controlled Substance Record Book. For one resident with a diagnosis of malnutrition and an order for dronabinol, a controlled substance, staff did not document medication administration for two consecutive days and failed to count the medication at shift changes because it was stored in a medication refrigerator rather than the medication cart. The Medication Administration Record indicated the medication was administered as ordered, but the inventory page showed missing and inconsistent entries, with staff later entering documentation for the missed days after being questioned. For another resident with an order for oxycodone as needed for pain, the facility's incident report revealed that documentation in the Controlled Substance Record Book was missing administration times and included entries for days when the resident was not present in the facility. The Director of Nursing confirmed that staff had not followed procedures for documenting and reconciling controlled substances, and multiple documentation errors were identified, including failure to review all pages of the record book and to ensure accurate medication counts during shift changes.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Facility staff failed to perform proper hand hygiene during medication administration, as observed with two staff members. One registered nurse was seen entering resident rooms and administering medications, including eye drops and a medication patch, without performing hand hygiene before or after resident contact, after glove removal, or after touching the resident's environment. The nurse also handled personal items and the medication cart without cleaning their hands between tasks. Another nurse, an LPN, was observed providing intravenous medication under enhanced barrier precautions, but removed their gown and gloves and exited the room without performing hand hygiene, then accessed the medication cart and continued down the hallway. A family member reported that nurses did not wash their hands when entering or leaving the resident's room and did not use gloves or perform hand hygiene when administering eye drops. The facility's policy required hand hygiene before and after resident contact, after touching the resident's environment, and immediately after glove removal. The Director of Nursing confirmed that staff were expected to follow these protocols, but observations and interviews demonstrated that these procedures were not consistently followed.
Failure to Inform and Document Advance Directive Options for Residents
Penalty
Summary
The facility failed to inform and provide written information to residents regarding their right to formulate an advance directive upon admission, as required. For three residents reviewed, there was no documentation that they were offered or declined the opportunity to establish an advance directive, such as a living will or durable power of attorney (POA) for health care. Specifically, one resident was cognitively moderately impaired at admission and was documented as their own responsible party, but neither the resident nor their family was provided information about establishing a POA until well after admission. Another resident, who was cognitively intact, had no documentation in their electronic health record of being offered or declining an advance directive, and only received POA paperwork after the issue was raised during the survey. A third resident, also cognitively intact, similarly had no documentation of being offered the opportunity to formulate an advance directive. Interviews with social services staff and administration confirmed that the process for offering and documenting advance directives was not consistently followed. Staff acknowledged that advance directives should be reviewed on admission and care planned, but admitted that documentation was lacking and that residents who were their own decision makers were not always offered the right to formulate an advance directive. Residents interviewed indicated they had not been approached about designating a decision maker in the event of incapacity, and expressed interest in doing so when the process was explained to them.
Failure to Log and Resolve Resident Grievances Raised in Resident Council Meetings
Penalty
Summary
The facility failed to implement and maintain a system to ensure that grievances verbalized by residents during Resident Council (RC) meetings were properly initiated, logged, addressed, and resolved in a timely manner. Over a period of four out of six months, residents repeatedly raised concerns during RC meetings regarding issues such as the lack of beverages with meals, delayed response to call lights, loud televisions, and privacy curtains not being closed. Despite these recurring complaints, the facility did not document the specific residents involved, the number of residents affected, or the details necessary to investigate and resolve the issues. Additionally, these concerns were not entered into the facility's grievance log as required by policy. Review of facility policies revealed that staff were responsible for reporting RC meeting concerns to the Administrator or department heads, and for providing written responses to grievances in accordance with the grievance policy. The policy also required that all grievances be logged, investigated, and followed up with the resident or their representative within five days. However, interviews and record reviews confirmed that these procedures were not followed, as no grievances related to the RC meeting concerns were logged or investigated, and residents were not informed of findings or actions taken. During interviews, residents confirmed that staff did not act promptly on grievances brought forward in RC meetings and did not follow up with them individually or as a group regarding corrective actions or the effectiveness of any interventions. Some residents indicated that unresolved issues, such as the lack of beverages with meals and slow call light response times, persisted over several months, leading them to stop raising the issues. The Director of Nursing acknowledged that grievances should have been generated and logged for these concerns, but this did not occur.
Failure to Notify Ombudsman of Resident Hospitalizations
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman regarding the hospitalization of two residents. Specifically, documentation and notification were not provided for the hospital transfers of one resident on two separate occasions and another resident on one occasion. Interviews with facility staff confirmed that ombudsman notifications for these hospitalizations had not been sent at the time of the events, and the Social Services Director acknowledged that no such notifications had been made since February. The Administrator stated that the expectation was for monthly notifications to the ombudsman regarding resident hospitalizations, but this was not followed.
Failure to Complete and Update PASRR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Reviews (PASRR) were completed accurately and in a timely manner for seven out of eight residents reviewed. In several cases, residents were admitted with mental health diagnoses such as anxiety disorder, schizophrenia, depression, delusional disorder, and psychosis, but their PASRR Level I screenings either did not reflect these diagnoses or were not updated when new diagnoses were added. For example, one resident with an anxiety disorder and on antianxiety medication had a Level I PASRR that did not identify the diagnosis or trigger a Level II referral, which staff later acknowledged was inaccurate. Another resident with schizophrenia, depression, and anxiety had a Level I PASRR that triggered a Level II referral, but there was no documentation of follow-up or completion of the referral process. Additional deficiencies were observed where residents' PASRR Level I screenings failed to capture new or existing mental health diagnoses, such as delusional disorder or psychosis, even after these were added to the residents' medical records. In some cases, the PASRR forms were not updated for several months after a new diagnosis was made, and staff interviews confirmed that these omissions did not meet expectations. For one resident, the PASRR Level I did not indicate the need for a Level II evaluation despite the presence of a psychotic disorder, and the form was not corrected until months later. Staff interviews revealed a lack of oversight and follow-through in reviewing and updating PASRR evaluations. Social Services staff acknowledged that it was their responsibility to ensure the accuracy of Level I evaluations and to refer cases for Level II evaluation as needed, but admitted that several forms were inaccurate or not updated in a timely manner. In some instances, there was no documentation to confirm that required Level II referrals or invalidations had been completed, and mental health diagnoses such as PTSD and bipolar disorder were not consistently reflected on PASRR forms.
Failure to Follow Physician Orders and Document Care for Bowel Management, Hospice, and Skin Conditions
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals in several key areas. For bowel management, multiple residents experienced extended periods without bowel movements, yet staff did not administer as-needed (PRN) bowel medications as ordered. For example, one resident went up to 12 shifts without a bowel movement on several occasions, with no PRN medication given, despite clear orders to administer medications after three days without a BM. Similar failures were observed for other residents, including those with severe cognitive impairment and those on hospice, where the bowel protocol was not initiated or documented as required by facility policy and physician orders. In the area of hospice services, the facility did not maintain or document coordinated hospice plans of care for residents receiving hospice. For two residents on hospice, there was no evidence in the electronic health record (EHR) of a current hospice plan of care, hospice intake, terminal diagnosis, or documentation of hospice visits and services provided. Staff were unable to locate required hospice documentation, including the hospice plan of care, hospice election form, physician certification/recertification of terminal illness, and visit notes, either in the EHR or in hospice binders. This lack of documentation meant that staff could not determine what hospice disciplines were involved or the frequency of their visits. Regarding non-pressure skin monitoring, the facility did not routinely assess or monitor skin conditions or implement recommended interventions for a resident with self-inflicted abrasions and a generalized rash. Despite wound care consultant recommendations for specific treatments and monitoring, these were not implemented or documented in the MAR/TAR. There was no ongoing documentation or monitoring of the resident's skin abrasions, and staff confirmed that these issues were not tracked as required. The lack of assessment and follow-through on consultant recommendations contributed to the deficiency in skin care management.
Failure to Accurately Monitor Fluid Intake and Address Significant Weight Loss
Penalty
Summary
Facility staff failed to consistently and accurately monitor, document, and calculate fluid intake for a resident with end stage renal disease who was on a physician-ordered 1500 ml/day fluid restriction. The care plan required staff to record all food and fluid intake, with dietary and nursing staff responsible for providing and documenting specific fluid amounts per meal and shift. However, over a 14-day review period, staff did not consistently document fluid intake for all meals and did not accurately calculate the resident's 24-hour fluid intake on 14 of 15 days reviewed. In several instances, the documented totals did not match the actual intake, and some meal intakes were missing or not recorded at all. The administrator confirmed that the fluid intake records were incomplete and inaccurate, attributing the issue in part to confusing order entry. Additionally, the facility failed to identify significant weight loss and implement or evaluate nutritional interventions for another resident who was severely cognitively impaired and prescribed a controlled carbohydrate diet. Despite a documented weight loss of 14.5% over several months, staff were unaware of the weight loss and had not made a referral to the Registered Dietitian or implemented further interventions. The resident's care plan stated there should be no unplanned significant weight changes, and the nutritional evaluation had previously noted weight stability. However, upon review, both the RN Unit Manager and the Director of Nursing Services confirmed the weight loss and the lack of additional interventions. These deficiencies were identified through observation, interview, and record review, and were found to place residents at risk for continued weight loss, malnutrition, fluid volume overload, and other medical complications. The facility did not have an effective system in place to ensure accurate monitoring and documentation of fluid and nutritional intake, nor did it ensure timely identification and response to significant changes in residents' nutritional status.
Failure to Provide Restorative Nursing Services Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff to deliver restorative nursing services to residents with limited range of motion. Specifically, two residents who were cognitively impaired and dependent on staff for activities of daily living were not provided with restorative nursing programs, despite being identified as at risk for further decline in function and mobility. Occupational and physical therapy evaluations and discharge summaries documented that these residents would have benefited from restorative services, and referrals were made for such programs. However, the restorative nursing programs were never implemented, and there was no documentation showing that the recommended interventions, such as passive range of motion exercises and splint and brace programs, were initiated. Interviews with facility staff, including the Director of Rehabilitation, Administrator, and Director of Nursing, confirmed that the lack of restorative nursing services was due to insufficient and unqualified staff. The therapy department acknowledged that residents who were at risk for declines in range of motion and contracture formation were not referred for restorative programs because there were not enough staff to provide these services. As a result, the residents did not receive the restorative care recommended by therapy, and the facility did not meet the regulatory requirement to provide adequate nursing staff to meet the needs of every resident.
Failure to Properly Explain Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that binding arbitration agreements were properly reviewed and explained to residents or their legal representatives in a manner and language they could understand. For three sampled residents, including two who were cognitively intact and one with a legal Power of Attorney (POA) due to severe cognitive impairment, there was no evidence that the arbitration agreement was adequately explained. Residents reported not understanding the nature of the agreement, the rights they were waiving, or the voluntary nature of signing. One resident stated they did not know what an arbitration agreement was and were unaware they were giving up their right to a court proceeding. Another resident did not recall the agreement being explained and signed documents without understanding them. The POA for a severely cognitively impaired resident reported receiving the agreement via email with no explanation or discussion of the rights being waived. Staff interviews revealed inconsistent and incomplete explanations of the arbitration agreement process. The Business Office Manager (BOM) stated that the agreement was provided at admission or within 72 hours and described it as a voluntary legal document, but did not inform residents of the 30-day revocation period or that signing was not a condition of admission. The BOM also did not consistently assess residents' cognitive ability to understand the agreement, relying on basic questions or referring to Social Services if concerns arose. When agreements were sent to family or next of kin, there was no evidence of a thorough explanation or discussion, especially when using electronic signature systems. Further interviews with administrative staff confirmed that residents were told the agreement was voluntary, but staff did not consistently communicate that it was not a requirement for admission, the specific rights being waived, or the 30-day revocation period. When questioned, administrative staff acknowledged that the explanations provided by the BOM were lacking and did not meet expectations. There was no documentation or evidence that residents or their representatives were fully informed about the arbitration agreement in a manner they could understand, leading to the deficiency.
Failure to Arrange Transportation Results in Missed Medical Appointment
Penalty
Summary
A resident who was cognitively intact and able to communicate was admitted to the facility and had a neurology appointment scheduled for diagnostic testing to determine the cause of their inability to walk. The resident was expecting a nerve conduction test on their lower spine, which had been promised upon admission. However, transportation for the appointment was not arranged by the facility, resulting in the cancellation of the appointment. The resident was not informed by the facility about the cancellation and only discovered it by checking their own email. Staff responsible for transportation acknowledged that the failure to schedule transportation was an error on their part, which led to the missed appointment. The resident expressed significant distress and frustration over the delay, having already waited a month for the appointment and now facing an additional month’s wait due to the rescheduling. The DON confirmed that missing the appointment due to lack of transportation did not meet facility expectations.
Failure to Obtain Consent Prior to Administering Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents or their representatives were fully informed and provided consent prior to the administration of psychotropic medications. For one resident with a diagnosis of depression who was cognitively intact, Sertraline was ordered and administered before the consent form was signed, with staff acknowledging that consent should have been obtained at the time the order was placed. The Director of Nursing Service confirmed that the expectation was for consent to be obtained before medication administration. In another case, a resident who was severely cognitively impaired and had a court-appointed guardian received psychotropic medications, including Mirtazapine and Risperidone, before the guardian was notified and consent was obtained. The guardian reported not being alerted to the resident's arrival and did not receive the consent forms until after the medications had already been administered. Staff interviews confirmed that consents should have been obtained prior to the first dose, but this did not occur.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications were regularly monitored and properly documented for two residents. For one resident with diagnoses including depression, anxiety disorder, dementia with psychotic disturbance, and psychosis, the electronic health record showed missing documentation for behavior monitoring related to delusions, hallucinations, and paranoia on several dates. Additionally, side effect monitoring for both antipsychotic and antidepressant medications was either missing or not documented for multiple days, with no antidepressant side effect monitoring found for two consecutive months. Staff interviews confirmed that these omissions did not meet facility expectations for monitoring and documentation. For another resident with bipolar disorder and depression, there was no documentation of adverse side effect monitoring for a prescribed mood stabilizer. The resident was also taking an antipsychotic medication that required regular AIMS testing, but the required monitoring was not completed in a timely manner, despite a pharmacist's recommendation. Staff acknowledged that side effect monitoring and timely follow-through on pharmacist recommendations were expected but not performed in these cases.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with severe cognitive impairment within the required 24-hour timeframe. The resident, who was admitted on a specified date and assessed as severely cognitively impaired, made a statement indicating possible abuse, documented in a social services progress note. Despite this, the facility did not report the allegation to the State Agency until three days after it was made, as confirmed by a review of investigation logs and staff interview. The DON acknowledged that the delay did not meet expectations for timely reporting as required by regulation.
Failure to Complete and Update Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive, person-centered care plans were completed and updated to address all aspects of care for three residents. For one resident with Stage 3 and Stage 4 pressure injuries and an indwelling urinary catheter, the care plan did not document the indication or justification for catheter use, despite the need to prevent contamination of pressure ulcers. Staff acknowledged that the care plan should have specified the catheter's purpose but did not. Another resident with therapeutic nutritional risk had a care plan that was not updated to reflect their history of refusal, need for encouragement with food and fluid intake, and other relevant interventions, as confirmed by the dietician and resident care manager. A third resident with a diagnosis of anemia and recent hospitalization for blood transfusions did not have a specific care plan addressing anemia, monitoring considerations, or transfusion history. Additionally, the care plan for this resident's visual impairment did not mention their use of corrective lenses or related needs, despite the resident reporting difficulty reading and requiring staff assistance. Staff interviews confirmed that these omissions were not in line with facility expectations for care plan updates following changes in condition or hospitalizations.
Failure to Follow Professional Standards in Medication Administration and Management
Penalty
Summary
The facility failed to meet professional standards of practice in several areas related to medication administration and management. One resident with hypothyroidism had a physician's order for levothyroxine to be administered at 6:00 AM, prior to breakfast and on an empty stomach. However, medication administration records showed that the medication was frequently given more than one hour after the scheduled time, often after breakfast, on 27 out of 36 reviewed days. Both the resident and nursing staff confirmed that the medication was not being administered as ordered, and staff acknowledged that this did not meet expectations for proper medication timing. Another resident with hypertension had an order for lisinopril 20 mg twice daily, with instructions to hold the dose if systolic blood pressure was below 100. The resident reported that at home, they only took the medication once daily and expressed concern about receiving too much medication at the facility. Documentation showed that the medication was held on several occasions due to low blood pressure, and a progress note indicated the resident's concern about the dosing. However, there was no evidence that staff communicated this concern to the provider or followed up to clarify the appropriate dosing regimen. Additional deficiencies were observed in medication administration practices, including a resident receiving a chewable aspirin tablet in a manner inconsistent with the order, as the resident preferred to swallow all medications together rather than chew the tablet. Staff did not seek a provider order to change the medication form. Furthermore, a controlled substance (Oxycodone) was found improperly stored in a plastic bag attached to the controlled substance book, rather than being wasted immediately as required. Staff acknowledged that the leftover medication should have been destroyed promptly, but this was not done.
Failure to Consistently Assess Pressure Injuries and Maintain Pressure Redistribution Equipment
Penalty
Summary
The facility failed to ensure that pressure injuries (PIs) were consistently assessed and that ordered pressure redistribution equipment was in place and functional for a resident with multiple PIs. Upon admission, the resident was cognitively intact, required substantial to maximal assistance with bed mobility, was at risk for PI formation, and had two Stage 3 and one Stage 4 PIs. The resident had an order for a low air loss (LAL) mattress for pressure redistribution, but observations revealed that the mattress was not functioning properly, as indicated by red flashing lights for low pressure and power failure. The resident reported feeling the bed frame through the mattress since admission, requiring pillows for comfort, and staff did not notice or address the malfunction until several days later. In addition to equipment issues, the facility did not consistently assess or document the resident's pressure injuries. While the initial evaluation and hospital records documented unstageable PIs to both heels and other areas, subsequent wound care consults failed to mention or assess the right heel PI. Facility progress notes indicated ongoing wound care and dressing changes for both heels, but there was no documentation of measurements or assessments for the right heel PI after admission. The wound care company responsible for weekly assessments also did not document the right heel PI in their consults. Interviews with facility leadership confirmed that the resident was admitted with PIs to both heels, consistent with hospital records, and that facility staff documented heel wounds through several weeks. However, there was no evidence that the right heel PI was measured, assessed, or monitored after admission, despite ongoing wound care. This lack of consistent assessment and failure to ensure functional pressure redistribution equipment constituted the deficiency identified in the report.
Failure to Assess and Discontinue Indwelling Catheter After Resolution of Pressure Injuries
Penalty
Summary
The facility failed to ensure that a resident admitted with an indwelling urinary catheter was properly assessed for catheter removal as soon as possible, and did not ensure that a clinical justification existed for the continued use of the catheter. The facility's policy required a medical justification for both the initiation and ongoing use of indwelling catheters, including a Bladder Data Collection/Evaluation and a plan of care documenting justification for continued catheterization beyond 14 days. For the resident in question, who was cognitively intact and dependent on staff for toileting, the initial justification for the catheter was the presence of Stage 3 pressure injuries to the sacrum and right buttock. Subsequent wound care consults documented that both pressure injuries had resolved, and a recent Bladder Data Collection and Evaluation did not identify any ongoing conditions that would justify continued catheter use. Despite this, the catheter remained in place, and staff confirmed that no action was taken to contact the provider for a trial discontinuation order after the wounds had healed. The resident's medical record did not contain diagnoses such as obstructive uropathy, neurogenic bladder, benign prostate hyperplasia, or urinary retention that would otherwise justify the catheter's continued use.
Failure to Provide and Document Non-Pharmacological Pain Interventions and Medication Review
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications by not providing or documenting non-pharmacological interventions (NPIs) for pain management, not monitoring for side effects, and not reassessing the necessity of certain medications upon admission. For one resident on hospice care with severe cognitive impairment, morphine was administered multiple times for pain and dyspnea, but there was no documentation that NPIs were attempted prior to medication administration, despite facility policy and staff expectations that NPIs should be tried and documented before giving medication. Another resident with a pelvic fracture and constant pain received both acetaminophen and morphine as needed for pain, but there was no documentation of NPIs being offered or attempted, nor was there documentation of side effect monitoring, even though these were ordered. Additionally, this resident was given omeprazole for GERD without an active diagnosis for the condition, and staff confirmed that the necessity of this medication was not reassessed upon admission. A third resident with a history of hip fracture and pain received as needed acetaminophen on multiple occasions, but again, there was no documentation that NPIs were attempted or provided. Staff interviews confirmed that NPIs should have been offered and documented, and that the lack of documentation did not meet facility expectations. The facility's own pain management policy required staff to determine and document both pharmacological and non-pharmacological interventions and to evaluate their effectiveness, which was not followed in these cases.
Improper Storage, Labeling, and Expired Medications Found on Medication Carts
Penalty
Summary
Surveyors observed that medications and biologicals were not properly stored or labeled in two of five medication carts reviewed. On one cart, an unattended bottle of Tylenol was found on top, and a bottle of Day Time Cold and Flu Relief with an expired date was inside the cart. Additionally, two antifungal creams were found in the cart drawers without resident names or labels. Staff confirmed the Tylenol was left by a new employee from central supply and acknowledged the expired medication. On another medication cart, four opened bottles of nystatin powder were found without any resident identifiers or labels. Staff confirmed the lack of labeling and disposed of the bottles. The Resident Care Manager/Registered Nurse stated that expired medications should be removed and destroyed, and all medications should be labeled with resident names, confirming that the observed practices did not meet expectations.
Failure to Maintain Food Storage Temperature Logs
Penalty
Summary
The facility failed to store food in accordance with professional standards by not maintaining documented refrigerator and freezer temperature logs for all five refrigeration/freezer units reviewed. Temperature logs for the snack refrigerators on multiple halls, as well as the walk-in cooler and walk-in freezer in the kitchen, showed numerous missing entries over several months. Specific dates were identified where no temperatures were recorded, indicating a lack of consistent monitoring of food storage conditions. During an interview, the Dietary Manager confirmed that kitchen staff were responsible for checking all refrigerators daily and acknowledged the presence of many missing temperature records. The issue was identified upon the Dietary Manager's hiring, and it was noted that the missing dates should have been filled in. This failure to document and monitor refrigerator and freezer temperatures was observed and verified through record review and staff interview.
Infection Control Deficiencies in Wound Care, Meal Delivery, and Laundry Practices
Penalty
Summary
Staff failed to maintain infection control practices in several areas. During wound care for a resident, a nurse did not perform hand hygiene before donning gloves and, after holding the resident's leg, continued wound care without changing gloves or performing hand hygiene. Additionally, during meal tray delivery, a CNA repeatedly entered multiple resident rooms, touched various surfaces and residents, and did not perform hand hygiene between room entries or after assisting residents, contrary to facility expectations. The CNA stated that hand hygiene was only performed once during the entire meal pass, and there was confusion about the correct protocol among staff. A review of the laundry room's washer temperature logs revealed multiple days with missing documentation, indicating that regular temperature checks were not consistently completed. The Housekeeping and Laundry Manager confirmed that these checks were necessary to ensure proper sanitation of laundry. The facility administrator also acknowledged that the temperature logs should have been completed as required.
Failure to Implement Care Plan for Dependent Resident
Penalty
Summary
The facility failed to implement the care plan for a resident with multiple complex needs, including diabetes, multiple sclerosis, severe cognitive impairment, and a stage III pressure ulcer. The resident required substantial to maximal assistance with bed mobility, transfers, and activities of daily living, and was dependent on staff for repositioning, dressing, personal hygiene, and eating. Despite care plan interventions specifying frequent repositioning, scheduled check/change for incontinence, and 1:1 assistance with meals, the resident was repeatedly observed lying in bed for extended periods in uncomfortable and improper positions, with the head of the bed at 90 degrees and the resident slumped or with their head bent at an angle. The resident was also observed with exposed skin, uncombed hair, and without staff present to assist with meals, leaving the meal tray untouched and the resident unable to eat due to their position. Staff interviews revealed inconsistent implementation of the care plan, with CNAs indicating confusion or lack of follow-through regarding getting the resident out of bed and providing meal assistance. Documentation showed that after a recent incident where the resident slid out of their wheelchair, staff hesitated to transfer the resident, and therapy had recommended repositioning and returning the resident to bed after meals or when fatigued. However, these recommendations were not consistently followed, as evidenced by multiple observations of the resident remaining in bed, improperly positioned, and without necessary assistance for eating and personal care.
Failure to Administer Seizure Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications to prevent seizures were administered according to physician orders for a resident with dementia and a seizure disorder. The resident was admitted with severe cognitive impairment and had physician orders for Valproic Acid, Dilantin, and Levetiracetam to manage epilepsy. However, the resident did not receive these medications as prescribed due to unavailability and refusals, and there was a failure to notify the physician or the resident's representative about these omissions. The resident's Medication Administration Record (MAR) indicated multiple instances where the resident refused or did not receive their prescribed medications. Specifically, the resident refused Valproic Acid, Dilantin, and Levetiracetam on several occasions, and the Valproic Acid was noted as unavailable on one day. Despite these issues, there was no documentation in the electronic medical record (EMR) that the physician or the resident's representative was informed of the medication refusals or the unavailability of the medication. As a result of these failures, the resident experienced harm when they were found unresponsive and required emergency medical intervention, including CPR and hospitalization. The hospital records indicated that the resident had subtherapeutic levels of anticonvulsant medications, which likely led to a seizure. The Acting Director of Nursing confirmed that the staff should have notified the physician about the medication refusals and unavailability, especially for seizure medications.
Non-compliance with PPE Protocols for COVID-19
Penalty
Summary
The facility failed to ensure that three staff members adhered to CDC guidelines for using personal protective equipment (PPE) when caring for residents with known COVID-19 infections. Staff B, a Licensed Practical Nurse, entered a resident's room with the appropriate PPE but failed to remove the N95 respirator upon exiting, continuing to wear it while interacting with others in the hallway. Staff C, a Certified Nursing Assistant (CNA), also did not change the N95 respirator or eye protection after exiting a resident's room and proceeded to engage with other residents. Similarly, Staff D, another CNA, did not remove the N95 respirator or eye protection after leaving a COVID-19 positive resident's room, citing a lack of available PPE as a reason. The Acting Director of Nursing, Staff A, confirmed that residents with COVID-19 were placed on aerosol precautions and expected staff to remove all PPE upon exiting such rooms. However, the staff did not follow these infection control procedures, as evidenced by their actions. This non-compliance with PPE protocols placed both residents and staff at risk of contracting and spreading COVID-19, as the staff continued to interact with others without changing their PPE.
Failure to Assist Residents with Daily Living Activities
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, such as bathing, dressing, and personal hygiene, for two residents. Resident 1, who was cognitively intact and required substantial assistance, reported receiving only one shower 11 days after admission despite repeated requests. The resident's care plan indicated a need for assistance with bathing twice a week and total assistance with personal hygiene, yet documentation showed only one shower was provided since admission. Similarly, Resident 2, also cognitively intact, reported inadequate assistance with daily hygiene and dressing. The resident stated they were left in bed for extended periods without regular hygiene care, and documentation confirmed only one shower was provided since admission, with one additional shower offered and refused. Staff interviews revealed that the assigned Certified Nursing Assistant was too busy to provide the necessary care, and the Acting Director of Nursing acknowledged the expectation for staff to follow the care plans, which was not met in these cases.
Improper Use of Restraints in Wheelchairs
Penalty
Summary
The facility failed to ensure that three residents were free from the use of physical restraints, which placed them at risk for injury, frustration, and decreased quality of life. Resident 1, who had severe cognitive impairment and a history of falls, was observed with a Velcro strap securing their contracted right arm to the wheelchair armrest. This restraint was used without any documented assessment, care plan, consent, or physician order. Staff members were unaware of the requirement for such documentation and continued to use the Velcro strap to prevent further contraction of the resident's arm. Resident 2, also with severe cognitive impairment, was placed in a tilt-in-space wheelchair that was tilted back as far as possible to prevent the resident from getting up and walking, as they were considered a fall risk. The care plan and physician orders did not specify the degree of tilt or provide guidance on managing the resident's attempts to get out of the wheelchair. Staff members admitted to tilting the wheelchair back to restrict the resident's movement, which was not in line with the intended use of the wheelchair for positioning. Similarly, Resident 3, who had severe cognitive impairment, was placed in a tilt-in-space wheelchair tilted at approximately 45 degrees, which restricted their ability to engage in activities and maintain proper body alignment. The care plan and safety device evaluation did not provide adequate instructions on the use of the wheelchair, and staff members used the tilt to prevent the resident from climbing out of the chair. The Director of Nursing acknowledged that the wheelchairs were being used improperly, as they should not have been tilted beyond 20 degrees for positioning purposes.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess and take timely action to prevent the development of pressure ulcers in a resident, leading to significant harm. The resident, who had a history of pressure ulcers and was at risk due to conditions such as developmental delay, diabetes, and morbid obesity, developed pressure ulcers on both heels. These ulcers required hospitalization, surgical intervention, and ultimately resulted in a below-the-knee amputation of the right lower extremity. The facility's policy required weekly monitoring and documentation of wounds, but there were significant lapses in the assessment and documentation of the resident's condition. Despite having orders for weekly diabetic foot checks and a history of pressure ulcers, the resident's skin evaluations were not consistently documented, and there were gaps in the monitoring of the resident's feet. Staff failed to document changes in the resident's condition, and there was a lack of communication among the nursing staff and the interdisciplinary team regarding the resident's deteriorating condition. Interviews with staff revealed a lack of awareness and communication about the severity of the resident's wounds. Staff members were not fully informed about the resident's condition, and there was confusion about whether the resident was on the wound consultant's caseload. The Director of Nursing Services acknowledged inaccuracies in the documentation and a failure to communicate the resident's condition effectively, which contributed to the delay in addressing the resident's needs and ultimately led to the resident's hospitalization and amputation.
Failure to Implement Care Plans for Two Residents
Penalty
Summary
The facility failed to implement care plan interventions for two residents, leading to deficiencies in their care. Resident 2, who was admitted with dementia and depression, was dependent on staff for various activities of daily living, including transfers, dressing, and hygiene. Despite having a care plan that required the use of hearing aids and TED hose, Resident 2 was repeatedly observed without these aids and remained in bed wearing a hospital gown. Staff, including a CNA and the Unit Manager, were either unaware of or did not follow the care plan, resulting in Resident 2 not receiving the necessary assistance to get out of bed or maintain hygiene. Resident 3, who was cognitively intact and required assistance with bathing, did not receive a shower or bed bath during the first week of admission, contrary to their care plan. The task report for bathing showed no documentation of showers, and the Unit Manager could not provide a reason for this oversight. The Director of Nursing acknowledged that the care plans for both residents were not consistently implemented by the facility staff.
Resident Burned Due to Unsafe Heater Conditions
Penalty
Summary
The facility failed to ensure a safe environment free from hazards for residents in the locked dementia unit, resulting in a significant incident involving Resident 1. This resident, who had Alzheimer's Disease, dementia, and hypertension, was found unsupervised and seated on a baseboard heater, leading to a second-degree burn on the left hip. The resident's care plan indicated cognitive impairment, wandering behaviors, and impaired safety awareness, yet the resident was able to access the heater unsupervised, resulting in harm. The incident occurred when Staff F, a Nursing Assistant, found Resident 1 sitting on the heater with skin between the heater panels, causing burns. Despite moving the resident away and seeking assistance, the resident returned to the heater before being sent to the hospital for evaluation and treatment. The facility's investigation could not determine why the resident was near the heater, highlighting a lack of adequate supervision and environmental safety measures. Observations revealed that the baseboard heaters in the dementia unit were difficult to regulate, with several being too hot to touch, posing a burn risk. Staff reported issues with the heaters, and the facility's infrared thermometer was malfunctioning, preventing accurate temperature assessments. This lack of proper equipment and supervision contributed to the unsafe conditions that led to Resident 1's injury.
Removal Plan
- Review of the temperature logs
- Staff education related to temperature checks
- Verification of repairs to the baseboard heaters
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to adhere to its elopement prevention policy for a resident with cognitive impairment and a history of elopement. The policy required completing an admission assessment, elopement evaluations, and developing individualized interventions, including the use of an electronic monitoring/alarm system. However, the resident's care plan did not indicate a risk for elopement, and there was no physician's order for the application of a wander guard, which was applied after the resident's initial elopement. The facility's accident and incident logs also lacked documentation of the resident's elopement. The resident, diagnosed with hepatic encephalopathy and cirrhosis of the liver, left the facility unattended and was returned by police. Despite this incident, the care plan was not updated to reflect the risk of elopement. The wander guard alarm was reportedly not functioning properly, and staff acknowledged the failure to follow the facility's policy. The resident later left the facility against medical advice, highlighting the ongoing issue with elopement prevention measures.
Failure to Administer Pain Medication to Newly Admitted Resident
Penalty
Summary
The facility failed to assess and treat pain for a resident who was admitted with a fractured left femur, neuropathy, and hypertension. Upon admission, the resident was on a scheduled pain medication regimen, including oxycodone and pregabalin. However, the resident did not receive any medications on the day of admission and only received oxycodone the following day. The resident reported experiencing significant pain throughout the night without any relief, as the facility staff did not administer the prescribed pain medications. The deficiency occurred because the nurse responsible for the resident's care during the night shift was new and did not have access to the Omnicell, a secure electronic medication dispensary, to retrieve the necessary medications. Additionally, the nurse was not trained on admissions and was unaware of the procedure to obtain medication or whom to contact for assistance. The Director of Nursing Services later acknowledged that all nurses should have access to the Omnicell and that the nurse should have reached out to her or another staff member for help.
Failure to Notify Resident and Ombudsman of Emergency Transfer
Penalty
Summary
The facility failed to provide a written notice of an emergency transfer to a resident, their representative, and the Office of the State Long-Term Care Ombudsman. This deficiency was identified during a review of hospitalization cases, specifically for one resident who was transferred to the hospital from a scheduled appointment. The resident, who had no cognitive impairment and required moderate to total dependence on staff for assistance with activities of daily living, was admitted to the intensive care unit without receiving the required notification of transfer. The resident had an active plan to return to the community, but no referrals had been made for discharge planning. The facility's Director of Nursing Services acknowledged that the notification was not completed because the transfer did not occur directly from the facility. This oversight placed the resident and their representatives at risk of not being informed about the transfer and their rights, as there was no documentation of the required written notification in the resident's electronic record.
Failure to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to consider the re-admission of a resident after an unplanned hospitalization, which placed the resident at risk for increased anxiety and diminished quality of life. The resident, who was admitted with chronic inflammatory demyelinating polyneuritis, required infusions to manage her condition and needed assistance with mobility. After being transferred to the hospital from an infusion appointment, the resident did not receive any communication from the facility regarding her return. The facility did not document any inability to provide care, nor did they issue a formal notice to the resident about the discharge or discuss plans for her return. Staff at the facility, including the Business Office Manager and the Director of Nursing Services, acknowledged that they informed the resident they could not provide the necessary care due to staffing constraints for the infusion appointments. However, there were no documented efforts or discharge planning notes to find a suitable placement for the resident. The facility's administrator admitted to not documenting conversations with the resident about the facility's inability to meet her needs, resulting in a lack of formal communication and planning for the resident's discharge.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly personal fund statements to residents with personal fund accounts, affecting four sampled residents. Resident 24, who has a neurological condition and is capable of expressing needs, reported not receiving statements of their account balance. A review of the Trial Balance document confirmed that Resident 24, along with Residents 4, 5, and 19, had balances held in trust by the facility. During interviews, the Business Office Manager admitted to not consistently providing these statements and could not specify when the last statements were issued. The Administrator was unaware of this lapse, although the expectation was for the business office staff to provide these statements quarterly.
Deficiencies in Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for two residents. For Resident 129, the facility nurses did not obtain, accurately transcribe, or clarify physician's orders for pain medication and oxygen therapy. The orders for oxycodone did not include parameters for use, such as a pain scale, to determine the appropriate dosage. Additionally, the hospital transfer order for oxygen therapy was not transcribed into the resident's electronic health record, resulting in the resident receiving oxygen without a proper order. The Director of Nursing acknowledged that the nurses should have identified and corrected these issues. For Resident 69, the facility failed to administer a prescribed antibiotic, Levaquin, on two occasions due to the nurse's inability to locate the medication. The nurse did not utilize available options such as checking the Pyxis system or contacting the pharmacy. Furthermore, there was no alert charting completed for the resident's antibiotic therapy, which was necessary to monitor side effects and effectiveness. The Director of Nursing indicated that the nurse had entered the wrong type of note, preventing the alert charting from being triggered.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to provide timely vision services for two residents, leading to a deficiency in maintaining their vision. Resident 50, who was admitted with diagnoses including diabetes and kidney failure, was assessed to have moderately impaired vision. Despite expressing issues with their vision and waiting for several months, an appointment with the eye doctor was not scheduled as expected. The Social Service Assistant acknowledged that multiple appointments, including Resident 50's, were not made, and the resident should have been seen in March 2024. Similarly, Resident 69, admitted with multiple diagnoses including depression and a recent myocardial infarction, reported difficulty with vision, specifically gray splatters in her right eye. Despite requesting an eye appointment upon admission, no follow-up was conducted. The Social Services Assistant revealed that the resident was not seen during the eye exam company's visit due to a COVID infection and was unable to explain why a community appointment was not arranged. The assistant also noted limited working hours and poor communication within the facility.
Staffing Shortages Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff to meet the needs of residents, as evidenced by interviews and observations involving four residents and two staff members. Residents reported delays in receiving assistance with activities of daily living (ADLs) such as showers, nail care, and shaving. One resident mentioned waiting four hours for pain medication, while another reported wait times of 45 minutes or longer for assistance. Staff interviews confirmed that due to insufficient staffing, certain tasks like showers, nail care, and range of motion exercises were not completed regularly. The Resident Council Meeting Minutes further highlighted ongoing issues with nursing care, including grievances about call lights not being answered and residents not being checked as scheduled. The Director of Nursing Services and the Administrator acknowledged the staffing issues and the lack of Registered Nurse (RN) coverage on multiple occasions. These deficiencies were previously cited, indicating a persistent problem with staffing levels and RN availability at the facility.
Failure to Record Refrigerator Temperatures in Medication Room
Penalty
Summary
The facility failed to ensure that refrigerator temperatures were recorded for one of the two refrigerators in the locked medication rooms. This deficiency was identified during an observation on May 8, 2024, when a Registered Nurse (RN), Staff E, was unable to find a temperature log for the locked refrigerator in the medication room near the front entrance of the facility. Staff E confirmed that there should have been a temperature log, which is typically recorded by the night shift staff. Later, the Director of Nursing Services (DNS), Staff B, also could not locate the temperature log and acknowledged that it is usually placed on top of the refrigerator. On May 10, 2024, Staff B reiterated that refrigerator temperatures should be monitored and documented, and if the log is missing, a new one should be started.
Deficiency in Food Storage and Sanitation
Penalty
Summary
The facility failed to ensure food was stored and served under safe and sanitary conditions, as observed in the kitchen. During an initial tour, several uncovered cups of juice were found on a rolling cart in the industrial refrigerator, and uncovered bowls of pudding were observed on a separate cart in the path of a fan blowing visible dust and debris. In the industrial freezer, packages of hot dogs, chicken patties, and manicotti were found unsealed and undated, with the chicken patties and manicotti having a thick layer of frost. Additionally, three plastic containers of used spices were found without a date. During a follow-up kitchen observation, uncovered desserts were again found in the path of a fan with visible dust and debris. Staff J, the Dietary Manager, acknowledged that the desserts should not have been in the path of the fan and disposed of them. Staff J also noted that the evening staff was responsible for pouring juices the night before and that they should have been covered and labeled. Staff A, the Administrator, confirmed that the expectation was for food to be stored, prepared, and served according to required guidelines.
Failure to Honor Resident Preferences for Bathing and Room Assignment
Penalty
Summary
The facility failed to honor the bathing preferences of Resident 24, who was admitted with a neurological condition. Despite the resident's care plan specifying a bath or shower twice a week, documentation revealed missed showers on specific dates. Interviews with Resident 24 and staff confirmed the inconsistency in providing the scheduled showers, with staff acknowledging the lack of documentation for refusals or missed showers. Additionally, the facility did not respect the room preference of Resident 74, who was admitted with anxiety, depression, and PTSD. After being moved due to quarantine, Resident 74 expressed a desire to return to their original room. Despite daily complaints and acknowledgment from staff and the administrator, the resident was not moved back because the room was occupied by a new admission. The administrator admitted awareness of the resident's dissatisfaction but had not yet acted to resolve the issue.
Failure to Notify Resident of Excess Personal Fund Balance
Penalty
Summary
The facility failed to notify a Medicaid recipient, Resident 19, when their personal fund account balance reached $1,800, which is within $200 of the $2,000 resource limit that could impact their Medicaid coverage. Resident 19, who was admitted with diagnoses including diabetes and depression, had a balance of $2,888.64 as of May 8, 2024, and the balance had been over $2,000 since August 2023. This oversight placed the resident at risk for personal financial liability for their care. Interviews with facility staff revealed that the Business Office Manager, Staff H, did not consistently provide residents with quarterly personal fund statements. Although Staff H had recently discussed the balance with Resident 19, they found it challenging to assist with spending the money due to the resident's limited mobility and existing burial trust. The Administrator, Staff A, acknowledged that there should have been ongoing conversations and documentation regarding the resident's trust fund balance, especially when it was within or over the resource limit, and that these discussions should occur at quarterly conferences.
Failure to Initiate Grievance for Resident's Room Change
Penalty
Summary
The facility failed to initiate a resident grievance for a resident who was dissatisfied with their room assignment following a quarantine period. The resident, who had been admitted with diagnoses of anxiety, depression, and post-traumatic stress disorder, expressed a desire to return to their original room, which had a private shower. Despite the resident's repeated complaints about the new room, which they described unfavorably, no grievance was initiated by the staff. Interviews with staff revealed that the resident's concerns were communicated to management, but no action was taken to address the grievance formally. The Director of Nursing Services acknowledged the resident's dissatisfaction but did not initiate a grievance, citing logistical reasons for not moving the resident back. The facility's grievance logs showed no record of the resident's complaint, and the Administrator admitted that a grievance should have been initiated given the resident's repeated expressions of concern.
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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