Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fir Lane Care during CMS and state inspections, most recent first.
Restorative services were not provided as ordered for multiple residents with documented restorative programs. One resident with post-stroke L-sided weakness had a ROM program for the LUE 6 days/week but only received restorative 3 times in 30 days, with an outdated restorative eval and a program noted as on hold due to therapy. Another resident with significant orthopedic and spinal diagnoses had a restorative plan for both shoulders, but staff reported the program was inconsistent because of staffing shortages and only 4 visits were documented in 30 days. A third cognitively intact resident with BLE and BUE restorative orders 5 to 6 days/week also received restorative only 4 times in the month, and the resident reported not receiving those specific services in months.
Cross contamination occurred during tray line meal prep when the Dietary Manager repeatedly touched chicken, cheese, burger patties, hot dogs, and oven doors with gloved hands while continuing to plate meals without changing gloves. The Dietary Manager later acknowledged the food and environmental surfaces should not have been touched and that gloves should have been changed.
Arbitration Agreements Not Explained in an Understandable Manner: Three cognitively intact residents signed binding arbitration agreements, but interviews showed they did not understand what arbitration was or that they were giving up the right to litigation in court. One resident said the agreement was not explained in a way they understood, another relied on family to comprehend things, and a third stated they were never told arbitration could not be required for admission or continued stay.
Failure to complete GDR review and medication-specific psychotropic monitoring. A resident with dementia and depression remained on trazodone for insomnia without provider documentation supporting why dose reduction was not done, despite documented daytime sedation and prolonged sleep periods. Two other residents receiving multiple psychotropics had broad, nonspecific TAR behavior monitoring, and one resident’s clonazepam had no target behavior or side effect monitoring tied to that medication.
The facility failed to follow bowel management orders for three residents with constipation and cognitive impairment. Records showed prolonged periods without documented BMs, yet PRN bowel meds and the bowel protocol were not consistently initiated as ordered. Staff, including the RCM/RN and DON, confirmed the missed interventions and stated the orders should have been followed.
Incomplete Skin Assessments and Missing Wound Care Documentation: A resident with a stage 2 PU had weekly skin evaluations that did not accurately identify the wound, and the TAR had multiple blank or missing entries for scheduled and PRN wound care across several months. The RN/RCM and DON acknowledged the skin checks were not charted correctly and that documentation should have been entered whenever an active wound care order existed.
A resident with ESRD and dialysis dependence had elevated BP readings, but PRN hydralazine was not given when parameters were met. Dialysis communication was not accurately reflected in the chart, including a pneumococcal vaccine entry, and the resident’s dry weight goal was not known to nursing. The resident’s 1,000 mL fluid restriction was inconsistently tracked, with MAR entries above and below the ordered amount, and observation showed extra fluids at the bedside and during meals.
The facility failed to prevent unnecessary medication use for three residents by not following ordered medication parameters, not clearly indicating use for some medications, not reassessing a scheduled opioid, and not addressing a pharmacy recommendation. One resident received carvedilol outside hold parameters, another with dementia received scheduled oxycodone repeatedly despite 0/10 pain and without use of available non-opioid pain meds, and a third resident’s scheduled Miralax order was not adjusted after a pharmacist recommended a hold for loose stools.
Medication error rate exceeded the allowed threshold when an LPN made 2 errors during a medication pass, resulting in an 8% error rate. The nurse gave a resident Lasix without checking required BP and pulse parameters and also administered the wrong cough medication from house stock instead of the ordered NyQuil Cold & Flu, with the amount given not matching the bottle directions.
A resident with severe cognitive impairment and hospice services had no hospice nursing or aide visit notes in the binder or EHR, despite the care plan calling for regular RN and HHA visits. Staff said hospice notes were kept in the binder and uploaded to the EHR, but the documentation was not present until later, when 20 RN visits were found to have not been recorded and no HHA records were provided.
Failure to Provide Written Transfer/Discharge and Bed-Hold Notices: The facility did not provide written transfer/discharge and bed-hold notices for two residents reviewed. One resident’s guardian reported not receiving the discharge evaluation for review and signature, and another resident, who was severely cognitively impaired and had a guardian, was sent to the hospital with the notice completed in the chart but with no documentation that the guardian was contacted or given a written copy.
Unsanitary shared bathroom conditions and improper handling of urine containers: A resident and another resident were affected by a bathroom that was not kept clean and in working order. A shared bathroom had a toilet with a plastic liner containing urine and stool, plus two unlabeled urinals containing urine left in the room. Staff gave conflicting accounts about the clogged toilet, the use of the liner, and the lack of a bedside commode, and the DON acknowledged the bathroom conditions did not meet expectations.
A resident with severe cognitive impairment and wandering behaviors repeatedly entered other residents' rooms, while another resident with dementia, poor impulse control, and a history of physical behaviors frequently targeted them in the hallway and in shared areas. Staff reported often having to physically block the aggressive resident from approaching the vulnerable resident. Despite prior documented incidents where the aggressive resident had pushed another resident down and had previously pushed this same vulnerable resident causing a fall with head impact, the aggressive resident again shoved the vulnerable resident in their room, requiring staff to lower the victim to the floor. An incident report later described the action as guiding the resident out, but staff and the administrator confirmed it was a deliberate shove and the second such episode between these two residents.
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.
Restorative services not provided as ordered for multiple residents
Penalty
Summary
The facility failed to ensure restorative services were provided for 3 residents who had restorative programs in place. Resident 10 was admitted with paralysis and severe weakness on the left side following a stroke. The quarterly MDS showed the resident was cognitively intact and had received 2 days of restorative services during the assessment period. The care plan called for a restorative range of motion program for the left upper arm 6 days a week, but the restorative evaluation had not been updated since 03/02/2026 and documented the program was on hold due to therapy services. The last 30 days of task documentation showed restorative was only completed on 3 days. Therapy records showed occupational therapy discharged the resident with recommendations for restorative related to ADLs and ROM, and physical therapy later worked with the resident on use of a powered wheelchair. Resident 6 was admitted with diagnoses including arthritis due to bacteria of the left shoulder, acute osteomyelitis of the left humerus, spinal stenosis, and osteomyelitis of the lumbar vertebrae. The quarterly MDS documented the resident was cognitively intact. The care plan revised in May 2026 identified limited physical mobility and included restorative goals for both shoulders with active ROM and weights. Therapy discharged the resident from PT and referred the resident to restorative. Staff reported the restorative program was inconsistent because of staffing shortages, that the program was being offered only one day a week, and that the resident had been picked up for restorative after PT discharge. Review of the 30-day restorative history showed multiple missed opportunities, including entries that the activity did not occur and one entry that the resident was not available, with only 4 restorative visits documented in 30 days. Resident 32 was cognitively intact and receiving restorative services per the quarterly MDS. The June 2026 restorative order called for BLE seated exercises with resistance and BUE shoulder exercises with weights 5 to 6 days per week. The 30-day task documentation showed restorative was completed only 4 times during the month. When interviewed, the resident said they had not received those specific restorative services in months and had instead been working with physical therapy for an ankle injury. The Administrator and DON reviewed the June restorative dates and confirmed the resident only received restorative services 4 times that month, stating that did not meet expectations and that the resident should have gotten services as ordered.
Cross Contamination During Tray Line Meal Preparation
Penalty
Summary
The facility failed to prevent cross contamination during meal preparation services for 1 of 1 kitchen reviewed for food service safety. During tray line observations on 07/08/2026, the Dietary Manager was observed plating food for lunch meal service and repeatedly touched chicken strips, chicken, cheese, burger patties, and hot dogs with a gloved hand while continuing to dish up other plates. The Dietary Manager also touched the small oven door, opened and closed the small oven, and turned on a second oven with the same gloved hand while continuing meal assembly. Throughout the observation period, the Dietary Manager did not change gloves after touching food or environmental surfaces. At 12:06 PM, a new pair of gloves was donned, but afterward the Dietary Manager again touched chicken, the small oven door, cheese, burger patties, and hot dogs without changing gloves. When asked later about touching food and environmental surfaces, the Dietary Manager stated the food should not have been touched and acknowledged that the food and environmental surfaces should not have been touched and that gloves should have been changed.
Arbitration Agreements Not Explained in an Understandable Manner
Penalty
Summary
The facility failed to ensure binding arbitration agreements were explained in a manner that residents understood for 3 of 3 residents reviewed for arbitration agreements. Resident 64, Resident 27, and Resident 78 were each admitted to the facility and had brief interview for mental status forms showing they were cognitively intact. Each resident signed a binding arbitration agreement, but during interviews they demonstrated they did not understand what arbitration meant or that they were giving up the right to litigation in a court proceeding. Resident 64 stated they did not know what the arbitration process was and said the agreement was not explained in a way they understood. Resident 27 asked, "What is arbitration?" and stated they did not know they were giving up their right to litigation in a court proceeding, adding that they relied on their son to comprehend things for them and were working on getting a power of attorney. Resident 78 said they were unclear on arbitration, asked whether it had something to do with patient rights, and stated they were never told the facility could not require arbitration as a condition of admission or remaining in the facility. The Administrator stated the expectation was that arbitration agreements be explained in a way understandable to the residents or whoever was in charge of their care.
Failure to complete GDR review and medication-specific psychotropic monitoring
Penalty
Summary
The facility failed to follow gradual dose reduction (GDR) requirements and to monitor psychotropic medications for 3 residents reviewed for unnecessary medications. The facility policy stated a GDR should be attempted unless clinically contraindicated, and if a resident with dementia had target symptoms return or worsen after a prior GDR, the physician was to document the clinical rationale for why another dose reduction would likely impair function or increase distressed behavior. Resident 2 had diagnoses of dementia and depression and was assessed as having severe cognitive impairment. A pharmacist noted on 02/04/2026 that trazodone for insomnia was due for GDR review, and the interdisciplinary team stated the resident benefited from the current dose and no change was recommended to maintain stability. A provider signed the form on 02/11/2026 without additional documentation or clinical rationale. A psychology follow-up note from 02/06/2026 documented daytime sedation and sleeping during the day, which could have been related to trazodone or an antipsychotic medication. Sleep monitoring showed multiple days in January and February with 10 hours or more of sleep, including several days with 13 to 20 hours of sleep. Resident 56 had diagnoses including dementia with behavioral disturbance, major depressive disorder, insomnia, delusional disorder, and anxiety disorder, and was moderately cognitively impaired. The resident was ordered multiple psychotropic medications, including Depakote, lorazepam, mirtazapine, and Risperdal. The TAR showed target behavior monitoring entries that were broad and did not specify which psychoactive medication or medication class each behavior related to. Resident 32 had diagnoses of unspecified psychosis and dystonia and was cognitively intact. The resident was ordered quetiapine for psychosis and clonazepam for dystonia, but the TAR only showed target behavior monitoring for psychoactive medication generally, with no specific monitoring for clonazepam and no side effect monitoring for that medication.
Failure to Initiate Bowel Protocol for Residents With Constipation
Penalty
Summary
The facility failed to ensure bowel interventions were initiated for three residents who had orders and care plan interventions related to constipation management. Facility policy stated that when a resident had no or a small bowel movement documented for 48 hours, the licensed nurse was to assess the resident and determine whether the bowel protocol should be initiated, with Miralax, then Dulcolax suppository, then Fleet enema if needed. The deficiency involved Residents 82, 2, and 56, all of whom had diagnoses including dementia or cognitive impairment, and Resident 56 also had a care plan goal to have a normal bowel movement at least every third day. For Resident 82, the record showed extended periods without documented bowel movements, including 8 days and 6 days without a bowel movement in June 2026. Although PRN Dulcolax was documented on two dates and PRN Miralax was documented once, the record did not show bowel protocol interventions being initiated in response to the prolonged absence of bowel movements. The RCM/RN stated that the resident did not have bowel movements documented per the record and that the bowel protocol should have been initiated in addition to scheduled Miralax. The DON stated staff were expected to follow the bowel protocol. For Resident 2, the record showed 5 days without a bowel movement and another 4-day period without a bowel movement. PRN Miralax was given on day 4 of one no-bowel-movement period, but no PRN bowel medications were given on other days when the resident remained without a bowel movement. The RCM/RN confirmed no PRN bowel medications were given during the identified periods, and the DON stated the doctor’s orders should have been followed, including giving PRN bowel medications on the days identified. For Resident 56, the record showed no bowel movement for 5 days in June, 6 days in May, and 9 days in April 2026, with no PRN bowel medications administered during those periods. The RCM/RN confirmed the lack of documented bowel movements and the absence of PRN bowel medications, and stated this did not meet expectations for constipation management.
Incomplete Skin Assessments and Missing Wound Care Documentation
Penalty
Summary
The facility failed to ensure weekly skin evaluations were completed accurately and failed to document wound care on the Treatment Administration Record (TAR) for Resident 13, who was cognitively intact and had a stage 2 pressure ulcer on the Quarterly Minimum Data Set. The Total Body Skin Evaluation Weekly dated 06/17/2026 and 06/25/2026 documented no skin concerns and did not identify the pressure ulcer, even though staff later acknowledged that the ulcer should have been documented on those assessments. The TAR for Resident 13 contained multiple wound care orders for the pressure ulcer across March, April, May, and June 2026, but several scheduled treatment boxes were left blank and some as-needed wound care entries were not documented. Blank or missing documentation was noted on 03/31/2026, 04/02/2026, 04/14/2026, 05/05/2026, 05/09/2026, 05/14/2026, 05/30/2026, 06/09/2026, and 06/13/2026. The RN/RCM and DNS stated the skin evaluations were not charted correctly and that something should have been documented on the TAR when an active wound care order existed, even if the resident had been seen by United Wound Healing, was out of the facility, or there was overlap in wound care orders.
Dialysis Care, Fluid Restriction, and Medication Monitoring Not Followed
Penalty
Summary
The facility failed to ensure a resident with end stage renal disease and dependence on renal dialysis was appropriately monitored and treated for blood pressure and fluid restrictions, and failed to accurately record dialysis communication into the medical record. The resident was cognitively intact and had an order for hydralazine every 8 hours as needed for systolic blood pressure over 170 or diastolic blood pressure over 110. Blood pressure readings showed elevated values on multiple dates, including 173/75, 174/80, 182/90, and 177/71, but the June and July MARs showed hydralazine was not administered on those dates. Dialysis communication forms showed the resident received a pneumococcal vaccine from dialysis, but the facility’s immunization record was not updated and instead documented that the resident had refused the vaccine after education. The resident also had a weight order for post-dialysis dry weights to be recorded after returning from dialysis, but the order did not list the goal dry weight established by dialysis. A later dialysis communication form showed a large amount of fluid removed during dialysis, with a pre-dialysis weight of 50.8 kg and a post-dialysis weight of 46.6 kg. The resident had a 1,000 mL fluid restriction with amounts assigned to nursing and dietary, but the MAR documented multiple days below the dietary amount and multiple days above the total restriction. During observation, the resident had hot water, bottled water, milk with cereal, and an unopened apple juice available at the bedside. Staff interviews showed the CNA was unsure of the restriction amount, dietary stated the resident should only get one cup of fluids in the morning, nursing did not know the dry weight goal, and the RCM/LPN acknowledged the facility missed the fluid restriction and that the resident should not have had both water and milk for breakfast or the apple juice.
Unnecessary Medication Use and Inadequate Medication Parameter Management
Penalty
Summary
The facility failed to ensure residents were free from unnecessary medications by not following medication parameters, not ensuring medications had a clear indication for use, not re-evaluating the necessity of a scheduled opioid, and not addressing a pharmacy recommendation for three residents. The deficiency involved Resident 56, who had chronic pain diagnoses, moderate cognitive impairment, and an order for Biofreeze as needed for pain and carvedilol for hypertension with hold parameters for low blood pressure or low heart rate. Review of the MAR showed carvedilol was administered outside the ordered parameters on multiple dates. Resident 2 had dementia with severe cognitive impairment and was prescribed scheduled oxycodone three times daily, oxycodone as needed for pain, and Tylenol for mild discomfort. The MAR showed the scheduled oxycodone was repeatedly given when pain was documented as 0/10 or not applicable, while the as-needed oxycodone and Tylenol were not given. The sleep tracker showed days with prolonged sleep, including one day with 18 hours of sleep when the scheduled opioid was given twice for 0/10 pain. Staff stated the resident could not verbalize pain, that it was difficult to tell whether the scheduled opioid was effective, and that the opioid should have had pain-scale parameters when non-opioid pain medication was available. Resident 82 had dementia and an order for Miralax twice daily for constipation. The consultant pharmacist’s medication regimen review noted the resident had a scheduled Miralax order and recommended considering a hold for loose stools. Staff later stated the recommendation did not appear to have been addressed for this resident. The report cited WAC 388-97-1060(3)(k)(i).
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
Medication error rates were not kept below 5%, as observed during 25 opportunities for error when 1 of 3 LPNs made 2 medication errors for an 8% error rate. The facility policy titled Medication Administration, updated 12/2024, required staff to hold medications per provider orders if vital signs or blood sugars were outside parameters and to verify the correct medication, expiration date, dose, dosage form, route, and time against the MAR before administration. During a medication pass, an LPN administered Lasix to Resident 35 even though the order required notification of the provider if systolic blood pressure was less than 110 or pulse was less than 60, and the nurse did not take the resident’s vital signs before giving the medication. In the same medication pass, the LPN gave Resident 35 5 ml of Geri-Tussin even though the physician order was for NyQuil Cold & Flu 30 ml; the nurse acknowledged Geri-Tussin and NyQuil Cold & Flu were not the same medications and stated the house stock medication had been given, and that the amount administered did not match the bottle directions.
Missing Hospice Visit Documentation
Penalty
Summary
The facility failed to maintain complete and accessible medical records of hospice nursing and hospice health aide visits for one resident receiving hospice services. The resident was readmitted with hospice in place and had a minimum data set assessment documenting severe cognitive impairment. The nursing facility services agreement with the hospice stated that hospice and the facility were to communicate regularly and document such communication in their respective clinical records to ensure the needs of hospice patients were met 24 hours per day. On review of the resident's hospice binder at the nurse's station, the certification and plan of care were present, but there was no record of hospice nursing or health aide visits. The electronic health record also contained no visit notes since admission. Staff stated that hospice staff wrote notes in the hospice binder and that the notes would then be uploaded into the EHR, but when asked for the documentation, staff had to contact the hospice. The hospice visit notes later received showed 20 nursing visits between 06/11/2026 and 07/09/2026 that had not been recorded in the EHR, and no health aide visit records were provided.
Failure to Provide Written Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide the notice of transfer or discharge and the bed-hold policy in writing for 2 of 3 residents reviewed for discharge notice, including Resident 1 and Resident 2. The report states this failure placed residents and/or representatives at risk for lack of advocacy for discharge rights, housing options, and frustration. The facility policy required that when a resident was transferred to a hospital, a written notice be provided to the resident, family member, or responsible party regarding bed-hold rights and the center's bed-hold policy, with a copy of the completed WA-Nursing Home Transfer or Discharge Notice provided at the time of transfer and follow-up contact within 24 hours. Resident 1 was discharged from the facility, and the notice was presented to the guardian on the discharge date, but a grievance later showed the guardian was concerned that the facility had not sent the WA State Transfer and Bed Hold evaluation to be confirmed and signed upon discharge. The grievance also stated staff acknowledged they had provided verbal notification, but the guardian was not present at discharge and the notice was completed by phone. Resident 2 was severely cognitively impaired, had unclear speech, was sometimes understood, and had a legal guardian. Although the transfer/discharge notice was completed and given to the resident when Resident 2 was transferred to the hospital, the record contained no documentation that the guardian was contacted or provided a written copy, and staff later acknowledged there was no evidence they followed up with the guardian to provide written notice.
Unsanitary shared bathroom conditions and improper handling of urine containers
Penalty
Summary
The facility failed to ensure a functional and sanitary environment for residents in shared bathroom areas used by Resident 3 and Resident 4. Resident 3’s record showed admission to the facility and later discharge, and Resident 3’s family member stated during interview that the facility was filthy. Resident 4 was admitted to the facility and, according to the MAR, received morning doses of docusate and MiraLAX. During interview and observation, Resident 4 stated their bathroom was a mess and said staff had been supposed to bring a bedside commode but had not done so, so they used the toilet with a plastic liner in it. The shared bathroom between the rooms was observed with a plastic lining/bag over the toilet containing urine and stool, an unlabeled urinal with 600 mL of dark yellow urine on the floor, and another unlabeled urinal with 650 mL of dark yellow urine on top of the toilet. Staff interviews showed conflicting and incomplete handling of the bathroom condition. Resident 4 said the plastic liner had been placed on the toilet the previous night and that staff had given stool softeners. Staff D stated urinals used for catheter drainage should be dated and labeled and said urinals with urine should not be left in a shared bathroom. Staff E said they had fixed a clogged toilet at 2:00 AM and did not place the plastic bag over it. Staff F said they had emptied a catheter bag into the toilet, saw a bag on the toilet with urine and feces in it, and left one urinal with urine in the bathroom; they also said they were aware Resident 4 needed a bedside commode but had not been able to find a clean one. The DON stated resident bathrooms were expected to be clean and in working order and acknowledged that leaving urinals with urine in a shared bathroom should not happen.
Failure to Prevent Repeated Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident when it did not prevent repeated physical aggression despite prior incidents and known behavioral risks. Resident 1, who had Alzheimer's disease and was assessed as severely cognitively impaired, had a care plan noting behavior issues related to confusion, pacing, and wandering, including entering other residents' rooms. Staff B, a CNA, reported that Resident 1 frequently ambulated in the hallway and entered other residents' rooms, while Resident 2, who was independent with ambulation and often stayed in their room, would quickly approach Resident 1 whenever they encountered them. Staff B stated they frequently had to physically block Resident 2 from getting close to Resident 1, including standing in doorways to prevent Resident 2 from entering areas where Resident 1 was present. Resident 2's care plan documented a history or potential for physical behaviors, including slamming doors and throwing an overbed table, related to anger and dementia with poor impulse control, with a goal that Resident 2 would not harm self or others. Medical provider notes for Resident 2 and Resident 1 dated 02/26/2026 showed that Resident 2 had previously walked up to another resident and pushed them down, unprovoked, and that Resident 1 had been pushed by another resident, resulting in a fall and head impact. On 04/17/2026, Staff B witnessed Resident 1 wandering into Resident 2's room, after which Resident 2 immediately entered the room and shoved Resident 1; Staff B caught and lowered Resident 1 to the floor. The facility incident report characterized Resident 2's actions as guiding Resident 1 out by placing hands on their shoulders, but Staff B later clarified that Resident 2 was not guiding Resident 1 out the door and instead pushed Resident 1 down to the floor. The Administrator acknowledged that Resident 2 deliberately shoved Resident 1 when finding them in their room and that this was the second time Resident 2 had shoved Resident 1.
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
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Shelton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shelton Health And Rehabilitation | 0.3 mi | ★★★★★ | 21 | 0 |
| Puget Sound Care | 15 mi | ★★★★★ | 13 | 0 |
| Regency Olympia Rehabilitation And Nursing Center | 17.6 mi | ★★★★★ | 12 | 0 |
| Olympia Transitional Care And Rehabilitation | 17.6 mi | ★★★★★ | 20 | 0 |
| Woodard Creek Health & Rehabilitation | 17.7 mi | ★★★★★ | 39 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.