Fircrest Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 15230-15th Northeast, Seattle, Washington 98155
- CMS Provider Number
- 50A260
- Inspections on file
- 23
- Latest survey
- November 7, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Fircrest Nursing Facility during CMS and state inspections, most recent first.
A resident with profound intellectual disabilities, severe cognitive impairment, self-injurious behavior, and pica was left unsupervised when the assigned CNA, responsible for 1:1 protective supervision, was found asleep while on duty. The lapse was discovered after the resident missed a meal, and staff confirmed that the CNA failed to follow the care plan and facility policy requiring constant, alert supervision.
A resident's baseline care plan was found to contain another individual's name and included care instructions for colostomy care that did not apply to the resident. Both the RN who created the care plan and the DON confirmed these inaccuracies during record review and interviews, acknowledging that the care plan did not accurately reflect the resident's clinical status.
A resident was observed with bruising and discoloration on their left foot, later confirmed as a fracture of the fifth metatarsal. Despite facility policy requiring immediate reporting of injuries of unknown origin, staff delayed notifying the State Agency until several days after the injury was first identified and confirmed, resulting in a failure to ensure timely reporting.
A resident with a known fall risk and behavioral concerns was left briefly unattended in a shower room by a CNA, contrary to their care plan requiring constant supervision. The resident, seated in a wheelchair on a sloped floor, fell when the staff member turned away to place lotion on the counter. Staff interviews confirmed the care plan was not followed and that the environmental hazard contributed to the incident.
The facility failed to inform the representatives of two residents with profound intellectual disabilities about their positive RSV test results and treatments. Despite the facility's policy, there was no documentation to show that the representatives were notified, leading to a lack of informed decision-making regarding the residents' medical conditions.
The facility failed to post nurse staffing information daily in prominent locations accessible to residents and visitors across five units. Observations revealed that the information was placed in file holders or on clipboards, making it difficult for residents and visitors to access. Staff responsible for completing the forms were unaware of the requirement to post the information prominently, and some shifts' information was left blank.
The facility failed to accurately assess six residents using the MDS tool, leading to potential risks for unmet care needs. A resident's MDS was completed while they were absent, another's MDS incorrectly coded aspirin as an anticoagulant, and a third resident's tracheostomy care was omitted. Additionally, two residents had MDS sections completed prematurely, and another's discharge was inaccurately recorded. These errors reflect a failure to follow RAI Manual guidelines.
The facility failed to develop and implement comprehensive care plans for several residents, including those with pressure ulcers, on antidepressant and antibiotic medications, and exhibiting care refusal behaviors. This oversight led to unmet care needs and potential risks to residents' quality of life.
The facility failed to dispose of expired medications and properly account for controlled substances. An LPN found an expired antacid in a medication cart, and a discrepancy was noted in the controlled substance inventory for lacosamide tablets, which were not recorded as administered to a resident. Staff acknowledged the need for timely disposal and accurate recording.
The facility failed to follow professional standards of food safety, with expired and unlabeled food items found in storage, and staff not adhering to hand hygiene protocols. Observations showed improper handling of kitchen equipment, with a meal tray placed on the floor and returned to clean storage without washing. These actions were against the facility's policies, posing risks of foodborne illnesses and cross-contamination.
The facility failed to ensure timely fit testing and correct usage of N95 masks for two staff members, and did not adhere to proper hand hygiene and glove use protocols among several staff. Additionally, medical equipment was not disinfected between uses, and sharp containers were improperly stored with medication supplies, increasing the risk of contamination.
A resident with moderately impaired cognition was assisted with their meal by staff standing over them, contrary to the care plan directive to sit at eye level. The staff acknowledged the training to assist while seated but cited broken highchairs as a reason for standing. The care plan was not updated to reflect the situation, and the importance of following the care plan was emphasized by nursing staff.
The facility failed to obtain informed consent for the use of physical restraints for two residents. One resident with impaired cognition used a wheelchair seatbelt without updated consent, while another with cerebral palsy used a tilt-in-space wheelchair with a seatbelt and shoulder harness without documented consent. Staff interviews revealed a lack of clarity and adherence to the facility's informed consent policy.
A facility failed to complete an annual MDS assessment for a resident within the required timeframe, as per the RAI 3.0 User's Manual. The assessment, due 14 days after the ARD, was completed six days late, placing the resident at risk for delayed care. Staff acknowledged the delay, and the facility's policy assigns responsibility for timely completion to the Health Care Coordinator.
A resident experienced significant weight loss and developed pressure ulcers, leading to a decline in condition and placement on comfort care. Despite these changes, the facility failed to complete a Significant Change in Status Assessment (SCSA) MDS, as required by the RAI manual. Interviews with staff revealed uncertainty about the necessity of the assessment, highlighting a deficiency in care planning and assessment processes.
The facility failed to consistently provide ROM therapy for two residents, risking a decline in their ROM and unmet care needs. One resident did not consistently receive a right-hand soft splint as prescribed, while another did not receive bilateral upper extremity passive ROM therapy as scheduled. Staff shortages contributed to these lapses in care.
The facility failed to properly store medical supplies used for medication administration in two medication rooms, leading to potential exposure to cleaning chemicals. In the Cherry and Hickory Buildings, supplies like tongue depressors and pill cups were stored under sinks with Lysol and Clorox products. Staff acknowledged the improper storage and the risk of exposing residents to toxic chemicals.
A facility failed to ensure proper G-tube management for a resident, as an LPN did not check the G-tube placement by aspiration before administering water flushes and medications. The resident, diagnosed with gastrostomy status, required this procedure to ensure safe medication administration. Despite facility policy and expectations from RNs, the LPN proceeded without verifying tube placement, leading to a deficiency.
The facility failed to properly label and store oxygen tubing for two residents, leading to potential risks for unmet care needs. A resident's nasal cannula tubing was found on the floor, while another resident's tubing was undated, contrary to facility policy. Staff acknowledged these oversights, indicating a lapse in adherence to oxygen administration guidelines.
A facility failed to maintain accurate clinical records for a resident, leading to a discrepancy between the POLST form indicating DNAR status and the EHR showing full code. Staff interviews revealed inconsistencies in documentation and communication regarding the resident's code status, which should have matched across records.
A resident with Diabetes Mellitus was not offered the pneumococcal vaccine upon admission, despite being eligible and having received the PPSV23 vaccine in the past. A registered nurse confirmed that the facility follows CDC guidelines but could not find documentation that the resident was offered the PCV15 or PCV20 vaccine, indicating a lapse in immunization protocol adherence.
A resident accused staff of inappropriate touching, but the incident was not reported to the State Agency until two days later, contrary to the facility's policy requiring immediate reporting. The delay in reporting was identified as a deficiency in the facility's handling of abuse allegations.
Failure to Provide Required 1:1 Supervision for High-Risk Resident
Penalty
Summary
A deficiency occurred when a staff member assigned to provide 1:1 protective supervision for a resident with profound intellectual disabilities, severe cognitive impairment, self-injurious behavior, and pica was found asleep while on duty. The resident required total care with activities of daily living and had a care plan specifying the need for constant supervision in both the morning and evening. The facility's policy emphasized maintaining resident safety and well-being, and the care plan clearly outlined the need for vigilant monitoring due to the resident's high-risk behaviors. The incident was discovered when the resident was absent from the dining room during lunch, prompting a staff member to check on them. Upon entering the resident's room, the staff member found both the resident and the assigned CNA asleep, with the CNA failing to provide the required supervision. Interviews with facility staff, including the DON and a registered nurse, confirmed that staff assigned to 1:1 supervision are expected to remain alert and attentive at all times, and that sleeping while on duty constitutes a failure to follow the care plan and facility policy.
Inaccurate Baseline Care Plan Documentation
Penalty
Summary
The facility failed to ensure that the baseline care plan for one resident was accurate and reflected the resident's actual care needs. Upon review, the baseline care plan for a resident admitted for respite care contained another individual's name in the recreation (activity) care plan section. Additionally, the self-care deficit care plan included information about colostomy care, which was not applicable to the resident in question, as confirmed by the physician's progress note and staff interviews. During joint record reviews and interviews, both the registered nurse responsible for formulating the baseline care plan and the Director of Nursing acknowledged that the care plan contained inaccurate information, including references to another person and care needs not relevant to the resident. Both staff members confirmed that the care plan is part of the resident's medical record and must accurately reflect the resident's clinical status, which was not the case in this instance.
Delayed Reporting of Injury of Unknown Source
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown source for one resident. Clinical notes indicated that the resident was first observed with discoloration and bruising on their left toe, which later was found to be a fracture of the fifth metatarsal bone in the left foot. The cause of the injury was unknown, and the facility's own investigation confirmed there was no probable cause for the injury. Despite policies requiring immediate reporting of such incidents, the injury was not reported to the State Agency until several days after initial observation and confirmation of the fracture. Staff interviews revealed that both nursing and administrative staff were aware of the requirement to report injuries of unknown origin immediately or within 24 hours. However, the report to the State Agency was delayed until staff connected the bruising and discoloration to the confirmed fracture. The delay in reporting was inconsistent with both facility policy and regulatory requirements, as staff did not act promptly upon first awareness of the injury.
Failure to Follow Fall Prevention Care Plan and Provide Adequate Supervision
Penalty
Summary
The facility failed to follow the established plan of care and provide adequate supervision for a resident identified as being at risk for falls and accident hazards. According to the resident's care plan, staff were required to always remain in front of the resident during showers and maintain line-of-sight supervision at all times, without leaving the resident unattended. On the day of the incident, a CNA briefly turned away from the resident in the shower room to place lotion on the counter, leaving the resident in their wheelchair on a sloped section of the floor. During this short interval, the resident, who was known to exhibit rocking and agitated behaviors, tipped over and fell to the floor. The investigation revealed that the wheelchair's placement on the curved, sloped floor contributed to the fall, and staff did not adhere to the care plan's supervision requirements. Further review showed that after the fall, the resident was found back in their wheelchair and appeared stable upon initial RN assessment. Interviews with staff confirmed that the expectation was for staff to remain with the resident at all times, especially for those on one-on-one supervision due to behavioral risks and mobility. The facility's fall protocol also required that a nurse assess any resident who had fallen before they were moved, which was not followed in this case. Staff and administrative interviews acknowledged that the care plan was not followed and that the environmental hazard of the sloped shower room floor was a contributing factor to the incident.
Failure to Inform Representatives of Positive RSV Tests and Treatments
Penalty
Summary
The facility failed to inform the representatives of two residents about their positive Respiratory Syncytial Virus (RSV) test results and the treatments provided. Resident 1, who has a profound intellectual disability, exhibited symptoms such as a dry cough, wheezing, and a mild runny nose. A nasal swab confirmed RSV, and the resident was treated with Guaifenesin and DuoNeb. However, Resident 1's representative was not informed about the change in condition, the positive test result, or the treatment administered. Staff C claimed to have notified the representative but could not provide documentation to support this claim. Similarly, Resident 2, also diagnosed with a profound intellectual disability, showed symptoms of a dry cough, tiredness, and lethargy. A nasal swab confirmed RSV, and the resident was treated with Guaifenesin. Resident 2's representative only became aware of the condition and treatment upon visiting the facility. Staff C again claimed to have notified the representative but lacked documentation to verify this. Staff D and Staff B confirmed that no notifications were made to the representatives of either resident, despite the facility's policy requiring such communication.
Failure to Post Nurse Staffing Information in Accessible Locations
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily at the beginning of each shift in prominent locations accessible to residents and visitors across five units: [NAME], Hickory, Elm, Cherry, and Birch. Observations on multiple dates revealed that the nurse staffing information was not displayed in a manner that was easily accessible or visible to residents and visitors. Instead, the information was placed on clipboards or in file folders within wall file holders, mixed with other files, making it difficult for residents and visitors to access. On the [NAME] Unit, observations showed that the nurse staffing information was not posted prominently and was placed on a clipboard within a wall file holder. Additionally, the staffing information for the evening shift on 10/30/2024 was not completed, leaving the form blank. Staff W, responsible for completing the form, confirmed that the information used to be posted on the wall but was now placed in the file holder. Similar issues were observed in the Hickory Unit, where the staffing information was consistently placed in a wall file holder, as confirmed by Staff S, the AC Manager. In the Elm Unit, the nurse staffing information was placed in a blue file folder within a wall file holder, and the information for the night shift on 11/04/2024 was not completed. Staff U, responsible for the form, was unaware that the posting was intended for residents and visitors. The Cherry Unit had similar issues, with the staffing information placed in a green file folder labeled as Census. Staff T confirmed this practice. In the Birch Unit, the staffing information was placed on a clipboard labeled as Census, and Staff V believed the information was for facility staff, not residents or visitors. Staff A, the Nursing Facility Program Area Team Director, stated that the expectation was for the information to be posted daily in a prominent area accessible to residents and visitors.
Inaccurate MDS Assessments in LTC Facility
Penalty
Summary
The facility failed to accurately assess six residents using the Minimum Data Set (MDS) assessment tool, leading to potential risks for unidentified and unmet care needs. Resident 348's annual MDS was completed inaccurately as the resident was not present in the facility during the observation period. Despite this, the MDS was submitted, which was acknowledged as incorrect by the staff involved. Similarly, Resident 82's MDS inaccurately coded aspirin as an anticoagulant, contrary to the guidelines in the RAI Manual, which specifies that aspirin should not be coded as such. Resident 45's quarterly MDS failed to include tracheostomy care and suctioning, despite records indicating that these procedures were performed. This oversight was identified during a joint record review, where staff confirmed that the care should have been coded. Additionally, Resident 35's annual MDS had sections completed before the start of the look-back period, which is against the RAI Manual's instructions. Staff acknowledged that these sections should not have been completed prematurely. Resident 97's discharge MDS was inaccurately marked as discharged to an acute hospital, while records showed the resident was discharged to their home. Lastly, Resident 12's annual MDS was completed before the observation period, with multiple sections signed off prematurely. Staff confirmed that the MDS should have been completed after the observation period, as per the RAI Manual. These inaccuracies in MDS assessments highlight a failure to adhere to the required guidelines, potentially impacting the quality of care provided to the residents.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for five residents, leading to unmet care needs and potential risks to their quality of life. Resident 44 had unhealed pressure ulcers, but no care plan was initiated for pressure ulcer care. Despite being aware of the condition, staff did not include it in the comprehensive care plan, relying instead on an alert care plan, which was deemed insufficient by other staff members. Resident 88 was prescribed antidepressant medication, yet there was no care plan for its use. Staff initially believed a separate care plan was unnecessary, but other staff members, including a psychologist, indicated that a care plan should have been in place. Similarly, Resident 45 was on multiple antibiotics, but there was no comprehensive care plan addressing the long-term use of these medications, which staff acknowledged should have been documented. Resident 24 exhibited behaviors and refusal of care, such as resisting shaving, but there was no care plan for these behaviors. Staff noted the difficulty in providing care and the lack of documentation for refusals. Lastly, Resident 77 was on antipsychotic medication and required regular assessments for side effects, but the assessments were not conducted within the required timeframe, indicating a failure to follow the care plan. Staff recognized the oversight and the need for timely assessments.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure the timely disposal of expired medications and proper handling and accounting of controlled substances. During an observation and interview, a Licensed Practical Nurse (LPN) identified an expired bottle of over-the-counter liquid antacid with a manufacturer's expiration date of September 2024 in a medication cart. The LPN acknowledged the medication was expired and needed to be removed from the cart. A Registered Nurse (RN) later confirmed the expectation that expired medications should be disposed of promptly. Additionally, a discrepancy was found in the controlled substance inventory for lacosamide 200 mg tablets, a medication used to control seizures. The total count of tablets in a blister pack did not match the recorded count in the controlled substance inventory ledger for a resident. The LPNs involved stated that the 8:00 AM dose for the resident was not recorded in the ledger as expected. Another RN confirmed that the inventory ledger should accurately reflect the medications administered to residents and that nurses are expected to record medications immediately after they are given.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards of food safety, as evidenced by improper handling and storage of food items in two refrigerators and a dry storage room. Observations revealed expired food items, such as a chef salad and shredded cabbage, that were not discarded as per the facility's policy. Additionally, there were unlabeled food items, including roast beef and raisin bread, which should have been labeled with preparation and discard dates. Staff interviews confirmed that these practices were against the facility's policy, which mandates the removal of expired food and proper labeling. The report also highlighted deficiencies in hand hygiene practices among staff members. Staff NN was observed using the same gloves for multiple tasks without performing hand hygiene in between, despite being aware of the requirement to wash hands between glove use. Similarly, Staff OO failed to perform hand hygiene between tasks and glove changes while handling food items. These actions were contrary to the facility's policy, which requires hand hygiene between tasks and glove use to prevent cross-contamination. Furthermore, the handling of kitchen equipment was found to be inadequate. Staff PP placed a meal tray on the floor and then returned it to a stack of clean trays without washing it, which was against the facility's procedures. Staff interviews confirmed that any equipment that touched the floor should be considered dirty and placed in the dish room for cleaning. The facility's failure to follow its own policies and procedures in food handling, hand hygiene, and equipment sanitation placed residents at risk for foodborne illnesses and cross-contamination.
Infection Control Deficiencies in Mask Fit Testing, Hand Hygiene, and Equipment Disinfection
Penalty
Summary
The facility failed to ensure timely fit testing and correct usage of N95 masks for two staff members, Staff EE and Staff FF. Staff EE was observed wearing an N95 mask with a surgical mask underneath, which compromised the mask's seal, while working in a quarantine unit. Staff EE had previously failed a fit test for the N95 model they were using. Staff FF had not undergone fit testing in 2024, despite being required to do so annually. The facility's Safety Officer confirmed the oversight in fit testing and acknowledged that Staff EE should not have been using the 3M 1870+ mask. The facility also failed to adhere to proper hand hygiene and glove use protocols among several staff members. Staff Z, L, JJ, Q, and R were observed not performing hand hygiene between glove changes or after providing resident care. For instance, Staff Z did not perform hand hygiene between glove changes during a dressing change for a resident's pressure ulcer. Similarly, Staff L and Staff JJ failed to perform hand hygiene after removing gloves and before donning new ones, despite handling potentially contaminated materials. Additionally, the facility did not ensure the disinfection of medical equipment between uses. Staff II used an oximeter on a resident without disinfecting it afterward, and Staff U and Y did not disinfect a Hoyer lift between resident transfers. Furthermore, the storage of sharp containers in medication rooms was not managed according to infection control practices, with biohazardous materials stored alongside medication administration supplies, increasing the risk of contamination.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain and promote the dignity of a resident during meal assistance. Resident 29, who had moderately impaired cognition, was observed being assisted with their meal by Staff O while standing over them, contrary to the care plan directive that staff should sit at the resident's eye level. Staff O acknowledged that they were trained to assist residents while seated but did not follow this protocol due to the resident dropping food. The care plan for Resident 29, printed on 11/04/2024, clearly instructed staff to sit down at the resident's eye level during meal assistance. Staff P, the Attendant Counselor Manager, initially stated that the care plan specified not to sit while assisting Resident 29 due to the high wheelchair, but later acknowledged that the care plan should be updated. Staff P also mentioned that highchairs were broken and unavailable, leading to staff assisting while standing. Staff B, a Registered Nurse, emphasized the importance of following the care plan and communicating any shortage of chairs. Staff A, the Nursing Facility Program Area Team Director, reiterated the expectation for staff to be seated at eye level with the resident during meal assistance.
Failure to Obtain Informed Consent for Restraints
Penalty
Summary
The facility failed to inform residents and/or their representatives of the risks and benefits before applying physical restraints, specifically for two residents. Resident 41, who had severely impaired cognition, was observed using a wheelchair seatbelt without updated informed consent. The consent on file was signed by the resident's representative over a year ago, and staff acknowledged that it should have been updated annually. This oversight meant that the resident's representative was not fully informed of the continued use of the restraint. Resident 12, diagnosed with athetoid cerebral palsy, used a tilt-in-space wheelchair with a seatbelt and shoulder harness for support. However, there was no documentation indicating that the resident or their representative had been informed or had consented to the use of these devices. Staff interviews revealed a lack of clarity regarding the need for consent for the tilt-in-space wheelchair, although it was acknowledged that consent was necessary for the seatbelt and shoulder harness. The facility's policy on informed consent requires that consent be obtained for treatments and services that involve restraints or support devices that limit voluntary or involuntary movement. Despite this policy, the facility did not ensure that informed consent was obtained and documented for the use of these devices, placing residents at risk of not being fully informed about their care options.
Failure to Timely Complete Annual MDS Assessment
Penalty
Summary
The facility failed to complete the annual Minimum Data Set (MDS) assessment for a resident within the required timeframe, as outlined in the Resident Assessment Instrument (RAI) 3.0 User's Manual. The manual specifies that the annual assessment must be completed no later than 14 days from the Assessment Reference Date (ARD). For Resident 24, the ARD was set on January 25, 2024, but the MDS was not completed until February 14, 2024, which was six days late. This delay in completing the assessment placed the resident at risk for delayed and/or unmet care needs, potentially affecting their quality of life. During interviews, staff members acknowledged the delay. Staff E, a Registered Nurse, confirmed that the MDS was completed late and should have been finalized within the 14-day period following the ARD. Staff B, another Registered Nurse, emphasized the importance of timely and accurate MDS completion. The facility's policy assigns the Health Care Coordinator the responsibility for ensuring the MDS is completed by the due date, but this was not adhered to in this instance.
Failure to Complete SCSA MDS for Resident with Multiple Declines
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who experienced multiple areas of decline. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, an SCSA is required when a resident undergoes a significant change in condition, impacting more than one area of their health status. The resident in question, identified as Resident 35, had a pressure ulcer/injury on their left shoulder and right scapula, and experienced unintentional significant weight loss of 6.8 pounds, which constituted a 6.1 percent loss of body weight in the last month. Additionally, the resident was placed on comfort-focused treatment due to a decline in condition, yet no SCSA MDS was completed to address these changes. Interviews with facility staff revealed a lack of clarity and understanding regarding the necessity of completing an SCSA MDS for Resident 35. Staff E, a Registered Nurse, acknowledged the resident's significant weight loss and placement on comfort care but was unsure if a significant change assessment was needed. Another staff member, RN 4, confirmed that an SCSA MDS should have been completed due to the resident's multiple areas of decline. The absence of this assessment placed the resident at risk for delayed care planning, unmet care needs, and a diminished quality of life.
Inconsistent ROM Therapy for Two Residents
Penalty
Summary
The facility failed to consistently provide services to maintain or improve the range of motion (ROM) for two residents, leading to a risk of decline in ROM and unmet care needs. Resident 12, who had limited ROM in both upper and lower extremities, was supposed to have a right-hand soft splint applied five times a week as part of their therapy program. However, documentation showed that the splint was not applied consistently throughout October 2024, with several days missed each week. Observations confirmed that Resident 12 was not wearing the splint on multiple occasions, and staff interviews revealed that the therapy team was short-staffed, leading to lapses in care. Similarly, Resident 81, who also had limited ROM, was on a therapy program for bilateral upper extremity passive ROM three times a week. Documentation indicated that the program was not provided consistently, with several days missed in the last two weeks of October 2024. Observations showed Resident 81 with arms crossed and hands in a fist, suggesting a lack of therapy intervention. Staff interviews confirmed that the therapy aide program was not carried out as expected, and there was a lack of coverage when therapy aides or therapists were unavailable.
Improper Storage of Medical Supplies with Chemicals
Penalty
Summary
The facility failed to ensure that medical supplies used for medication administration were stored properly in two of the three medication rooms reviewed, specifically in the Cherry and Hickory Buildings. During observations and interviews, it was found that in the Cherry Building medication room, an open box of tongue depressors and plastic pill cups were stored under the hand washing sink alongside a spray canister of Lysol and a portable heater. Staff L, an RN, acknowledged that these supplies should not have been stored with the Lysol spray and should have been kept in the nurse supply room instead. Similarly, in the Hickory Building medication room, an open box of plastic spoons and pill cups were found stored together with a Clorox spray bottle under the hand washing sink. Staff D, an LPN, confirmed that these supplies should be stored separately from chemicals in the medical supply room. Interviews with other staff members, including RNs, revealed a consensus that medication administration supplies should not be stored with cleaning chemicals due to the potential risk of exposing residents to toxic chemicals. Staff B, an RN, stated that these supplies should be stored in wall cabinets above the hand washing sink, not with chemical cleaning supplies.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure appropriate treatment and services related to gastrostomy tube (G-tube) management for one resident. Specifically, the deficiency involved the failure to check for G-tube placement by visual inspection of aspirated stomach content prior to medication administration. This oversight was observed during an interaction where a Licensed Practical Nurse (LPN) dissolved crushed medications into a cup of water and proceeded to flush the resident's G-tube with water without first checking the tube's placement by aspiration. This action was contrary to the facility's policy, which mandates checking the enteral tube for correct placement by aspiration before administering water flushes and medications. The resident involved had a diagnosis of gastrostomy status, requiring nutrition and medication through a G-tube due to an inability to eat or swallow normally. The facility's policy, revised in March 2024, clearly outlines the procedure for checking G-tube placement, which was not followed in this instance. Interviews with registered nurses confirmed the expectation that nurses should aspirate to check for G-tube placement before administering water flushes and medications, highlighting a lapse in adherence to established protocols by the staff involved.
Failure to Properly Label and Store Oxygen Tubing
Penalty
Summary
The facility failed to ensure proper labeling and storage of oxygen tubing for two residents, leading to potential risks for unmet care needs. For Resident 4, the nasal cannula tubing was observed on the floor beside the oxygen concentrator, with the nasal prongs directly touching the floor. Staff members acknowledged that the tubing should not have been on the floor and should have been stored in a resealable plastic bag attached to the concentrator. It was also noted that once the tubing touched the floor, it should not be used again and should be replaced immediately. For Resident 80, the nasal cannula tubing was found to be undated during multiple observations, despite the facility's policy requiring weekly changes and dating of the tubing. Staff interviews confirmed that the tubing should have been dated, as per the facility's guidelines. The lack of proper labeling and storage of oxygen supplies for both residents indicates a failure to adhere to the facility's oxygen administration and safety guidelines, potentially compromising the residents' respiratory care.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurate for a resident, identified as Resident 18, which placed the resident at risk for unmet care needs and medical complications. The deficiency was identified through observation, interview, and record review. The facility's policy on supporting end-of-life decisions required that all direct care staff be shown and trained to implement the Physician Orders for Life-Sustaining Treatment (POLST). However, discrepancies were found between Resident 18's POLST form, which indicated a Do Not Attempt Resuscitation (DNAR) status, and the Electronic Health Record (EHR), which showed the resident as full code. Interviews with various staff members, including an Attendant Counselor, a Licensed Practical Nurse (LPN), and a Registered Nurse (RN), revealed inconsistencies in the documentation of the resident's code status. Staff members were unable to find consistent information regarding the resident's code status in the 24-hour communication log, paper medication administration record, or the EHR. The RN confirmed that the POLST form and the EHR should match, but they did not. This inconsistency in documentation and communication among staff members led to the deficiency identified by the surveyors.
Failure to Offer Pneumococcal Vaccine to Resident with Diabetes
Penalty
Summary
The facility failed to ensure that the pneumococcal vaccine was offered to a resident, identified as Resident 80, who was reviewed for immunizations and infection control. Resident 80, who was admitted to the facility with a diagnosis of Diabetes Mellitus, had previously received the PPSV23 vaccine in 2001 and 2017. However, there was no documentation indicating that the resident was offered the newer PCV15 or PCV20 vaccines upon admission in July 2023, despite being eligible due to her age and medical condition. During an interview and joint record review, a registered nurse confirmed that the facility follows CDC recommendations for offering immunizations to residents. The nurse acknowledged that Resident 80, who was in her 40s and had Diabetes Mellitus, should have been offered the PCV15 or PCV20 vaccine at the time of admission. The absence of documentation showing that these vaccines were offered highlights a deficiency in the facility's adherence to immunization protocols, potentially placing residents at risk of acquiring or transmitting pneumococcal disease.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to ensure the timely reporting of an abuse allegation to the State Agency for a resident, which placed the resident at risk for potential unidentified and ongoing abuse. The facility's policy required immediate reporting of suspected abuse, with no delay between awareness of the incident and making the report. However, an incident involving a resident who accused staff of inappropriate touching occurred on 08/25/2024, but was not reported to the Department's 24-hour Hotline until 08/27/2024. This delay in reporting was contrary to the facility's policy and the expectations set by the Nursing Facility Director. The incident involved a resident who was admitted to the facility and later accused staff of inappropriate touching during care. The allegation was initially communicated via email by a Certified Nursing Assistant to facility staff, rather than being reported immediately to the State Agency. Interviews with facility staff, including Registered Nurses and the Nursing Facility Director, confirmed that the incident should have been reported immediately, as per the facility's policy and state law. The delay in reporting was identified as a deficiency in the facility's handling of abuse allegations.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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