Frontier Rehabilitation And Extended Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Longview, Washington.
- Location
- 1500 3rd Avenue, Longview, Washington 98632
- CMS Provider Number
- 505276
- Inspections on file
- 22
- Latest survey
- April 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Frontier Rehabilitation And Extended Care during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of falls, who required two-person assistance for transfers, was left unattended during a medical appointment. The resident went to the bathroom alone, fell while attempting to transfer, and sustained a pelvic fracture. The facility failed to ensure care-planned supervision was provided, and the transport form did not indicate the need for caregiver assistance, leading to the incident.
The facility failed to implement bowel management interventions for two residents, did not follow physician orders for a resident with a toe fracture, and neglected care plan interventions for another resident with renal insufficiency. These oversights led to prolonged discomfort and unmet medical needs.
A facility failed to provide altered consistency liquids as per a resident's care plan, risking aspiration and dehydration. The resident, with a history of stroke, required nectar thick liquids, but thin liquids were found in their room. Staff interviews revealed communication lapses regarding dietary orders, with some staff unaware of the resident's needs. The DON confirmed that liquids inconsistent with medical orders should not be at the bedside.
A resident with paraplegia reported being verbally abused by staff and expressed multiple concerns about care, which were not adequately addressed by social services. The social services staff failed to document or implement care plan interventions, and the Social Services Director noted the lack of advocacy and interdisciplinary approach, leading to unmet psychosocial care needs.
The facility failed to maintain complete and accurate medical records for two residents, leading to potential risks for unmet care needs. One resident's PASARR Level I was outdated and lacked a Level II evaluation, while another resident required a Level II evaluation for SMI, which was not found in their EHR. Staff was unable to locate the necessary documentation, indicating a deficiency in record-keeping.
A licensed nurse failed to properly don and doff PPE while providing care to a resident under contact precautions. The nurse, identified as Staff O, was observed in the resident's room without the required PPE, despite a sign indicating contact precautions. The nurse acknowledged the expectation to wear PPE, and the facility administrator confirmed this requirement.
The facility failed to maintain mechanical lifts in safe operating condition, leading to battery failures during resident transfers and tangled wheels. A resident reported being left suspended when the lift battery died, and staff struggled with maneuvering due to hair in the wheels. The Maintenance Supervisor cited user error in charging batteries, and there was no maintenance log for battery checks.
A resident with paraplegia was denied the use of a personal refrigerator, despite facility policy allowing it, leading to grievances about missing personal food items. Staff were unaware of the policy, resulting in a failure to honor the resident's rights.
A resident's EHR was left unsecured on a medication cart computer, exposing personal health information. An LPN admitted to being distracted and failing to lock the screen, while the facility's Administrator was unable to secure the computer when questioned. The protocol required the computer to be locked or closed to protect residents' EHRs.
The facility failed to ensure comfortable noise levels, affecting two residents' quality of life. A resident reported difficulty relaxing due to a slamming door outside her room, confirmed by observations of the door slamming 22 times in 15 minutes. Another resident, new to the facility, also noted excessive noise. The Maintenance Director acknowledged the issue, citing the need to keep doors closed due to a flu outbreak, while the Administrator deferred maintenance concerns to the Maintenance Director.
A resident with paraplegia and chronic pain reported verbal abuse by a staff member, including profanity and condescending comments. Despite the resident's request for the staff member not to provide care, the staff member continued to be assigned to the resident, causing psychological harm. The facility failed to document the incident or properly investigate the grievance, relying instead on the staff member's account, leading to ongoing distress for the resident.
A resident reported verbal abuse by an LPN, but the facility failed to investigate the allegation. Despite the resident's immediate report to social services and the resident care manager, no formal investigation was conducted, and the incident was not documented. The staff did not follow the facility's abuse prevention policy, leading to a deficiency that placed residents at risk.
A facility failed to implement Level II PASARR recommendations for a resident with severe cognitive impairment, who required mental health interventions for new behaviors. The recommendations were not fully integrated into the care plan, leaving the resident without necessary support for agitation and aggression. Observations revealed the resident lacked activities and functional headphones, while staff could not locate the behavior intervention recommendations in the electronic health record.
The facility failed to develop comprehensive care plans for two residents, one with PTSD and another with dementia, as required. Both residents were alert and oriented, yet their conditions were not addressed in their care plans. A Resident Care Manager and the Director of Nursing confirmed the absence of these care plans in the electronic health records.
The facility failed to develop a comprehensive care plan for a resident's oxygen use, despite a physician's order and observations of the resident using oxygen. Staff confirmed that the care plan should have included this information but did not.
The facility failed to ensure nursing hours were accurately posted and updated daily for 14 of 42 shifts reviewed. Discrepancies between posted and actual staff schedules were observed, with the Staff Coordinator unaware that updates were required throughout the day. The DON expected accurate and updated postings, but this was not done, risking misinformation for residents and visitors.
Failure to Provide Required Supervision During Out-of-Facility Appointment Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, poor safety awareness, and a history of falls was not provided with the care-planned level of supervision during an out-of-facility medical appointment. The resident, who required two-person maximal assistance for toilet transfers and sitting to standing, was left unattended in the clinic lobby after her appointment while waiting for facility transportation. The facility's transportation driver, whose role was limited to driving, checked the resident in and left her in the lobby without a staff assistant, despite the resident's care plan indicating the need for such supervision. Clinic staff were not informed that the resident required assistance, and after the appointment, the resident was left alone in the waiting area. The resident subsequently went to the bathroom unaccompanied, locked the door, and fell while attempting to transfer herself from a seated position. She was found on the floor by clinic staff after they heard her calling for help. The incident resulted in a pelvic fracture, confirmed by a CT scan, and required transfer to the hospital for evaluation and treatment. Interviews with facility staff revealed that the process for determining which residents required staff assistance for out-of-facility appointments was not consistently followed. The transport form for the appointment was not properly completed to indicate the need for caregiver assistance, and the staff member responsible did not identify themselves on the form, preventing follow-up. Both facility and clinic staff confirmed that the resident was not safe to transfer or sit to stand without assistance, and that she had a history of attempting self-transfers. The lack of adequate supervision and failure to follow the resident's care plan directly led to the accident and injury.
Failure to Implement Bowel Management, Physician Orders, and Care Plan Interventions
Penalty
Summary
The facility failed to implement bowel management interventions for two residents, leading to prolonged periods without bowel movements. Resident 61 did not have a bowel movement for over four and a half days on two separate occasions, yet the facility did not initiate the bowel protocol as required by their policy. Similarly, Resident 295 went seven days without a bowel movement, and although Milk of Magnesia was administered, it was ineffective, and no further interventions were documented. Staff acknowledged that the bowel protocol should have been followed, but it was not implemented as per the physician's orders. In another instance, the facility did not ensure that physician orders were followed for Resident 57, who had a fracture in her left great toe. Despite a physician's order for a hard sole open-toe post-operative shoe, the order was not documented in the resident's electronic health record, and the shoe was never provided. The resident expressed concern about not receiving the shoe and was observed without it, indicating a failure to follow through with the physician's directive. Additionally, the facility did not implement care plan interventions for Resident 86, who was supposed to have her feet elevated to prevent swelling due to renal insufficiency. Observations showed the resident sitting with her feet on the floor, contrary to the care plan. Staff admitted that the intervention was not included in the care directives for nursing assistants, resulting in the resident experiencing discomfort and swelling.
Failure to Provide Altered Consistency Liquids as Per Care Plan
Penalty
Summary
The facility failed to provide altered consistency liquids as per the care plan for a resident, placing them at risk for aspiration, dehydration, and decreased quality of life. Resident 74, who was alert and oriented with a history of stroke, had a diet order for nectar thick liquid consistency. However, during an observation, a water pitcher containing thin liquid was found in the resident's room. The resident confirmed that some staff were unaware of her thickened liquid requirement. The care plan, which was posted in the resident's room, documented the need for mildly thick liquids. Staff interviews revealed inconsistencies in communication and adherence to the resident's dietary orders. Staff E, an LPN, acknowledged the presence of thin water as a mistake and mentioned that CNAs received diet order information during morning reports and from care plans. Staff F, a CNA, stated that thickened liquids were usually provided by the kitchen and given to nurses, and she was aware of the resident's thickened liquid orders from shift reports. Staff G, a Residential Care Manager and LPN, confirmed that thickened liquid orders were documented on care plans and meal tickets, and noted a recent change in the resident's diet order. The Director of Nursing Services emphasized that residents should not have liquids at the bedside that are inconsistent with medical orders.
Failure to Provide Adequate Social Services for Resident
Penalty
Summary
The facility failed to provide adequate medically related social services to Resident 17, who was admitted with a diagnosis of paraplegia and was alert and oriented. The care plan for Resident 17, revised in January 2025, indicated a need for social services to assist in setting realistic goals due to being a younger resident in long-term care. However, Resident 17 reported being verbally abused by a staff member in August 2024 and expressed multiple concerns about staff treatment, training, and personal challenges to Staff C, the social services staff. Despite these reports, Staff C acknowledged not formally addressing the concerns between nursing staff and Resident 17, nor consulting with the Social Services Director to mitigate these issues. Staff C admitted to not following Resident 17 closely enough and failing to document or implement care plan interventions to assist staff in providing care. The Social Services Director, Staff D, stated that she would expect a social worker to advocate for the resident, troubleshoot concerns, and ensure an interdisciplinary approach to address Resident 17's issues. Staff D also emphasized the importance of providing emotional support and identifying coping strategies, which were not adequately addressed in the care plan. This lack of action placed Resident 17 at risk for unmet psychosocial care needs and a diminished quality of life.
Incomplete Medical Records for Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, which placed them at risk for unmet care needs and a diminished quality of life. Resident 43, who was admitted with diagnoses including Depression and PTSD, had an Annual MDS assessment indicating they were alert and oriented. However, their PASARR Level I, dated 11/13/2020, showed indicators for mood disorders but did not indicate service needs. The electronic health records (EHR) for Resident 43 did not contain a corrected PASARR Level I or a Level II PASARR determination or evaluation. Staff H, a Social Services Assistant, acknowledged the need for a new PASARR but was unable to locate a corrected Level I PASARR in the EHR. Similarly, Resident 70, admitted with diagnoses including Major Depressive Disorder and Psychotic Disorder with Delusions, had an Annual MDS documenting alertness and orientation. Their Level I PASARR, dated 10/19/2023, indicated a Level II evaluation was required for serious mental illness (SMI). However, a Level II PASARR evaluation was not found in Resident 70's EHR. Staff H was unable to locate a Level II PASARR in the EHR for Resident 70, further highlighting the facility's failure to maintain accurate and complete medical records.
Failure to Properly Use PPE Under Contact Precautions
Penalty
Summary
The facility failed to ensure proper donning and doffing of personal protective equipment (PPE) by a licensed nurse, identified as Staff O, during care of a resident under contact precautions. On February 7, 2025, at 12:45 PM, Staff O was observed in the room of Resident 46, holding the resident's right arm with gloved hands. A sign outside the room indicated that contact precautions were in place, requiring the use of PPE. Staff O admitted to not wearing the required PPE while providing care to Resident 46, acknowledging the expectation to do so. The facility administrator, Staff A, confirmed the expectation for staff to follow posted precaution signs.
Mechanical Lift Battery and Maintenance Issues
Penalty
Summary
The facility failed to ensure that essential equipment, specifically mechanical lifts, was in safe operating condition. This deficiency was observed when batteries died during the transfer of residents, leaving them suspended in the air. Resident 17 reported that the battery on the mechanical lift had died numerous times during transfers, causing him to be left hanging between the bed and chair while staff left the room to swap out the battery. Additionally, the mechanical lifts were difficult to maneuver due to hair tangled in the wheels, which further compromised the safety and smoothness of the transfer process. Observations revealed that the mechanical lift in the Country Side short hall had hair tangled in its rear wheels, and during a transfer, Resident 17 was left hanging for two minutes when the battery died. Staff members acknowledged that some batteries held charges longer than others and that the wheels were difficult to turn due to hair and lint. The Housekeeping Supervisor admitted there was no schedule for cleaning the wheels, and the Maintenance Supervisor noted that the battery issue was ongoing due to user error in charging. However, there was no maintenance log for battery checks, as they were done randomly.
Failure to Allow Personal Refrigerator for Resident
Penalty
Summary
The facility failed to honor a resident's right to use personal possessions, specifically a personal refrigerator, which did not infringe on the rights of other residents. The facility's policy, updated in August 2020, allowed residents to provide their own UL-approved personal refrigerator if the room could accommodate it. However, Resident 17, who was alert and oriented with a diagnosis of paraplegia, was denied this request by both social services and administration. This denial occurred despite the resident's grievances about missing personal food items from the shared refrigerator. Interviews with facility staff revealed a lack of awareness and adherence to the facility's policy regarding personal refrigerators. Staff G, a Resident Care Manager and RN, incorrectly stated that regulations did not allow personal refrigerators. Staff A, the Administrator, was unsure of the policy and suggested an ice chest instead. Staff C from Social Services was unaware of the policy and acknowledged that if the policy allowed personal refrigerators, there was no reason to deny the request. This oversight placed Resident 17 at risk of a diminished quality of life due to the inability to secure personal food items.
Failure to Secure Resident EHR on Medication Cart
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' medical information when a resident's electronic health record (EHR) was left unsecured on a medication cart computer. On the morning of February 6, 2025, Resident 36's personal health information was observed being displayed on the computer screen of the medication cart without any facility staff present. Shortly after, a Licensed Practical Nurse (LPN), identified as Staff O, was seen leaving the nurse's station and heading towards the resident hallway. The facility's Administrator, Staff A, walked past the medication cart and was questioned about the process for securing EHRs. Staff A attempted to lock the computer but was unsuccessful and subsequently retrieved Staff O from the hallway. Staff O admitted to usually locking the screen but stated she was distracted at the time. The medication cart computer was supposed to be locked or closed to protect residents' EHRs, as per facility protocol.
Excessive Noise from Slamming Doors Affects Residents' Quality of Life
Penalty
Summary
The facility failed to maintain comfortable noise levels, impacting two residents' quality of life. Resident 86 reported difficulty relaxing or sleeping due to a constantly slamming door outside her room, which repeatedly jolted her awake. Observations confirmed that the double doors in the countryside corridor slammed shut loudly, opening and closing 22 times in 15 minutes. Staff J, the Maintenance Director, acknowledged the noise, attributing it to the doors being solid and heavy, and stated they needed to remain closed due to a flu outbreak. Resident 244, who had been at the facility for only one day, also reported excessive noise in the hallway resembling a door slamming. Staff A, the Administrator, deferred maintenance concerns to Staff J, indicating a lack of immediate action to address the noise issue.
Failure to Address Verbal Abuse Concerns
Penalty
Summary
The facility failed to protect Resident 17 from verbal abuse, as reported concerns about such abuse were not adequately followed up on, and preventative interventions were not initiated. Resident 17, who was cognitively intact and had diagnoses including paraplegia, pressure wounds, and chronic pain, reported being verbally abused by a staff member, Staff E, in August 2024. The resident claimed that Staff E used profanity and condescending comments, which caused him distress. Despite Resident 17's request for Staff E not to provide care, the staff member continued to be assigned to him on multiple occasions, exacerbating the resident's psychological harm. The facility's policy on abuse prevention required supervisors and staff to intervene in situations where abuse was likely to occur. However, the incident involving Resident 17 was not documented in the facility's August 2024 Accident/Incident Log or Grievance Log. When Resident 17 reported the verbal abuse to Staff C, Social Worker, and Staff G, Resident Care Manager and RN, no effective action was taken to address the resident's concerns. Staff G admitted to not interviewing Resident 17 and instead relied on Staff E's account of the incident. This lack of proper investigation and response to the resident's grievance contributed to the ongoing issue. Furthermore, the facility's Director of Nursing Services, Staff B, and the Administrator, Staff A, were not fully informed or did not recall the details of the incident. Staff B assumed that Staff G had handled the situation, while Staff A could not remember if he had followed up with Resident 17. This lack of communication and failure to adhere to the facility's abuse prevention policy resulted in Resident 17 experiencing continued distress and a diminished quality of life due to the unresolved issue with Staff E.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to investigate allegations of verbal abuse involving a resident, identified as Resident 17, who was cognitively intact and had diagnoses including paraplegia, multiple pressure wounds, and chronic pain. The incident occurred when Resident 17 reported being verbally abused by a Licensed Practical Nurse (LPN), referred to as Staff E. The resident claimed that Staff E used derogatory language and made condescending comments after a disagreement about the delivery of pain medication. Despite the resident's immediate report to social services and the resident care manager, no formal investigation was conducted, and the incident was not documented in the facility's logs. The facility's policy on abuse prevention requires supervisors and staff to intervene in situations where abuse is likely to occur. However, in this case, the staff failed to follow the protocol. Staff G, the Resident Care Manager, did not interview Resident 17 or notify the Director of Nursing Services (DNS) and the Administrator (ADM) as required. Instead, Staff G relied on the account provided by Staff E, who was involved in the incident. The DNS, Staff B, was unaware of the details and assumed that Staff G had handled the situation. This lack of communication and failure to follow procedures resulted in the incident not being addressed appropriately. Furthermore, the facility's training on abuse reporting was not effectively implemented. Staff members, including the Staff Development Coordinator and Nursing Assistant, were aware of the reporting procedures, but the process was not followed in this case. The Administrator, Staff A, was informed of the incident through a text message from Resident 17 but did not recall taking any action. This series of inactions and miscommunications led to the deficiency, placing residents at risk for abuse and a diminished quality of life.
Failure to Implement PASARR Recommendations for Resident
Penalty
Summary
The facility failed to implement the recommendations from a Level II Preadmission Screen and Resident Review (PASARR) for a resident who was severely cognitively impaired. The resident, identified as Resident 35, was admitted to the facility and later triggered a significant change PASARR due to new or changed behaviors, necessitating a Level II assessment. The recommendations from this assessment, received by the facility on January 2, 2025, were not fully implemented to assist staff with interventions and strategies to manage the resident's symptoms of agitation and aggression. During observations, Resident 35 was found sitting on the side of the bed, expressing a lack of activities and interest in listening to music, but unable to do so due to non-functional headphones. Staff H, a Social Services Assistant, acknowledged the process of updating PASARR forms and forwarding them for interventions but was unable to locate the completed recommendations for behavior interventions in the resident's electronic health record. This oversight placed the resident at risk of not receiving necessary mental health services and a diminished quality of life.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, which resulted in a deficiency. Resident 43, who was admitted with a diagnosis of Post Traumatic Stress Disorder (PTSD), did not have PTSD addressed in their comprehensive care plan, despite being alert and oriented as per the Annual Minimum Data Set (MDS) assessment. Staff I, a Resident Care Manager and Licensed Practical Nurse, confirmed the absence of a care plan for PTSD upon review of the electronic health record (EHR). Similarly, Resident 70, admitted with a diagnosis of Unspecified Dementia, also did not have dementia addressed in their comprehensive care plan. The Annual MDS documented that Resident 70 was alert and oriented. Staff I confirmed the lack of a care plan for dementia in the EHR. The Director of Nursing Services, Staff B, acknowledged that it was expected for residents with such diagnoses to have care plans addressing their individual needs.
Failure to Develop Comprehensive Care Plan for Oxygen Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for oxygen use for Resident 39, who was admitted on [DATE]. The quarterly Minimum Data Set (MDS) dated 03/05/2024 indicated that the resident was cognitively intact. On 04/15/2024, Resident 39 was observed using an oxygen mask and concentrator but was unable to provide information regarding his oxygen use. A review of the resident's electronic health record revealed that the use of oxygen was not addressed in the comprehensive care plan, despite a physician's order dated 11/09/2023 for oxygen 1-4 L to keep oxygen levels above 90% as needed. Staff D, an RN, confirmed that the oxygen use was not documented in the care plan and stated that it should have been. Staff E, a Resident Care Manager and LPN, also confirmed that oxygen use should be included in the care plan and noted its absence. Staff B, the Director of Nursing Services and RN, acknowledged that the care plan should have been updated to include the oxygen use orders.
Failure to Accurately Post and Update Nursing Hours
Penalty
Summary
The facility failed to ensure nursing hours were accurately posted and updated daily for 14 of 42 shifts reviewed. This discrepancy was observed between the posted nursing staff information and the actual staff schedules from 04/01/2024 to 04/14/2024. For instance, on 04/01/2024, the posting showed 0.5 registered nurses (RNs) for the day shift, but no RNs actually worked. Similarly, on 04/04/2024, the posting indicated 14 nursing assistants (NAs) for the day shift, while only 12.5 NAs worked. These inaccuracies were consistent across multiple dates and shifts, affecting both RNs and NAs, as well as licensed practical nurses (LPNs). The discrepancies were confirmed through interviews and record reviews, revealing that the daily staff postings were not updated throughout the day to reflect actual staffing levels. Staff C, the Staff Coordinator, admitted to posting the daily staff information every morning but did not update it throughout the day when changes occurred. Staff C was unaware that the postings needed to be updated to maintain accuracy. The Director of Nursing Services (DON) expected the postings to be accurate and updated throughout the day. This failure to update the postings placed residents, their representatives, and visitors at risk of not being fully informed about the current staffing levels and census information.
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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