Garden Terrace Healthcare Center Of Federal Way
Inspection history, citations, penalties and survey trends for this long-term care facility in Federal Way, Washington.
- Location
- 491 South 338th Street, Federal Way, Washington 98003
- CMS Provider Number
- 505512
- Inspections on file
- 23
- Latest survey
- September 12, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Garden Terrace Healthcare Center Of Federal Way during CMS and state inspections, most recent first.
A resident with multiple complex medical conditions experienced several days of diarrhea, resulting in distress and fatigue. Despite care plan requirements, nursing staff did not assess the condition, intervene, or notify the physician, and the DON confirmed there was no documentation or policy for managing diarrhea.
The facility did not provide required skin care for a resident with a documented skin impairment, failing to assess and treat the condition as per policy. Additionally, two residents with GI diagnoses did not receive bowel management interventions according to physician orders and the facility's bowel protocol, resulting in prolonged periods without a bowel movement and lack of appropriate documentation or follow-up.
The facility did not ensure proper kitchen sanitation, as surface sanitizer was unavailable at an effective concentration and exhaust fans above the meal assembly area were visibly dirty, with one fan directly over the steam table showing accumulated dust and debris. The Food Service Manager confirmed the lack of sanitizer and the presence of debris, attributing the issues to communication lapses and maintenance responsibilities.
Staff failed to consistently follow infection control protocols, including not wearing required PPE when entering rooms of residents on Contact Precautions or EBP, incorrect signage for precautions, improper handling of soiled linens, and allowing visitors to use shared equipment like ice scoops without hand hygiene. These lapses were observed among multiple residents with infection risks and confirmed by staff interviews.
A resident was discharged home after completing treatment and meeting care goals, but the facility did not provide the required Notification of Medicare Non-Coverage (NOMNC) letter. Although other discharge paperwork and notifications were completed, staff confirmed that the NOMNC letter was not issued as required.
Several resident rooms were found with unblended paint patches, scratches, chipped and soiled baseboards, and a privacy curtain stained with dark spots and liquid. A resident reported dissatisfaction with the room's cleanliness, and maintenance staff acknowledged incomplete repairs and cleaning, contrary to facility policy requiring a clean, homelike environment.
The facility did not properly address grievances for three residents, including missing personal items and concerns about medication administration. In each case, required grievance forms were not completed or logged, and follow-up was inadequate. Staff interviews confirmed that the facility's grievance policy was not followed, resulting in unresolved issues for the affected residents.
A resident reported that a nurse exchanged their pain medication for a different pill, suspecting drug diversion. The facility's investigation was limited to reviewing the MAR, narcotic sheet, and progress notes, without interviewing the resident about medication effectiveness, identifying or interviewing the alleged nurse, or speaking with other staff or residents. The investigation did not meet facility policy requirements for thoroughness and documentation.
The facility did not develop or implement individualized care plans for three residents with specific needs, including respiratory care, monitoring of swelling, and assessment of bruising. Staff confirmed the absence of care plans and physician orders to guide care for these conditions, despite facility policy requiring comprehensive care planning.
Multiple dependent residents did not receive required assistance with ADLs such as personal hygiene, grooming, and bathing, despite being assessed as needing this care and not refusing it. Observations and interviews confirmed that staff did not consistently provide morning care, nail care, or shaving as outlined in care plans and facility policy.
Three residents did not receive individualized or meaningful activities, with limited and repetitive options such as nail painting and bingo offered regardless of personal interests. Residents reported boredom and a lack of engagement, and staff failed to document or consistently provide one-on-one activities, resulting in unmet needs for those with specific preferences or younger age.
A resident with anxiety and depression repeatedly requested a psychological evaluation, but the referral remained pending with no documented follow-up. The resident continued to display emotional distress, and staff confirmed that no referral was made, resulting in the resident not receiving necessary behavioral health services.
Surveyors found that medications and biologicals were not properly labeled or stored, including an opened sterile swab package without a date and inhalers lacking resident identification or open/discard dates. Additionally, narcotic logbooks were missing required nurse signatures during shift changes, indicating failures in medication documentation and accountability.
A resident with moderate memory impairment was placed on a mechanically altered diet without timely assessment by an SLP, despite expressing dissatisfaction and having no documented swallowing issues at admission. Due to delayed communication and referral processes, the resident did not receive an SLP evaluation or appropriate diet upgrade until eight days after admission.
The facility did not consistently follow physician orders for medication administration, failed to clarify unclear medication and monitoring orders, and did not properly monitor or document resident weights and edema. These deficiencies affected multiple residents with complex medical needs, resulting in unmet care requirements and unaddressed changes in condition.
Two residents with complex pain needs did not receive effective pain management, as staff failed to follow physician orders for pain medication dosages and did not implement required non-pharmacological interventions. One resident experienced ongoing pain after brain surgery and blood clots, while another with a bone infection received lower medication doses than ordered and was not provided alternative pain relief methods. Staff interviews confirmed that pain management protocols and facility policy were not consistently followed.
A resident with multiple medical conditions and a deep tissue injury on their buttocks did not receive the recommended honey-based dressing treatment due to a delay in processing the order. The treatment was not scheduled or carried out by the nursing staff, as it was not entered into the Treatment Administration Record, leading to a failure in providing necessary care.
A resident experienced a dislocated hip prosthesis during a rough brief change, highlighting the facility's failure to implement abuse and neglect policies. The staff did not follow care plan interventions, and the incident was not thoroughly investigated. The resident's care plan lacked necessary non-weight bearing instructions, indicating oversight in ensuring safety and adherence to protocols.
The facility failed to provide written transfer or discharge notices for three residents who were hospitalized. A resident was transferred to the hospital without a written notice being provided to them or their representative, who only learned of the transfer from the hospital. The facility's Executive Director confirmed that the notice was not completed due to an oversight. Similarly, two other residents were discharged to the hospital without receiving the required written notices, which was attributed to a transition of staff in social services.
A resident with a history of falls and multiple medical conditions, including COVID-19, fell in their room due to inadequate supervision and lack of specific interventions in their care plan. The facility's guidelines for fall prevention were not followed, as the resident's care plan did not include necessary measures such as frequent visual checks or a safety assessment for the bed's low position. Staff confirmed the absence of orders for monitoring, and the resident's fall was attributed to discomfort from COVID-19 and loose bowel movements.
The facility failed to maintain sanitary conditions in the kitchen and resident refrigerators, leading to unsanitary food storage and preparation. Observations revealed unlabeled and undated food, spoiled items, and dirty kitchen and refrigerator environments. Staff interviews confirmed lapses in following facility policies on food safety and cleanliness.
The facility failed to provide written notice of the bed hold policy to three residents or their representatives during hospitalizations, as required. Staff responsible for offering bed holds confirmed the oversight, and the Executive Director acknowledged the importance of this policy for residents' well-being.
The facility failed to develop comprehensive care plans for seven residents, leading to unmet care needs such as malnutrition, unmanaged psychiatric conditions, and unaddressed fall risks. Staff interviews and record reviews confirmed these deficiencies.
The facility failed to provide appropriate pain management for residents, including the lack of nonpharmacological interventions, failure to identify pain parameters for PRN medications, and failure to document the location of pain. Residents experienced untreated pain due to these deficiencies.
The facility failed to maintain an infection prevention and control program, did not implement or follow isolation precautions for five residents, and did not consistently perform hand hygiene during meal service on two resident units. These failures placed residents at risk for facility-acquired infections.
The facility failed to transmit a resident's assessment data to CMS within the required timeframe. The discharge assessment for a resident, completed on December 5, 2023, was not transmitted until April 10, 2024, exceeding the 14-day requirement. The delay was identified during a record review and confirmed by the Executive Director and DON.
The facility failed to ensure accurate MDS assessments for two residents. One resident's poor dental status was not identified, and another resident's active dementia diagnosis was missed. These inaccuracies were confirmed by staff and led to incomplete care plans.
The facility failed to provide necessary assistance with ADLs for two residents. One resident with severe memory impairment and swallowing difficulties was left to eat alone, while another resident dependent on staff for personal hygiene did not receive a bath for 24 days and was not assisted with shaving.
The facility failed to monitor a resident on anticoagulation therapy for signs of bleeding, as required by their care plan. The resident exhibited petechiae on their feet, which was not documented in a skin assessment, and no monitoring was recorded in the medication and treatment records.
The facility failed to provide adequate nutritional care for two residents, leading to significant weight loss. For one resident, the facility did not complete a timely nutrition assessment or develop a care plan, and failed to provide suitable food textures. Another resident, admitted without lower dentures, was unable to chew the provided food, and the facility did not offer appropriate meal replacements or downgrade the food texture. Both residents experienced significant weight loss due to these deficiencies.
The facility failed to properly document and track the tube feeding for a resident with multiple diagnoses, including malnutrition and a swallowing disorder. Incomplete documentation and conflicting orders led to inconsistencies in the administration of the tube feeding formula, placing the resident at risk for inadequate nutrition and hydration.
The facility failed to provide proper respiratory care for two residents. One resident did not receive ordered incentive spirometry treatments, and another received supplemental oxygen without a physician's order specifying the rate. Staff confirmed these deficiencies, which were contrary to the facility's policies.
The facility failed to provide appropriate treatment and services for a resident diagnosed with dementia. The resident's care plan was incomplete and not person-centered, lacking details about their mental condition, visual hallucinations, and non-pharmacologic interventions. Staff confirmed the deficiencies, emphasizing the importance of accurate and individualized care plans.
The facility failed to ensure that two residents were free from unnecessary psychotropic medications by not providing non-pharmacological interventions, not obtaining consent, and not documenting target behaviors. This placed the residents at risk of receiving unnecessary medications and experiencing adverse side effects.
The facility failed to ensure that one garbage dumpster and one recycling dumpster were properly covered and the surrounding areas were kept clean. The recycling dumpster was overflowing, the middle garbage dumpster's lid was not completely closed, and the area around the third dumpster was dirty. The Dietary Manager confirmed that staff are expected to keep these areas clean and sanitary.
A resident with a right hip fracture and other medical conditions did not receive the required frequency of PT and OT services due to inadequate scheduling around their Hemodialysis treatments. The facility lacked a proper system to ensure therapy services were provided as assessed.
The facility failed to ensure accurate and consistent medical records for two residents. One resident had conflicting dementia diagnoses, and another had an Advance Directive that was not properly documented. Staff acknowledged communication issues between departments.
The facility failed to administer a pneumococcal vaccine to a resident who had consented to receive it. The resident was scheduled to receive the vaccine but was out of the facility at the time, and there was no follow-up to re-offer the vaccine upon the resident's return, as confirmed by the DON.
Failure to Assess and Notify Physician for Ongoing Diarrhea
Penalty
Summary
Facility staff failed to provide care and treatment in accordance with a resident's assessed needs and professional standards of practice for bowel care. The resident, who had complex medical conditions including kidney and heart disease, unstable blood sugar, bone infection, and a recent toe amputation, began experiencing multiple episodes of loose bowel movements over a period of several days. Despite documentation of ongoing diarrhea and the resident expressing distress, fatigue, and lack of energy to therapy staff, there was no evidence that nursing staff assessed the resident's condition, addressed the symptoms, or notified the physician as required by the care plan. The care plan specifically indicated that timely communication with the physician or nurse practitioner was necessary for any change in the resident's condition. However, medical records and staff interviews confirmed that no assessment, intervention, or physician notification occurred regarding the resident's ongoing diarrhea. The Director of Nursing acknowledged the lack of documentation and stated that staff did not follow expected procedures. Additionally, the facility did not have a policy in place for managing residents with diarrhea.
Failure to Provide Skin and Bowel Care per Orders and Facility Protocol
Penalty
Summary
The facility failed to provide appropriate skin care and bowel management for several residents, as required by their own policies and physician orders. For one resident with a history of cancer and fractures, a skin impairment on the right elbow was observed and reported by the resident, but this impairment was not documented in the weekly skin assessment, nor was it identified by CNAs or addressed by nursing staff during routine care. The skin issue was only acknowledged after direct observation and inquiry, despite the facility's policy requiring comprehensive and weekly skin assessments with prompt reporting of changes. In addition, two residents with gastrointestinal diagnoses and specific physician orders for bowel management did not receive care according to the facility's bowel protocol. One resident, who was always incontinent of bowel and dependent on staff for toileting, went over seven days without a documented bowel movement. Although the resident received an initial dose of Milk of Magnesia (MOM), subsequent interventions such as a suppository or enema were not administered as ordered, and there was no documentation of the resident refusing care during this period. Another resident, who required moderate assistance with toileting and had no memory impairment, also experienced a seven-day period without a bowel movement. Despite clear physician orders for a stepwise bowel protocol, including MOM, suppository, and enema as needed, staff did not administer these interventions. Staff interviews confirmed that the bowel protocol was not followed, and the required medications were not given as ordered.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by the lack of effective surface sanitizer and the presence of dirty exhaust fans. During an observation, two red buckets of surface sanitizer were found to be at an ineffective concentration, as confirmed by test strips that did not change color as expected. The Food Service Manager acknowledged that the kitchen had run out of sanitizer concentrate and that weekend staff had not communicated this shortage, resulting in the inability to properly sanitize surfaces. Additionally, four ceiling exhaust fans in the steam table area, where resident meals are assembled, were observed to have significant accumulations of dirt, dust, and grime. One fan, located directly above the steam table, had visible debris, including a hanging piece of dust, increasing the risk of contamination. The Food Service Manager confirmed the buildup and stated that maintenance was responsible for cleaning the fans, but noted that the fan surfaces allowed dust to accumulate easily.
Failure to Adhere to Infection Control Protocols and Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances where staff did not adhere to established protocols for Transmission-Based Precautions (TBP) and Enhanced Barrier Precautions (EBP). Observations revealed that staff entered rooms of residents on Contact Precautions without donning required personal protective equipment (PPE) such as gowns and gloves, despite clear signage and facility policy. For example, a Certified Occupational Therapy Assistant entered a resident's room without PPE, and a Certified Nurse's Assistant delivered a meal tray without performing hand hygiene or wearing PPE as directed by posted instructions. Further deficiencies were noted in the application of EBP and the management of residents with specific infection risks. One resident with a PICC line was observed with an incorrect Contact Precautions sign instead of the required EBP sign, and both staff and the resident did not consistently use PPE when outside the resident's room. Another resident with a urostomy bag experienced ongoing leakage, with soiled linens left in the room and not promptly removed, contrary to infection control expectations. Family members also reported and observed lapses in maintaining a clean and sanitary environment for this resident. Additional lapses included improper handling of shared equipment, such as an ice scoop being used by visitors without hand hygiene or gloves, and staff confusion regarding the correct application of precautions for both residents and housekeeping tasks. Interviews with staff confirmed a lack of understanding and inconsistent implementation of the facility's infection control policies, including the use of correct signage and PPE requirements for both staff and visitors.
Failure to Provide Required Medicare Non-Coverage Notice Prior to Discharge
Penalty
Summary
The facility failed to provide a required Notification of Medicare Non-Coverage (NOMNC) letter to a resident prior to discharge. Record review showed that the resident was readmitted and later discharged home after meeting their goals and completing antibiotic treatment. Although the facility provided a Nursing Home Transfer or Discharge notice and notified the local Long Term Care Ombuds about the discharge, there was no documentation that the NOMNC letter was given to the resident. Staff confirmed during an interview that the NOMNC letter should have been provided but was not.
Failure to Maintain Homelike Environment and Cleanliness in Resident Rooms
Penalty
Summary
The facility failed to maintain a homelike environment in five resident rooms, as evidenced by multiple observations of unblended white paint splotches, scratches, chipped and soiled baseboards, and a soiled privacy curtain. Specifically, rooms 111, 112, 113, 116, and 120 were found to have walls with visible paint patches that did not match the original wall color, as well as scratches and unpainted, dirty baseboards. In one room, a privacy curtain was observed to be soiled with dark brown and red spots and brown liquid stains, and a resident expressed dissatisfaction with the cleanliness and appearance of their room. Staff interviews confirmed that maintenance was aware of the incomplete paint repairs and the need to replace the soiled privacy curtain to maintain a homelike setting, but these actions had not been completed. The facility's policy requires all staff to ensure a safe, clean, and comfortable environment and to promptly address cleaning needs, but these standards were not met in the sampled rooms.
Failure to Initiate, Investigate, and Resolve Resident Grievances
Penalty
Summary
The facility failed to properly initiate, investigate, and resolve grievances for three residents, as required by its grievance policy. For one resident with memory impairment and dependence on staff for daily living activities, the family repeatedly reported missing clothing to staff over several days. Despite these reports, no concern or comment form was completed, and the missing items were not found or replaced in a timely manner. Staff interviews confirmed that the appropriate grievance process was not followed, and the Director of Nursing acknowledged that a concern form should have been completed but was not. Another resident, who had no cognitive impairment and was able to communicate clearly, lost their dentures in the facility. The resident reported the loss to staff, and a staff member stated they completed a concern and comment form, but there was no documentation of the grievance in the facility's log or the resident's record. The administrator confirmed that the grievance was not logged as required, and staff did not follow up with the grievance process. A third resident, who used glasses and experienced frequent pain, submitted a grievance alleging that a nurse had swapped their pain medication for a different pill. The concern and comment form was incomplete, lacking staff signatures and dates, and the summary response did not indicate whether the resident was satisfied with the outcome or who authored the summary. Staff interviews confirmed that the grievance documentation was incomplete and did not meet policy requirements.
Failure to Investigate Alleged Drug Diversion
Penalty
Summary
The facility failed to thoroughly investigate an allegation of drug diversion involving a resident who reported that a nurse had exchanged their pain medication for a different pill on two occasions. The resident, who had intact memory and was familiar with their prescribed pain medication, documented their concerns in a grievance form, stating that they recognized the difference in the medication's appearance and suspected theft. The facility's investigation was limited to a review of the Medication Administration Record (MAR), narcotic sheet, and progress notes, which indicated the medication was administered and effective. However, the investigation did not include interviews with the resident regarding the effectiveness of the medication, did not identify or interview the nurse alleged to have diverted the medication, and did not include interviews with other residents or staff who may have been witnesses or involved. The investigation summary lacked essential details, such as the identity of the staff member who wrote it, and failed to follow the facility's policy, which required comprehensive interviews and documentation. Both the Director of Nursing and the Administrator acknowledged that the investigation did not meet policy requirements, as it did not determine which nurse was involved or whether the resident's concerns were fully addressed. The incident was not reported on the facility's state reporting log, and the process for determining whether the concern was a grievance or a reportable allegation was not clearly documented.
Failure to Develop and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans (CPs) for three residents with specific care needs. For one resident with pneumonia, asthma, and respiratory failure who required supplemental oxygen, there was no CP addressing respiratory conditions or oxygen use, despite observations of the resident using oxygen and staff confirming the absence of a relevant CP. Another resident with respiratory issues and kidney disease was observed with swollen feet, but no CP or physician's orders were in place to guide staff in monitoring or addressing the swelling, as confirmed by staff review. A third resident, who was blind in one eye and dependent on staff for daily care, was observed with multiple bruises on the arms, neck, and chest following a hospital readmission. There was no CP or physician's order directing staff to monitor or document changes in the bruises. Staff interviews confirmed the lack of care planning and monitoring instructions for these conditions, contrary to facility policy requiring comprehensive CPs to address all identified care needs.
Failure to Provide Required ADL Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to residents who were dependent on staff for personal hygiene, grooming, and bathing. According to the facility's policy, residents unable to perform their own ADLs should receive services such as bathing, dressing, grooming, oral care, and fingernail care based on their comprehensive assessment and care plan. However, observations, interviews, and record reviews revealed that multiple residents did not receive the required assistance, despite being assessed as needing it and not refusing care. For example, one resident with respiratory issues required staff help for toileting, transferring, personal hygiene, and bathing, but was repeatedly observed with long, dirty fingernails and unshaven. The resident reported that staff did not assist with shaving or nail care, and staff interviews confirmed that care was not provided as expected. Another resident with lower body impairment after a stroke was dependent on staff for personal hygiene and bathing, yet was observed multiple times with long, dirty fingernails and stated that staff did not help with nail care. Staff acknowledged that care, including nail clipping and hygiene, was not consistently provided. Additional residents with anxiety, respiratory, and vision issues were also observed with poor hygiene, including long, dirty fingernails, greasy hair, and unshaven appearance. These residents required moderate to total assistance with ADLs and did not refuse care, but staff interviews and observations confirmed that morning care, showers, and nail care were not provided as scheduled or as needed. The facility's failure to follow its own policies and care plans resulted in residents not receiving the necessary assistance with ADLs.
Failure to Provide Individualized and Meaningful Activities for All Residents
Penalty
Summary
The facility failed to provide activity programs that met the individualized needs and interests of all residents, as required by its own policy and regulatory standards. Observations, interviews, and record reviews revealed that three residents did not receive meaningful or personalized activities. Activity calendars showed limited and repetitive offerings, such as nail painting and bingo, with little variation or consideration for residents' preferences, especially for those who were younger or had different interests. Residents reported boredom and dissatisfaction, noting that activities were primarily designed for older residents and that there were few options available on their unit. Resident records and care plans indicated that activities were important to the residents, including interests in music, news, group activities, religious services, reading, and educational programs. However, there was no documentation of activity participation for any of the three residents reviewed. Interviews with residents confirmed that they were not offered activities aligned with their interests, and some reported spending most of their time with little to do, such as working on puzzles alone or watching TV with no other options provided. Staff interviews confirmed that activity documentation was lacking and that one-on-one visits were inconsistently provided or tracked. The Activities Director acknowledged the limited activity schedule in certain units and the need to develop more appropriate options for younger residents. Census lists used by the activities team showed that some residents received few or no one-on-one visits, further demonstrating the facility's failure to implement an ongoing, individualized activities program as outlined in its policy.
Failure to Provide Behavioral Health Services Following Resident Request
Penalty
Summary
Resident 264, who had diagnoses of anxiety and depression, was admitted to the facility and was identified as being at risk for changes in mood or behavior due to their medical conditions. The resident's care plan included interventions for staff to provide a psychological evaluation consult as indicated. Documentation showed that the resident requested a referral for a psychological evaluation, but the status of this referral remained pending with no documented follow-up. Multiple progress notes and interviews indicated that the resident continued to express emotional distress, including tearfulness, sadness, and frustration about their mental health needs not being addressed. Despite repeated requests from the resident for a psychological evaluation and clear indications of ongoing emotional distress, there was no evidence that the facility made or completed the necessary referral for behavioral health services. Staff interviews confirmed that there was no documentation of a referral being made, and the Director of Nursing acknowledged that the order for a psychological evaluation was still pending without explanation. This lack of action resulted in the resident not receiving the behavioral health services required to address their mental health needs.
Medication Storage, Labeling, and Documentation Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to the storage and labeling of medications and biologicals. In the Tea Garden Unit's nourishment pantry freezer, an opened package of sterile glycerine swabs was found without a date indicating when it was opened or how long the swabs could safely be used. The packaging was intended for single-use sterility, and the lack of dating did not comply with the facility's policy for recording the date opened and expiration for such items. Additionally, on a medication cart, a steroid inhaler was found without a box, unlabeled, and with no resident name, while another inhaler was opened without an open or discard date. Staff interviews confirmed that medications should be labeled with the resident's name and dated to ensure safety and prevent errors. Further review of the narcotic logbook on the same medication cart revealed five instances in May where nurses failed to sign the logbook to confirm the narcotic count during shift changes. Staff acknowledged that signatures were missing and that it was expected practice to reconcile and sign the narcotic logbook at each shift change to ensure accuracy and prevent drug diversion. These findings demonstrate lapses in following established medication storage, labeling, and documentation procedures.
Failure to Provide Timely SLP Evaluation and Diet Upgrade
Penalty
Summary
The facility failed to ensure that a resident received timely specialized rehabilitative services, specifically a Speech Language Pathologist (SLP) evaluation, after admission. The resident was admitted with a moderate memory impairment and was placed on a mechanically altered diet, despite having no documented chewing or swallowing issues at the time of admission. The resident expressed dissatisfaction with the food texture and reported not understanding the reason for the modified diet. Observations confirmed that the resident was served ground meat, which was left untouched, and the resident voiced complaints to the registered dietician about the food. The SLP evaluation was not completed until eight days after admission, at which point the SLP assessed a mild swallowing impairment and upgraded the resident's diet. Interviews with staff revealed that there was a lack of timely referral and communication between the dietary and rehabilitation departments, which delayed the SLP assessment and subsequent dietary changes. The delay in providing specialized rehabilitative services resulted in the resident remaining on an unnecessarily restrictive diet for several days.
Failure to Follow Physician Orders and Monitor Resident Status
Penalty
Summary
The facility failed to ensure that physician-ordered parameters for medications were followed for several residents. For example, one resident with a history of stroke and arthritis, who frequently experienced severe pain, was administered as-needed pain medication for a pain level below the physician-ordered threshold. Another resident with a pain disorder and muscle weakness received pain medication outside the specified parameters on multiple occasions. These actions were confirmed through review of medication administration records and staff interviews, which acknowledged that medications were not always given according to the prescribed parameters. The facility also failed to clarify physician orders as needed for residents with complex medication regimens. In one case, a resident with anxiety and heart failure had an order for an antianxiety medication that did not specify when to administer one versus two tablets, and an order to monitor edema that lacked details on which body part to assess or actions to take for severe swelling. Staff interviews confirmed that these orders were unclear and should have been clarified with the provider, but this was not done. Another resident with insomnia had an as-needed supplement order for sleep that lacked clear administration parameters, which staff also failed to clarify. Additionally, the facility did not consistently monitor resident weights as ordered, particularly for residents at risk for malnutrition. One resident with cancer and heart disease experienced a significant, unverified weight loss over one week, with inconsistent weighing methods and no documented re-weigh or physician notification. The facility's policy required re-weighing for significant weight changes and consistent weighing practices, but these were not followed. Furthermore, staff failed to monitor and document edema as ordered for another resident with congestive heart failure, despite observable swelling and resident complaints. Staff interviews confirmed that required monitoring and documentation were not completed.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for residents experiencing significant pain, as evidenced by the care of two residents with complex medical conditions. One resident, who had a history of brain cancer, brain abscess, recent brain surgery, back pain, bilateral leg pain from blood clots, and generalized deconditioning, was not effectively managed for pain. Despite physician orders specifying the use of over-the-counter pain medication for mild pain and narcotic pain relievers for severe pain, the resident continued to experience unrelieved pain, particularly in the legs, and expressed distress. The care plan directed staff to notify the physician if interventions were unsuccessful, but the resident's representative reported ongoing inadequate pain control. Another resident with a bone infection and back pain had a care plan and physician orders that required staff to assess pain, attempt non-pharmacological interventions before administering pain medication, and provide specific dosages based on pain severity. However, documentation showed that the resident received a lower dose of pain medication than ordered for high pain levels, and non-pharmacological interventions were not provided as required. The resident reported not receiving the correct medication dose for several days and was offered an ineffective over-the-counter medication instead, leading to frustration and continued pain. Interviews with staff confirmed that pain management protocols were not consistently followed. Staff acknowledged that the pharmacy should have been contacted to obtain the correct medication and that the provider should have been notified to ensure orders were followed. The facility's policy required collaboration with healthcare professionals and the use of both pharmacological and non-pharmacological interventions, but these standards were not met, resulting in untreated pain and discomfort for the residents involved.
Failure to Implement Wound Care Orders
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident with a pressure ulcer. Resident 1, who had multiple medical conditions including memory impairment, unstable blood sugar levels, heart and kidney disease, malnutrition, and a surgically repaired hip fracture, was identified with a deep tissue injury on their buttocks during an admission assessment. Despite a wound care provider recommending a treatment using a medical-grade honey-based dressing, the treatment was not scheduled or carried out by the nursing staff as ordered. The delay in treatment was attributed to the facility receiving the wound care orders late on a Friday night, which were not processed until the following Monday morning. Interviews with staff revealed a lack of awareness regarding the treatment order, as it was not entered into the Treatment Administration Record. The Interim Director of Nursing confirmed that the treatment was not provided and emphasized the importance of implementing and following provider treatment orders for effective wound management and healing.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement its abuse and neglect policies and procedures, specifically in the prevention, identification, investigation, and reporting of abuse and/or neglect. This deficiency was highlighted by an incident involving a resident who experienced a dislocation of their left hip prosthesis during a rough and fast incontinent brief change by the staff. The resident, who had intact memory and was able to communicate their needs, reported severe pain during the process and noted that staff did not adhere to the care plan interventions, such as using pillows between the legs during repositioning. The facility's failure to investigate the incident thoroughly was evident as the Resident Care Manager did not inquire about the cause of the dislocation before the resident was sent to the hospital. Additionally, the Director of Nursing and Administrator-In-Training were unaware of the incident and did not conduct an investigation to rule out abuse or neglect. The resident's care plan also lacked instructions for non-weight bearing restrictions on the left lower extremity, as indicated in the hospital discharge orders, further demonstrating the facility's oversight in ensuring the resident's safety and adherence to care protocols.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices as required for three residents who were hospitalized. For Resident 1, the facility did not complete or provide a written notice of transfer or discharge to the resident or their representative when the resident was transferred to the hospital due to increased confusion, elevated body temperature, and high pulse rate. The facility staff was unable to reach the resident's representative, and the representative only learned of the transfer from the hospital staff. The facility's Executive Director and Director of Nursing confirmed that the Social Services Director, who was responsible for completing the notice, did not do so for Resident 1's transfer. Similarly, for Residents 6 and 7, the facility did not provide written notices of transfer or discharge to the residents or their representatives when they were discharged to the hospital. The facility was unable to provide documentation to support that the required notices were completed for these residents. The Executive Director acknowledged that the oversight occurred during a transition of staff in social services, which led to the transfer/discharge process being overlooked.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision for a resident identified as a high-fall risk. The resident, who had a history of falls and multiple medical conditions including COVID-19, was found on the floor in their room. The resident's care plan did not include specific interventions such as positioning the bed in a low position or conducting frequent visual checks, despite the resident's high-fall risk status and the need to keep their room door closed due to COVID-19. The facility's fall prevention guidelines emphasize the importance of individualized care plans and frequent monitoring for residents at risk of falls. However, the resident's care plan lacked documentation of necessary interventions, and there was no safety assessment for the bed's low position. Staff interviews confirmed the absence of orders for frequent visual checks and the lack of documentation supporting active monitoring of the resident. The incident report and staff interviews revealed that the resident's discomfort from COVID-19 and loose bowel movements led them to attempt to get up independently, resulting in a fall. The facility's infection preventionist noted that dedicated rooms for COVID-19 positive residents who were high-fall risks were fully occupied, necessitating the resident's isolation in their current room. This situation, combined with the lack of appropriate interventions, contributed to the resident's fall.
Facility Fails to Maintain Sanitary Conditions in Kitchen and Resident Refrigerators
Penalty
Summary
The facility failed to ensure the physical environment was kept clean and food was stored under sanitary conditions in the kitchen and resident refrigerators. Observations revealed that food items in the kitchen were not labeled or dated, damaged or spoiled food was not discarded, and the kitchen vents were not kept free from dirt and dust build-up. Additionally, handwashing sinks and garbage bins were not maintained in a clean state. These lapses were confirmed by the Dietary Manager, who acknowledged the expectations for dietary staff to maintain food safety standards and the cleanliness of the kitchen environment. In the resident units, specifically Lily Garden and Tea Garden, the facility failed to monitor and manage the cleanliness and safety of resident refrigerators. Observations showed opened and undated food items, partially-eaten and spoiled food brought in from outside sources, and dirty refrigerator interiors. Staff interviews confirmed that nursing and dietary staff were responsible for labeling, dating, and discarding food items according to facility policy, but these practices were not consistently followed. These failures contributed to an unsanitary kitchen environment and unsafe storage of food and drinks, placing residents at risk for food-borne illness. The facility policies on sanitation, food from outside sources, and resident refrigerators were not adhered to, leading to the observed deficiencies in food safety and cleanliness.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide residents and/or their representatives with a written notice of the facility's bed hold policy at the time of transfer or within 24 hours, as required. This deficiency was identified through interviews and record reviews for three residents who were hospitalized. Resident 21 was sent to the hospital due to a change in their level of consciousness and swallowing issues, but there was no documentation indicating that a bed hold was offered. Staff F, responsible for offering bed holds, confirmed that a written bed hold was not provided to Resident 21 as required. Similarly, Resident 43 was hospitalized twice, but their records contained no information indicating that a bed hold was offered for either hospitalization. Staff N confirmed this oversight. Resident 41 was also sent to the hospital and returned to the facility, but there was no documentation of a bed hold being offered. Staff P confirmed that a bed hold was not provided to Resident 41 or their representative. The Executive Director acknowledged the importance of bed holds for residents' well-being and confirmed that the responsibility lies with the UCCs, but it was not being done. This failure placed residents and their representatives at risk of not being informed of their right to hold the resident's bed while hospitalized.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans (CPs) for seven residents, leading to unmet care needs. Resident 264 was admitted without lower dentures and was unable to chew food, resulting in significant weight loss and malnutrition. Despite multiple notifications to staff, no CP was developed to address the resident's missing teeth or malnutrition. Similarly, Resident 25, who was diagnosed with depression and anxiety and was on related medications, did not have a CP addressing these conditions, which was confirmed by staff interviews and medication records review. Resident 163, who had broken teeth and difficulty chewing, was assessed to be at risk for malnutrition, but no CP was developed to address these issues. Resident 167, who had respiratory failure, malnutrition, and muscle weakness, used bilateral side rails for bed mobility, but this was not captured in their CP. Additionally, Resident 2, who had a left heel pressure ulcer (PU), did not have this condition or the related interventions documented in their CP, despite an incident report indicating the need for such updates. Resident 43, who had a brain bleed and a swallowing disorder, received more than 51% of their nutrition via a surgically implanted tube but had conflicting goals in their CP regarding weight gain and loss, with no specific interventions related to tube feeding. Lastly, Resident 46, who had an amputation and difficulty walking, experienced two unwitnessed falls, but their CP was not updated with new interventions to prevent future falls. Staff interviews confirmed that these deficiencies in CP development and implementation were not in line with the facility's policy and expectations.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide appropriate pain management for residents, as evidenced by the lack of nonpharmacological interventions, failure to identify pain parameters for PRN medications, and failure to document the location of pain. Resident 167, who had multiple medical conditions including severe bladder infection and heart failure, reported pain affecting their sleep and daily activities. Despite physician orders to identify pain location and provide nonpharmacological interventions before administering PRN pain medications, the staff did not follow these instructions on multiple occasions, as documented in the Medication Administration Record (MAR) and progress notes. Resident 18, admitted for treatment following a hip fracture, also did not receive nonpharmacological interventions for pain. The physician orders did not include parameters for administering different pain medications based on pain levels, and there were no orders to monitor the resident's pain level. Staff confirmed that pain levels should be assessed every shift and that nonpharmacological interventions should be attempted before administering PRN pain medications, but these steps were not documented. Similarly, Resident 13 and Resident 213 experienced inadequate pain management. Resident 13, admitted for a hip fracture, received PRN opioid pain medication without documented nonpharmacological interventions or parameters for medication administration. Resident 213, with neck and shoulder pain, had multiple PRN pain medication orders without specific parameters, leading to inconsistent administration of pain medications. Staff confirmed the need for clarified pain medication orders and specific parameters for administering PRN medications, which were not in place for these residents.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a sanitary environment to help prevent the transmission of communicable diseases. Specifically, the facility did not implement or follow isolation precautions for five residents reviewed for Transmission-Based Precautions (TBP) and did not consistently perform hand hygiene (HH) during meal service on two resident units. These failures placed the residents at risk for facility-acquired or healthcare-associated infections and related complications. Resident 31 had a Stage 3 pressure ulcer and a physician order to implement Enhanced Barrier Precautions (EBP). However, there was no isolation cart or EBP sign outside their room. Staff confirmed that Resident 31 should have been on EBP but was not. Similarly, Resident 32, who also had a Stage 3 pressure ulcer, did not have an isolation cart or EBP sign outside their room, despite physician orders. Staff confirmed that Resident 32 should have been on EBP but was not. Resident 43 was incorrectly placed on droplet/contact precautions instead of EBP, as confirmed by staff. Resident 167 had a bladder infection and was frequently incontinent. The TBP sign outside their door was inconsistently changed between Contact Precaution and EBP, leading to confusion among staff. Resident 2 had an EBP sign posted outside their room, but staff were unsure which resident in the shared room required the precaution. During meal service, staff failed to perform HH between assisting residents, as observed in both the Lily Garden dining room and another resident unit. Staff acknowledged the importance of HH but did not follow the protocol.
Failure to Transmit Resident Assessment Data Timely
Penalty
Summary
The facility failed to encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for Resident 9. The discharge assessment for Resident 9, who was discharged on an unspecified date, was completed on December 5, 2023, but was not transmitted until April 10, 2024, which is four months after the completion date and well past the required 14-day transmission period. This delay was identified during a review of the facility's records and was confirmed by the Executive Director and the Director of Nursing during an interview on April 11, 2024. Staff B, the Director of Nursing, acknowledged the importance of timely MDS assessments for individualized care planning and the facility's financial stability. However, they were unaware that Resident 9's assessment had not been transmitted on time. The MDS nurse, Staff C, confirmed in a written response that the assessment was not transmitted as required and was found missing during a preliminary report review. This oversight placed residents at risk for inaccurate monitoring of their health status and compromised the quality of care provided.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments for two residents were completed accurately to reflect their conditions and overall health status. For Resident 28, the MDS did not identify the resident's poor dental status, despite observations of missing, chipped, and decayed teeth, and the resident's own admission of poor dental health and difficulty chewing harder foods. The admission nurse documented missing teeth but did not note chewing difficulties, and the resident's care plan did not address their poor oral health. Staff C, the MDS nurse, confirmed the inaccuracy and admitted to not performing an oral inspection due to being off at the time of the assessment. The Director of Nursing emphasized the importance of accurate MDS assessments for proper care planning but acknowledged the failure in this case. For Resident 166, the MDS failed to capture the resident's active diagnosis of dementia, despite the resident's diagnosis being documented in their medical records and physician notes. The resident was observed to be non-communicative and had a blank stare, consistent with their dementia diagnosis. The care plan noted impaired cognitive ability but did not specify dementia as the cause. Staff C admitted to missing the dementia diagnosis in the MDS, which is crucial for monitoring and care planning. The facility's policy requires that the MDS accurately reflect the resident's status, which was not adhered to in these cases.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to ensure residents who were dependent on staff for assistance with Activities of Daily Living (ADLs) received the necessary help. Resident 166, who had severe memory impairment and swallowing difficulties, was observed multiple times eating alone and struggling with their meal, despite being assessed to require one-person moderate assistance during meals. Staff interviews confirmed that Resident 166 needed assistance to avoid risks such as choking and malnutrition, but this assistance was not provided as required by the resident's care plan and assessment. Resident 32, who was totally dependent on staff for personal hygiene and bathing needs following a hip fracture, did not receive a bath for 24 days according to task documentation. Additionally, Resident 32 was observed with long facial stubble and reported not receiving assistance with shaving, despite expressing a preference for being clean-shaven. Staff interviews confirmed that the expected bathing and shaving assistance was not provided, as documented in the resident's care plan and task documentation.
Failure to Monitor Anticoagulation Therapy
Penalty
Summary
The facility failed to identify and provide care and services in accordance with the resident's goals and professional standards of practice for a resident on anticoagulation (AC) therapy. Specifically, Resident 163, who was on AC therapy following a right hip fracture, exhibited scattered red petechiae on the top areas of their bilateral feet. Despite the resident's clear speech and intact memory, and the facility's policy requiring additional monitoring for residents on AC therapy, the facility did not monitor for signs and symptoms of bleeding as indicated in the resident's care plan. The April Medication and Treatment Administration Records lacked documentation of such monitoring, and a skin assessment conducted on April 5, 2024, failed to identify the presence of petechiae on the resident's feet. Staff F, the Resident Care Manager, acknowledged the importance of monitoring AC adverse side effects, particularly signs and symptoms of bleeding, due to the severe consequences it could lead to. Staff F confirmed that the 04/05/2024 skin assessment did not identify the petechiae and stated that a baseline measurement of the affected areas should have been obtained to track any worsening of the skin condition. This oversight placed Resident 163 at risk for unidentified and/or worsening bleeding and a decreased quality of life.
Failure to Address Nutritional Needs and Weight Loss
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice to prevent weight loss for two residents. For Resident 163, the facility did not complete a comprehensive nutrition assessment within the required 72 hours of admission, nor did they develop and implement a nutrition care plan to address the resident's malnutrition risk, poor dental status, and chewing difficulties. Despite the resident's significant weight loss and requests for a more suitable diet, the facility did not make timely adjustments or provide adequate nutritional support. Additionally, the facility staff failed to document meal intake accurately and did not re-weigh the resident as required by the facility's protocol. Resident 264 also experienced significant weight loss due to the facility's failure to address their nutritional needs. The resident was admitted without lower dentures and was unable to chew the regular textured food provided. Despite multiple notifications from the resident about their inability to chew the food, the facility did not downgrade the food texture or offer appropriate meal replacements. The facility also failed to conduct a timely comprehensive nutrition assessment and did not hold weekly resident-at-risk meetings to review and address the resident's nutritional status. Both residents were at risk for malnutrition and experienced significant weight loss due to the facility's failure to follow its own policies and procedures. The lack of timely nutritional assessments, inadequate care planning, and failure to provide appropriate food textures and meal replacements contributed to the residents' compromised nutritional status and decreased quality of life.
Failure to Document and Track Tube Feeding for Resident
Penalty
Summary
The facility failed to implement proper care for a resident with a feeding tube, specifically in documenting and tracking the rate of tube feeding orders, and the amount of nutrition and water infused. Resident 43, who had multiple diagnoses including a brain bleed, malnutrition, and a swallowing disorder, required specific amounts of fluids and calories per day. However, the facility did not complete a readmission nutrition assessment until eight days after the resident's return from the hospital, and there were no orders to weigh the resident. Additionally, the facility did not document the total amount of water provided, the amount of tube feeding formula administered, or the rate at which it was administered, as required by the physician's orders. Observations showed inconsistencies in the administration rate of the tube feeding formula, and interviews with staff confirmed that the documentation was incomplete and conflicting. The Registered Dietician and the Director of Nursing both acknowledged that the lack of documentation made it difficult to ensure the resident received adequate nutrition and hydration. This failure placed Resident 43 at risk for inadequate calorie or protein intake and/or inadequate hydration.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents. Resident 167, who had a history of severe bladder infection, low blood count, heart, kidney, and respiratory failure, malnutrition, muscle weakness, and adult failure to thrive, was not provided with incentive spirometry (IS) breathing exercises as ordered by the physician. Despite documentation indicating that IS was provided four times a day, observations and interviews revealed that the resident did not receive the treatment, and the IS device was not found in the resident's room. Staff confirmed that the treatment was not administered as required, despite being signed off in the Treatment Administration Record (TAR). This failure left the resident without necessary respiratory support following a positive Covid-19 diagnosis and hospitalization for respiratory issues. Resident 31, who was admitted after sustaining a leg fracture and had no memory impairment, was observed receiving supplemental oxygen without a physician's order specifying the rate of administration. The oxygen tubing was undated, and staff confirmed that there were no physician orders to monitor the resident's blood-oxygen levels or administer oxygen. The Director of Nursing acknowledged that staff should have contacted the physician for proper orders but failed to do so. This oversight resulted in the resident receiving oxygen therapy without appropriate medical guidance and documentation, contrary to the facility's policy on oxygen administration.
Failure to Provide Person-Centered Dementia Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with dementia, specifically Resident 166. The resident had no verbal communication, was rarely or never understood, had both short-term and long-term memory problems, and was severely impaired with their daily decision-making. Despite being on an antipsychotic (AP) medication for dementia with behavioral disturbance, the resident's care plan (CP) was incomplete, not person-centered, and lacked necessary details about the resident's mental condition, visual hallucinations, and non-pharmacologic interventions. Observations showed Resident 166 sitting alone in the dining room, non-communicative, and not engaged in any meaningful activities, indicating a lack of individualized care and attention to their dementia needs. Interviews with staff confirmed the deficiencies in Resident 166's care plan. Staff F, the Resident Care Manager, acknowledged that the CP was incomplete and not person-centered, lacking resident-specific non-pharmacologic interventions. Staff B, the Director of Nursing, emphasized the importance of person-centered dementia care and the need for accurate care plans that reflect the residents' goals of care. The failure to develop and implement a comprehensive, person-centered care plan for Resident 166 placed the resident at risk for unmet care needs and a diminished quality of life.
Failure to Ensure Residents are Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. For Resident 18, the facility did not provide non-pharmacological interventions prior to administering an as-needed antipsychotic (AP) medication. Additionally, the facility did not re-evaluate and document the specific condition being treated with the as-needed AP medication, nor did they obtain consent prior to administering the psychotropic medication. The care plan for Resident 18 did not identify non-pharmacological interventions, and the physician did not justify the continued use of the as-needed AP medication despite recommendations from the facility's pharmacist. Observations showed Resident 18 was calm and did not exhibit behaviors that would necessitate the use of the AP medication, and there was no consent for the medication in the resident's records, as confirmed by the Director of Nursing and the Regional Director of Clinical Services. For Resident 13, the facility did not identify target behaviors for staff to monitor related to the use of an antidepressant (AD) medication. The care plan for Resident 13 lacked specific behaviors to monitor, and there was no consent for the AD medication in the resident's records. The Director of Nursing and the Regional Director of Clinical Services confirmed the absence of consent and stated that consent should be obtained and documented before administering psychotropic medications. The Director of Nursing also confirmed that target behaviors should be monitored and included in the care plan to assess the effectiveness of the medication and interventions. These deficiencies indicate that the facility did not adhere to its policy of obtaining informed consent before administering psychotropic medications and failed to implement non-pharmacological interventions and proper documentation. This placed the residents at risk of receiving unnecessary medications and experiencing adverse side effects, while also detracting from their ability to exercise their right to decline treatment.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that one of two garbage dumpsters and one recycling dumpster were properly covered and the surrounding areas were kept clean. During an observation and interview with the Dietary Manager, it was noted that the recycling dumpster lid was open and overflowing with boxes and recyclable materials. Additionally, the middle garbage dumpster's lid was not completely closed, with a clear plastic bag containing leftover food wedged in between and partially hanging out. The area around the third garbage dumpster was dirty, with trash and garbage debris, including a cigarette butt and several used surgical masks. The Dietary Manager confirmed that all staff are expected to keep the dumpsters covered, lids secured at all times, and surrounding areas clean to prevent insect and rodent infestations that could cause residents to get sick. The facility's policy on the disposal of garbage and refuse, dated 04/25/2024, mandates that all waste should be properly contained in the dumpsters and covered appropriately, and that all areas where garbage/refuse are located should be kept clean and maintained in a sanitary condition to prevent the harborage and feeding of pests.
Failure to Provide Required Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required for Resident 265, who was admitted with a right hip fracture and required both Physical Therapy (PT) and Occupational Therapy (OT) five times a week. Despite the assessment and care plan indicating the need for these services, Resident 265 reported receiving therapy only about three times a week. Therapy notes confirmed that for two consecutive weeks, the resident received OT and PT services fewer times than required. This discrepancy was further highlighted by a sign created by the resident's family to track therapy sessions, which indicated inconsistencies in the provision of therapy services. Interviews with Resident 265 and the Rehab Director revealed that the therapy schedule was not adequately coordinated with the resident's Hemodialysis (HD) treatments, which occurred three times a week. The Rehab Director acknowledged the lack of a proper system to ensure that residents who go out for HD receive their required therapy services. The family of Resident 265 expressed concerns about the missed therapy sessions and requested a revised schedule to accommodate the HD treatments, but the facility had not yet implemented an effective solution to address this issue.
Inconsistent Medical Records and Advance Directives Documentation
Penalty
Summary
The facility failed to ensure resident medical records were accurate and consistent for two residents. For Resident 166, the medical records showed conflicting information regarding the type of dementia diagnosis. The resident's diagnosis list indicated dementia without behavioral disturbance, while the Medication Administration Record (MAR) showed the resident was being treated with an antipsychotic medication for dementia with behavioral disturbance. This inconsistency was not clarified with the provider, leading to potential mismanagement of the resident's care needs. Staff F, the Resident Care Manager, acknowledged the documentation conflict but did not take steps to resolve it. For Resident 167, the facility failed to accurately document the resident's Advance Directives (AD) status. Although the resident had formulated an AD and designated a Durable Power of Attorney (DPOA) for healthcare decisions, this information was not reflected in the medical records. The Social Services (SS) progress notes initially indicated that the resident did not have a DPOA, and it was only after a delay that the AD was received and placed in the resident's records. Staff I, the Social Services Director, and Staff Q, the Admission Director, both acknowledged the lack of communication between their departments, which contributed to the inconsistency in the resident's records.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer a pneumococcal vaccine to Resident 213, who was one of five residents reviewed for vaccinations. According to the facility's policy, each resident should be offered a pneumococcal vaccine if eligible, and the vaccine should be administered per Physician Orders. Resident 213, who was admitted to the facility and not up to date on the pneumococcal vaccine, consented to receive the vaccine on 03/27/2024. The resident was scheduled to receive the vaccine on 04/11/2024, but it was not administered because the resident was out of the facility at that time. There was no follow-up to re-offer the vaccine when the resident returned, as confirmed by the Director of Nursing during an interview.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
