Garden Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Yakima, Washington.
- Location
- 206 South Tenth Avenue, Yakima, Washington 98902
- CMS Provider Number
- 505010
- Inspections on file
- 40
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at Garden Village during CMS and state inspections, most recent first.
A resident who was dependent on staff for ADLs, including bathing, did not receive a shower or bath for 11 days after admission, resulting in the development of a yeast rash. There was no documentation of refusals or alternative bathing methods, and the resident's name was not entered into the shower schedule, leading to the missed care.
The facility did not submit required direct care staffing information for one quarter, resulting in incomplete data being reported to CMS. Staff responsible for the submission could not confirm if the report was sent, and corporate review confirmed the data was missing. The current administrator was not aware of the issue until notified by surveyors.
A resident with a history of stroke and hemiplegia experienced a fall that was not reported to their physician or representative until 12 days later. The RN responsible for documenting the incident left abruptly due to a family emergency, leading to a lapse in communication and documentation. This failure to notify placed the resident at risk for delayed medical treatment and excluded the representative from healthcare decisions.
A resident with a femur fracture required substantial assistance for transfers, but the care plan was not updated to reflect this need. Staff were unsure of the transfer method and weight-bearing status, leading to an improper transfer without a gait belt. The MDS Coordinator missed updating the care plan, and the DON was unsure why the nursing staff did not update it upon readmission.
The facility failed to provide adequate supervision and safety measures for residents, leading to a tragic elopement incident, a burn injury from hot coffee, and unsafe smoking practices. A resident with impaired cognition was not assessed for elopement risk and was found deceased after leaving the facility unnoticed. Another resident suffered burns from hot coffee served without a lid, contrary to safety protocols. Additionally, a resident requiring supervision while smoking was observed smoking unsupervised and without safety equipment, posing a fire risk.
The facility failed to assess and address changes in residents' conditions, leading to significant deficiencies in care. A resident with a hip fracture and dementia experienced harm due to a pressure injury, while another resident with epilepsy continued to have seizures due to delayed medication administration. Additionally, a resident suffered from unmanaged constipation, and the facility failed to obtain or report lab results for several residents, highlighting deficiencies in care and communication.
A resident with dementia was hospitalized for four days after receiving the wrong medication due to an LPN's failure to follow the five rights of medication administration. The resident experienced acute toxic encephalopathy and low blood pressure, requiring intravenous fluids. The DON acknowledged the oversight in reviewing hospital records upon the resident's return.
The facility failed to discard expired foods in the dry storage room and walk-in refrigerator, as observed during a kitchen tour. Expired items included organic greens, salad mix, fresh onions, and coffee. The Dietary Manager admitted that the first in, first out system was not properly followed, and cooks missed checking expiration dates. There was also a lack of attention to dry storage items not often used.
The facility failed to provide adequate nursing staff, resulting in unmet care needs and delayed MDS assessments. Residents experienced insufficient assistance with activities of daily living, leading to frustration and potential negative health outcomes. The facility also failed to address significant changes in residents' conditions, prevent pressure injuries, and provide necessary restorative care. Additionally, inadequate supervision and training led to a resident elopement incident. Staffing shortages were a recurring issue, affecting care quality and response times.
The facility failed to complete quarterly MDS assessments within the required timeframes for six residents, resulting in delayed care planning. The MDS Coordinator, who was the only staff member completing these assessments after losing part-time help, acknowledged the delays. The Director of Nursing and Regional Nurse Consultant were aware of the issue and were seeking additional support.
The facility failed to provide necessary care and services for dependent residents, leading to unmet hygiene and care needs. A resident expressed frustration over missed showers due to staff shortages, while another was found in a state of neglect with unkempt grooming. Two other residents reported not receiving scheduled hygiene care, with documentation showing significant gaps in care. Staff interviews revealed inadequate communication and documentation of care refusals or attempts.
The facility failed to serve meals at safe and appetizing temperatures, affecting two residents. Multiple residents reported receiving cold meals, and observations confirmed that breakfast trays contained items below safe temperature ranges. Test trays also showed that both hot and cold foods were not maintained within safe temperature limits, and the correct process for handling such food was not followed.
During a COVID-19 outbreak, the facility failed to ensure staff compliance with infection control guidelines, as staff improperly used PPE and did not adhere to fit testing guidelines for N-95 respirators. Staff were observed exiting COVID-19 positive rooms with surgical masks over N-95 respirators and inconsistently applying PPE based on resident COVID-19 status. Additionally, staff with facial hair were improperly fit-tested, compromising mask effectiveness. Interviews revealed inconsistent instructions and a lack of understanding regarding PPE use.
The facility failed to provide written transfer notices to five residents and/or their representatives when they were hospitalized, despite their various medical conditions. Staff interviews revealed a lack of familiarity with the transfer notice form, leading to its omission during the discharge process. The Director of Nursing Services and other staff acknowledged the oversight and recognized the system's deficiencies.
The facility failed to provide bed hold notices to residents or their representatives during hospital transfers, affecting five residents. Staff interviews revealed a lack of awareness and responsibility for issuing these notices, leading to residents being uninformed about their rights and potential charges.
A facility failed to notify a resident or their representative when the resident's personal funds exceeded the SSI resource limit, risking Medicaid or SSI eligibility. The resident's account balance was $6419.37, surpassing the $2000 limit. The Business Office Manager acknowledged the oversight and confusion regarding the timeframe for spending down excess funds. The Social Services Director was not informed of the high balance, contrary to policy.
The facility failed to inform the Resident Representatives of two residents about significant weight loss. One resident with dementia experienced a 13.5% weight loss over six months, while another resident with malnutrition lost 29.92% of their weight over the same period. Staff interviews revealed confusion about the responsibility for notifying the RRs, resulting in a communication failure.
A resident with cognitive impairments left the facility with a family member and did not return as expected. The facility delayed notifying law enforcement and the State Agency, failing to report the incident in a timely manner. The resident's absence was noted, but there was a significant delay in contacting authorities, which hindered the search efforts. The DON and Regional Nurse Consultant did not consider the resident an elopement risk and did not use the facility's guidelines during the investigation.
The facility failed to complete admission MDS assessments within required timeframes for two residents, leading to potential delays in identifying care needs. One resident's assessment was 13 days late, while another's was 20 days late. The issue was attributed to staffing shortages, as acknowledged by an LPN and the DON.
The facility failed to implement comprehensive care plans for two residents. One resident, at risk when drinking hot beverages, was served coffee without a lid, resulting in a burn. Another resident with lymphedema did not have their condition adequately addressed in their care plan, leading to inconsistent application of prescribed leg wraps.
A resident at an LTC facility developed a pressure ulcer due to inadequate assessment and preventive care. Despite being at risk, the resident's sacral ulcer was not documented or measured, and preventive measures for heel protection were not implemented. Observations showed the resident's heels were often on the mattress, leading to a deep tissue injury on the right heel.
A resident with quadriplegia and other conditions did not receive the restorative care outlined in their care plan, including passive range of motion exercises. The facility lacked a fully staffed therapy department, and staff were not instructed to perform restorative programs or apply braces. The resident reported not receiving therapy for months, and the Therapy Director was unaware of the resident's contractures. The facility's restorative program was minimal, placing the resident at risk for decreased mobility and worsening contractures.
A facility failed to ensure proper communication and documentation for a resident requiring dialysis, leading to unmet professional standards of care. Despite attending 17 dialysis sessions, there was no evidence of communication between the facility and the dialysis center. Staff interviews revealed a lack of pre- and post-dialysis communication, and the Director of Nursing Services acknowledged the issue.
The facility failed to properly label and discard expired medications, as observed in medication carts and rooms. Expired glucagon shots, needles, Valproic Acid, and other medications were found, along with medications belonging to discharged residents. Staff acknowledged that medication destruction was not done timely, and some medications lacked proper labeling. The Director of Nursing stated that Unit Managers were responsible for ensuring medications were destroyed weekly and checked for expiration.
The facility failed to maintain accurate POLST documentation for two residents, leading to discrepancies between electronic records and scanned documents. One resident's electronic record indicated a DNR status, while a scanned document showed an order for CPR. Another resident's electronic record showed a DNR status, but the scanned document indicated CPR with full treatment. Staff interviews revealed potential system issues and a lack of awareness of the problem by the DON.
The facility failed to protect the privacy of two residents during care. A resident was left exposed during incontinent care by an NA, while another was found on a fall mat exposed to view. Staff did not initially ensure privacy, leaving residents vulnerable and exposed.
A facility failed to thoroughly investigate an abuse allegation involving a resident with dementia, insomnia, and kidney failure. The resident reported rough treatment by a staff member, leading to the staff's suspension. However, the investigation lacked necessary interviews to rule out abuse, as acknowledged by the DON, citing challenges with residents having dementia.
A facility failed to complete a significant change assessment for a resident admitted to hospice care with malnutrition and an untreated urine infection. Despite the requirement for such an assessment upon hospice admission, it was not completed, as confirmed by staff interviews. The oversight was acknowledged by the MDS Coordinator, and the facility was aware of the backlog in assessments.
Two residents experienced significant weight loss due to the facility's failure to implement RD recommendations and provide necessary assistance during meals. One resident, with schizoaffective disorder and malnutrition, lost 27.65% of their body weight over six months, while another resident, admitted with a fractured hip, lost 17.24% in less than four months. Observations showed a lack of staff assistance during meals and failure to monitor nutritional status, contributing to the residents' continued weight loss.
A resident with severe cognitive impairment was subjected to aggressive behavior and profanity by a Nursing Assistant during personal care. The incident was witnessed and reported by another staff member, and the resident received pain medication for wrist pain following the abuse. The facility's policy mandates the prevention of abuse, but it failed to protect the resident's rights.
Failure to Provide Timely Bathing Assistance for Dependent Resident
Penalty
Summary
A resident who was dependent on staff for activities of daily living (ADLs), including bathing and hygiene, did not receive a shower or bath for 11 days after admission. The resident was cognitively intact, incontinent of bowel and bladder, and required assistance from two staff members for ADLs. The resident reported not recalling being offered or refusing showers during this period. The resident developed a yeast rash in the perineal area, which was later treated with an antifungal medication after being examined by the facility physician. The resident's representative reported the lack of showers to facility staff, after which the resident received a shower. Review of the facility's records showed no documentation of shower refusals or alternative bathing methods, such as bed or sponge baths, during the first 11 days of the resident's stay. The resident's name was not entered into the shower/bath schedule book for the appropriate days, and staff confirmed that anyone reviewing the schedule would not have known it was the resident's shower day. The facility's policy required documentation of refusals and provision of necessary assistance for personal hygiene, which was not followed in this case.
Failure to Submit Required Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information, including data for agency and contract staff, to the Centers for Medicare and Medicaid Services (CMS) for the third quarter of 2024, as required by Payroll Based Journal (PBJ) reporting regulations. Review of the CASPER Payroll-Based Journal Staffing Data Report confirmed that the facility did not report staffing data for the period of July 1, 2024, through September 30, 2024. This omission resulted in CMS having inaccurate data related to the facility's nursing home staffing levels. Interviews with facility staff revealed that the Business Office Manager was responsible for PBJ reporting during the relevant period but could not recall if the report was run or submitted, and was unaware that the submission did not go through. The Director of Business Intelligence at the corporate office confirmed that the CASPER report showed no data was submitted and that a confirmation report should have been received. The current Administrator stated they were not in the role at the time and were unaware of the missing submission until the survey. This is a repeat citation from a previous Statement of Deficiencies.
Failure to Notify Physician and Representative of Resident Fall
Penalty
Summary
The facility failed to notify the physician and resident representative of a fall experienced by Resident 2, which was not reported until 12 days after the incident. Resident 2, who was admitted with diagnoses including a cerebral vascular accident and hemiplegia, had moderate cognitive impairment and required substantial physical assistance for transfers. The resident was at risk for falls due to confusion and unawareness of safety needs, as documented in their care plan. Despite these risks, the fall on 01/22/2025 was not communicated to the necessary parties, placing the resident at risk for a delay in medical treatment and excluding the resident representative from healthcare decision-making. The incident report for the fall was not completed until 02/03/2025, and the post-fall paperwork initiated by Staff C, an RN, was not documented in the resident's electronic health record. Staff C had a family emergency and left abruptly without notifying the next shift or completing the necessary documentation. The Director of Nurses, Staff B, was unaware of Staff C's departure and expected at least a text message notification. This oversight resulted in a failure to follow the facility's policy on notifying changes in condition and accident hazards supervision, as well as a repeat citation from a previous deficiency statement.
Failure to Revise Care Plan After Significant Change
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident after a significant change in their condition, which placed the resident at risk for injury and unmet care needs. The resident was readmitted with a left neck of the femur fracture and required substantial assistance for activities of daily living and transfers. However, the care plan, last revised on 11/18/2024, did not include updated interventions for the resident's transfer needs, such as the number of staff required for a safe transfer. During an observation, staff members were unsure of the resident's transfer method and weight-bearing status, leading to an improper transfer without the use of a gait belt. Interviews with staff revealed that the care plan should have been updated following the significant change assessment, but this was missed by the MDS Coordinator. The Director of Nursing stated that the nursing staff or unit manager should have updated the care plan upon the resident's readmission, but it was unclear why this was not done. The lack of updated information on the care plan and Kardex led to confusion among staff about the resident's transfer needs, resulting in a transfer that did not adhere to the necessary safety protocols.
Deficiencies in Resident Supervision and Safety Protocols
Penalty
Summary
The facility failed to ensure proper assessments and supervision for residents at risk of elopement, resulting in a tragic incident involving Resident 84. This resident, who had moderately impaired cognition and required assistance for activities of daily living, was not assessed for elopement risk upon admission. The facility's elopement procedures were not followed, as staff failed to recognize the resident's absence in a timely manner. Resident 84 was last seen by staff around midnight, but their absence was not noted until their significant other arrived for an appointment the next morning. By the time the facility initiated a search and notified law enforcement, Resident 84 was found deceased in the community. Another deficiency involved Resident 73, who suffered a second-degree burn from hot coffee served without a lid, despite being identified as a safety risk due to impaired cognition. The facility's policy required lids on hot beverages for residents like Resident 73, but this was not adhered to, leading to the resident spilling hot coffee in their lap. The coffee temperature was not consistently checked before serving, contributing to the incident. Additionally, the facility failed to implement safety interventions for Resident 12, who was assessed to require supervision and a smoking apron while smoking. Despite this assessment, Resident 12 was observed smoking unsupervised and without a smoking apron, both on and off facility grounds. The resident was also seen extinguishing cigarettes in a hazardous manner and storing them in their clothing, which posed a fire risk. The facility did not provide a designated area or device for safe cigarette disposal, further compromising safety.
Removal Plan
- Nursing staff identified all residents at risk for elopement who also had diagnoses of Substance Use Disorder (SUD) and updated the care plan.
- Implemented education on the elopement/missing person policy and process.
- Identified and recognized at-risk residents and the process for residents who wished to access the community.
- All education was to be completed prior to all staff's next scheduled shift.
Deficiencies in Resident Care and Medication Management
Penalty
Summary
The facility failed to adequately assess and address changes in residents' conditions, leading to significant deficiencies in care. Resident 83, who was admitted with a right hip fracture and dementia, experienced harm due to a facility-acquired pressure injury. Observations revealed that Resident 83 was often left in discomfort, with visible skin issues and without proper bedding or access to a call light. Despite documented new skin issues, there was a lack of follow-up treatment or monitoring, and staff failed to report or address the resident's pain and skin conditions. Resident 79, who was admitted with schizoaffective disorder and later diagnosed with epilepsy, continued to experience seizures due to the facility's failure to administer prescribed medications in a timely manner. Despite having orders for Midazolam nasal spray and Ativan, these medications were not processed or administered, resulting in ongoing seizure activity. The hospice nurse's orders were not reflected in the resident's medication administration record, and there was a lack of communication and follow-up to ensure the resident received necessary care. The facility also failed to manage constipation for Resident 12, who went extended periods without bowel movements despite having PRN medications available. The nursing staff did not document bowel assessments or notify the physician of the resident's condition. Additionally, the facility did not obtain or report laboratory results for several residents, including Residents 4, 30, and 68, despite repeated orders for necessary tests. This lack of follow-through on lab orders and referrals further exemplifies the facility's deficiencies in providing timely and appropriate care.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in harm to one of the residents. Resident 54, who had a diagnosis of dementia and severely impaired cognition, was mistakenly given an antipsychotic medication intended for another resident. This error led to the resident experiencing acute toxic encephalopathy and increased sleepiness, necessitating a four-day hospitalization. The incident occurred when Staff VV, an LPN, mixed up the medications of Resident 54 with their roommate's medications, failing to adhere to the five rights of medication administration: right patient, right drug, right dose, right route, and right time. The hospital discharge summary indicated that Resident 54 was admitted with low blood pressure and required intravenous fluids. The facility's incident investigation confirmed that Staff VV realized the error and contacted the physician, who ordered the resident to be sent to the hospital. Despite the Director of Nursing Services stating that the resident returned to their baseline with no negative effects, the failure to follow proper medication administration protocols was evident. The Director also acknowledged not reviewing the hospital records upon the resident's readmission, which was an oversight.
Expired Food Items Found in Storage
Penalty
Summary
The facility failed to adhere to its food safety policy by not properly discarding expired foods in both the dry food storage room and the walk-in refrigerator. During an observation conducted on a kitchen tour, several expired food items were found, including organic greens, a spring mix salad blend, fresh onions, and boxes of coffee. These items were past their expiration dates, indicating a lapse in the facility's food rotation and monitoring processes. Staff R, the Dietary Manager, acknowledged the deficiency during an interview, explaining that the facility's process involved a first in, first out system to prevent food expiration. However, it was revealed that the cooks, who were responsible for checking expiration dates during each shift, missed these items. Additionally, there was an oversight in monitoring the dry storage area, particularly for items not frequently used, highlighting a need for a more effective system.
Staffing Shortages and Inadequate Care in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in unmet care requirements and potential negative outcomes for their physical and mental health. Observations and interviews revealed that the facility was short-staffed, leading to delays in providing essential care such as bathing, grooming, and assistance with activities of daily living. Residents expressed frustration over not receiving scheduled showers, and staff confirmed that they were unable to complete tasks due to staffing shortages. The lack of adequate staffing also affected the completion of Minimum Data Set (MDS) assessments, with several being completed late or not at all. The facility also failed to address significant changes in residents' conditions, such as the admission of a resident to hospice care without completing a significant change MDS assessment. Additionally, the facility did not prevent the development of pressure injuries, as evidenced by a resident developing a deep tissue injury on their heel due to improper positioning and lack of preventive measures. The facility's restorative care program was insufficient, with residents not receiving necessary therapy to maintain range of motion and prevent contractures. Furthermore, the facility did not ensure proper supervision and training to prevent elopements, as demonstrated by a resident who went missing without an elopement risk assessment or care plan in place. Staff interviews indicated a lack of training on elopement procedures, and the facility's staffing issues contributed to the inability to provide adequate supervision. The resident council meeting and additional resident interviews highlighted ongoing concerns about staffing levels, long wait times for assistance, and inconsistent care quality, particularly on weekends and during shifts with high call-ins.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the regulatory timeframes for six residents, leading to a deficiency in timely care planning and assessment. The residents affected were identified as Residents 2, 11, 1, 19, 49, and 71. Each of these residents had their MDS assessments completed significantly past the required 92-day timeframe, with delays ranging from 26 to 43 days. This delay in completing the assessments placed the residents at risk for delayed care planning and potentially unidentified care needs. The deficiency was acknowledged by the facility staff during interviews. Staff E, the Licensed Practical Nurse and MDS Coordinator, admitted to being aware of the overdue assessments and attributed the delays to being the sole person responsible for completing them after losing part-time assistance. Additionally, the Director of Nursing Services and the Regional Nurse Consultant were also aware of the backlog and were in the process of seeking additional help for the MDS Coordinator. The failure to complete these assessments on time was a violation of the regulatory requirements, as outlined in the Resident Assessment Instrument manual.
Failure to Provide Adequate Hygiene and Care
Penalty
Summary
The facility failed to provide necessary care and services to ensure that dependent residents received assistance with dressing, personal hygiene, and shower/bathing. This deficiency was observed in four residents, who were at increased risk for skin breakdown and unmet care needs. Resident 5, who had intact cognition and required substantial assistance, expressed frustration over not receiving scheduled showers due to staff shortages. Documentation showed significant gaps between showers, and there was no record of the resident refusing care. Resident 83, with moderately impaired cognition, was observed in a state of neglect, with unkempt grooming and hygiene. Despite requiring assistance for hygiene and dressing, the resident was found in an unmade bed, with black debris under their nails and an untrimmed beard. Staff interviews revealed a lack of communication and follow-up on the resident's care needs, with no documentation of refusals or attempts to provide care. Resident 18, who was dependent on staff for hygiene, reported not receiving a bed bath for two weeks, despite preferring them. Documentation showed only one bed bath in a month. Similarly, Resident 51, who required substantial assistance, had not received a shower in three weeks and had minimal toenail care throughout the year. Staff interviews indicated a lack of adherence to care schedules and inadequate documentation of care refusals or attempts, contributing to the deficiency.
Failure to Serve Meals at Safe Temperatures
Penalty
Summary
The facility failed to serve meals at safe and appetizing temperatures, affecting two of the five residents reviewed for food quality. During a resident council meeting, multiple residents expressed concerns about consistently receiving cold meals. Observations and interviews revealed that Resident 3's breakfast tray was left out of reach and contained items at temperatures below the safe range, such as coffee at 91.1 degrees F and pureed eggs at 79.4 degrees F. Resident 3 reported that their food was often cold because staff were occupied with other tasks. Similarly, Resident 1 received a breakfast tray with items like scrambled eggs at 90.6 degrees F, which were also below the acceptable temperature range. Test trays checked by the Dietary Manager confirmed that both hot and cold foods were not maintained within the safe temperature ranges, with hot foods like breaded chicken at 130 degrees F and cold items like vanilla pudding at 58.5 degrees F. The Dietary Manager acknowledged that the process for handling food outside the acceptable temperature range was not followed, as trays should be reheated or replaced if they had been sitting for over an hour. This oversight placed residents at risk for decreased nutritional intake and potential foodborne illness.
Infection Control and PPE Non-Compliance During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure staff compliance with infection control guidelines during a COVID-19 outbreak, as observed through multiple instances of improper use of personal protective equipment (PPE) and non-adherence to fit testing guidelines for N-95 respirators. Staff members were seen exiting COVID-19 positive rooms wearing surgical masks over their N-95 respirators to avoid replacing them, and some staff did not don the required gown, gloves, or eye protection when entering these rooms. Additionally, staff were inconsistently applying PPE based on whether they were directly caring for COVID-19 positive residents, despite guidelines requiring full PPE for any entry into such rooms. The facility's Respirator Management Program was not followed, as staff with facial hair were improperly fit-tested and allowed to wear N-95 respirators, which compromised the effectiveness of the masks. Staff AA, T, and K were observed wearing N-95 respirators with facial hair, and their fit test records indicated discrepancies in adherence to the requirement for being clean-shaven. Staff H, responsible for fit testing, acknowledged not following the correct procedures and was unaware of the staff's assignments to COVID-19 positive rooms. Interviews with staff revealed a lack of understanding and inconsistent instructions regarding PPE use, with some staff being told to only wear full PPE when caring for COVID-19 positive residents. The Director of Nursing Services was aware of the non-compliance but unsure of the reasons behind it. The Infection Control Preventionist also acknowledged the importance of being clean-shaven for effective respirator use but was unaware of the staff's non-compliance with this requirement.
Failure to Provide Transfer Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to five residents and/or their representatives when the residents were hospitalized. This deficiency was identified during a review of the medical records and interviews with staff. The residents involved had various medical conditions, including cellulitis, toxic encephalopathy, dementia, lymphedema, diabetes, severe obesity, quadriplegia, scoliosis, and depression. Despite these conditions, the facility did not issue the required transfer notices, which are essential for ensuring that residents and their representatives are informed of their rights and the reasons for the transfer. Interviews with staff revealed a lack of familiarity with the transfer notice form and a failure to complete it during the discharge process. Staff J, a Licensed Practical Nurse/Unit Manager, admitted to not being familiar with the form and stated that if it was not in the computer system, it was not completed. Additionally, the Director of Nursing Services, Administrator Designee, and Regional Nurse Consultant acknowledged the oversight and recognized that the system for issuing transfer notices was broken. This failure to provide the necessary documentation placed the residents at risk for unmet discharge needs.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to issue a written notice of bed hold to residents or their representatives at the time of hospital transfer, as required by their policy. This deficiency was identified for five residents who were transferred to the hospital. The facility's policy, dated July 2018, mandates that bed hold notifications be provided at the time of transfer or within 24 hours in emergency situations. However, this protocol was not followed, leaving residents and their representatives uninformed about their rights and any associated charges. Resident 5, with intact cognition, was transferred to the hospital for an infection but did not receive a bed hold notice. Similarly, Resident 54, who had severe cognitive impairment, was transferred after receiving incorrect medication, and their representative was unaware of the bed hold policy. Staff interviews revealed a lack of awareness and responsibility regarding the issuance of bed hold notices, contributing to the oversight. Additional residents, including Resident 67 with severe cognitive impairment, Resident 18 with intact cognition, and Resident 51 with intact cognition, were also transferred to the hospital without receiving bed hold information. Staff members, including the Director of Nursing Services and other administrative staff, acknowledged the failure to provide the necessary documentation and recognized the need for system improvements.
Failure to Notify Resident of Excessive Personal Funds Balance
Penalty
Summary
The facility failed to notify a resident, their Resident Representative (RR), or payee when the resident's personal funds account balance was below $200 of the Social Security Income (SSI) resource limit of $2000. This deficiency was identified for one of the five residents reviewed for personal funds, specifically Resident 64. The facility's policy required that the resident or RR be informed when their trust balance was within $200 of the SSI limit, and a copy of the notification should be placed in the resident's financial file. However, this procedure was not followed, placing the resident at risk of losing Medicaid or SSI eligibility. Resident 64 had a trust fund account balance of $6419.37, which exceeded the SSI resource limit. The Business Office Manager, Staff S, acknowledged that there were residents with high balances due to back payments from Social Security and initially stated that residents had 180 days to spend down these funds. However, Staff S later mentioned a nine-month timeframe for spending down the funds, but could not provide documentation to support this claim. Additionally, Staff S admitted to not informing Resident 64's RR about the high balance. The Social Services Director, Staff F, was also not notified of the high balance, contrary to the facility's policy. The Administrator Designee, Staff C, expressed that they would have expected the family or RR to be notified and a spend down initiated.
Failure to Notify Resident Representatives of Significant Weight Loss
Penalty
Summary
The facility failed to inform the Resident Representatives (RR) of two residents, Resident 68 and Resident 79, about significant weight loss, which is a change in condition that should have been communicated. Resident 68, who was admitted with dementia, anxiety disorder, and failure to thrive, experienced a severe weight loss of 5.1% in one month and 13.5% over six months. Despite attending a nutrition at risk meeting where this weight loss was discussed, the RR was not notified, as confirmed by interviews with staff members who acknowledged that the RR should have been informed. Similarly, Resident 79, who was admitted with malnutrition and later to hospice care, experienced a 9.73% weight loss in one month and a 29.92% loss over six months. The RR was not informed of this significant weight loss until a hospice nurse mentioned it during the hospice admission process. Staff interviews revealed confusion about whose responsibility it was to notify the RR, with some staff assuming it was the responsibility of others, leading to a failure in communication.
Failure to Timely Report Missing Resident
Penalty
Summary
The facility failed to report an incident involving a missing resident in a timely manner to local law enforcement and the State Agency as required. The incident involved a resident with a history of stroke, frontal lobe deficit, and psychoactive substance abuse, who had moderately impaired cognition and required assistance for activities of daily living. The resident left the facility with a family member and did not return as expected. Despite the resident's absence being noted, there was a significant delay in notifying law enforcement and the State Agency, which hindered the opportunity for assistance in locating the resident. The nursing progress notes indicated that the resident left the facility at 4:30 PM, and it was not until 1:54 AM the following day that the resident's representative was contacted, who confirmed the resident was not with them. Law enforcement was only contacted at 7:02 AM, over 14 hours after the resident left the facility. The Director of Nursing Services and the Regional Nurse Consultant admitted to not reporting the incident to the State Agency and not considering the resident an elopement risk. They also acknowledged not utilizing the facility's guidelines, known as The Purple Book, during their investigation.
Failure to Complete Admission MDS Assessments Timely
Penalty
Summary
The facility failed to complete the admission Minimum Data Sets (MDS) for two residents within the required timeframes, as mandated by the Resident Assessment Instrument (RAI) guidelines. Resident 293 was admitted with diagnoses including respiratory failure, bipolar disorder, Parkinson's Disease, and acute kidney failure. The admission MDS for this resident had an Assessment Reference Date (ARD) of 09/29/2024, but the assessment was not completed until 10/22/2024, which was 13 days late. Similarly, Resident 245, admitted with diagnoses of stroke, depression, and pain, had an ARD of 09/29/2024, but the assessment was completed on 10/29/2024, 20 days late. The delay in completing the MDS assessments was acknowledged by Staff E, the Licensed Practical Nurse/MDS Coordinator, who stated that they were the only staff member currently completing the assessments due to the recent loss of part-time help. Staff B, the Director of Nursing Services, was also aware of the issue and mentioned efforts to provide assistance to Staff E. The failure to complete these assessments within the required timeframes placed residents at risk for delayed identification of care needs and/or unmet care needs.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement a comprehensive care plan for Resident 73, who was identified as being at risk when drinking hot beverages. Despite the care plan specifying that lids were required on their coffee cups, an incident occurred where a nursing assistant served the resident coffee without a lid, resulting in the beverage spilling and causing a second-degree burn. This incident highlights the failure to adhere to the care plan, which was acknowledged by the Director of Nursing Services during an interview. Additionally, the facility did not adequately address the care needs of Resident 18, who was admitted with lymphedema, severe obesity, and high blood pressure. The resident's care plan did not include specific interventions for managing lymphedema, despite physician orders for diuretics and leg wraps. Observations revealed that the resident often did not have the prescribed leg wraps applied, and the care plan lacked goals and interventions for this condition. The Director of Nursing Services admitted that the care plan should have addressed the resident's lymphedema.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer for Resident 293, who was admitted with multiple diagnoses including respiratory failure, bipolar disorder, Parkinson's Disease, and acute kidney failure. Upon admission, the resident was assessed as being at risk for pressure ulcers, but the assessment did not document the presence of a sacral pressure ulcer noted at admission. A nursing admission assessment indicated a skin impairment, directing a wound assessment, which was not completed. Despite treatment orders to cleanse and dress the sacral area, there were no measurements or staging documentation found in the records. Observations revealed that Resident 293 was frequently positioned in bed with their heels on the mattress, which is contrary to pressure ulcer prevention practices. The resident reported heel pain, and staff observations noted a darker pink area on the right heel, but no immediate action was taken to address this. It was only after a fall that a dark purple area was observed on the resident's right heel, which was later assessed as a deep tissue injury caused by pressure. Interviews with staff revealed a lack of awareness regarding the sacral wound's measurement and staging, and the necessity of preventive measures such as heel boots and floating heels. The facility's failure to adhere to its own skin integrity policy and professional standards of practice resulted in the development of a deep tissue injury on the resident's heel, highlighting deficiencies in the assessment, documentation, and preventive care for pressure ulcers.
Failure to Provide Restorative Care for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with limited range of motion (ROM), specifically Resident 51, who was diagnosed with quadriplegia, scoliosis, muscle weakness, and depression. Despite having a care plan that included a restorative program with passive range of motion exercises for both lower and upper extremities, the resident reported not receiving any therapy for months. Interviews with the resident and staff revealed that the facility lacked a fully staffed therapy department and did not have restorative staff to implement the care plan. The Therapy Director admitted to not being aware of the resident's contractures and confirmed that the resident was not on their caseload. Further investigation showed that the facility's restorative program was minimal, with staff acknowledging that it was a 'lost area' they were trying to address. Nursing assistants reported not being instructed to perform restorative programs or apply braces/splints for residents. The Director of Nursing Services and the Regional Nurse Consultant acknowledged the inadequacy of the restorative program, which was not robust due to minimal staffing. The lack of therapy and restorative care placed Resident 51 at risk for decreased mobility and worsening contractures, as evidenced by the resident's internally rotated feet and absence of braces or splints.
Deficiency in Dialysis Care Communication
Penalty
Summary
The facility failed to ensure that dialysis services met professional standards of care for Resident 193, who required dialysis due to end-stage renal disease. The resident was admitted with multiple diagnoses, including diabetes, heart failure, and anxiety, and required substantial assistance with activities of daily living. Despite the facility's policy mandating collaboration and communication with the dialysis center, there was no documented communication between the facility and the dialysis center regarding the resident's dialysis treatments. The resident had attended 17 dialysis sessions, yet there was no evidence of pre- or post-dialysis communication or documentation in the medical record. Interviews with staff revealed a lack of communication and documentation regarding the resident's dialysis care. Staff members, including LPNs and RNs, acknowledged that they did not receive or seek post-dialysis reports from the dialysis center. The resident reported receiving minimal attention from nurses after returning from dialysis, and staff confirmed that they had not seen any documentation from the dialysis center. The Director of Nursing Services and the Regional Nurse Consultant acknowledged the communication issues, indicating that nurses should document the resident's dialysis visits and obtain necessary communications from the dialysis center.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled according to professional principles and discarded when expired, as observed in one of two medication carts and one of two medication rooms. During an observation at the Main Nurse's Station, expired medications were found, including glucagon shots, needles, Valproic Acid, hemorrhoidal suppositories, and Prevnar injections. Additionally, medications belonging to discharged residents were not removed, and some medications lacked proper labeling, such as opened dates. Staff J, a Licensed Practical Nurse/Unit Manager, acknowledged that medication destruction was not done timely and assumed the pharmacist monitored for expired medications. Further observations on Hall 1 and Hall 2 medication carts revealed additional expired medications, including Acidophilus supplements and glucagon pens. There were also medications without opened dates, such as Lantus and fluticasone bottles. Staff B, the Director of Nursing Services, stated that Unit Managers were responsible for ensuring discontinued or discharged resident medications were destroyed weekly and that medications should be rotated and checked for expiration upon stocking. Staff B also mentioned that the consulting pharmacy monitored expired medications bi-weekly.
Inconsistent POLST Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that each resident's medical record was complete and accurately documented their Physician Orders for Life-Sustaining Treatment (POLST) for two residents reviewed for advanced directives. Resident 67, who had severe cognitive impairment and multiple diagnoses including chronic obstructive pulmonary disease and liver cirrhosis, had conflicting POLST documentation. The electronic medical record indicated a DNR status, while a scanned document showed an order to attempt CPR. Additionally, the POLST in the nurse's station binder matched the electronic record, indicating a DNR order. This inconsistency was confirmed during an interview with Staff V, who noted that the newest POLST might not have been scanned into the record, potentially causing staff confusion. Similarly, Resident 73, who also had severe cognitive impairment and was diagnosed with dementia and depression, had discrepancies in their POLST documentation. The electronic medical record showed a DNR status, but the scanned document indicated an order for CPR with full treatment. No POLST forms were found in the nurse's station binder for this resident. Staff V acknowledged a possible system issue after reviewing the records and noted that audits had been conducted to ensure each resident had a POLST, but the dates had not been matched. The Director of Nursing Service was unaware of the problem with the POLST forms until it was brought to their attention.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
The facility failed to protect the personal privacy of two residents during care activities. Resident 245, who was admitted with diagnoses including stroke, depression, and pain, was observed during incontinent care. The nursing assistant, Staff NN, left the resident exposed from the waist down after removing a soiled brief and cleaning the resident. This exposure occurred when Staff NN left the bedside to change gloves and wash hands, leaving the resident feeling cold. The resident had moderate cognitive impairment and was not continent of bowel or bladder, highlighting the need for careful and respectful handling during personal care. Resident 293, admitted with conditions such as respiratory failure, bipolar disorder, Parkinson's Disease, and acute kidney failure, was found on a fall mat between their bed and an open door, wearing only a brief. Staff Y, an NA, responded to the resident's call for help and found them exposed. The privacy curtain was open, and the resident was visible to anyone passing by. Staff P, an LPN, and other staff members entered the room without initially ensuring the resident's privacy. The Director of Nursing Service later instructed the staff to pull the privacy curtain, shut the door, and cover the resident with a blanket. This incident reflects a failure to maintain the resident's right to privacy during a vulnerable moment.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving a resident with dementia, insomnia, and kidney failure. The resident required substantial assistance with activities of daily living and had severely impaired cognition. An incident report indicated that the resident reported to a Nursing Assistant that another staff member was rude and rough during care. Although the staff member in question was suspended, the investigation was incomplete as it lacked additional resident or staff interviews to rule out abuse. The Director of Nursing Services acknowledged the investigation's incompleteness, citing challenges due to some residents having dementia. The facility's policy required a thorough investigation, including interviews, to rule out abuse, but this was not adhered to in this case. The failure to complete a comprehensive investigation placed the resident at risk for potential abuse and other negative health outcomes.
Failure to Complete Significant Change Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a significant change assessment for Resident 79, who was reviewed for hospice and end-of-life care. According to the Resident Assessment Instrument Manual, a significant change assessment is required when a resident is placed on hospice with a terminal prognosis and a life expectancy of six months or less. Resident 79 was admitted to hospice services with diagnoses of malnutrition and an untreated urine infection, for which the Resident Representative chose not to receive additional treatment. Despite these conditions, a significant change assessment had not been completed as of 10/29/2024. Interviews with facility staff revealed that the MDS Coordinator acknowledged the oversight, stating they had not yet completed the assessment for Resident 79. Further discussions with the Administrator Designee, Director of Nursing Services, and Regional Nurse Consultant confirmed awareness of the backlog in MDS assessments and their efforts to address the issue. This deficiency placed Resident 79 at risk for unmet care needs due to their declining health.
Failure to Implement Nutritional Interventions Leads to Significant Weight Loss
Penalty
Summary
The facility failed to consistently monitor or implement interventions per Registered Dietician (RD) recommendations for two residents, leading to significant weight loss and nutritional dissatisfaction. Resident 79, diagnosed with schizoaffective disorder and malnutrition, experienced a severe weight loss of 27.65% over six months. Despite recommendations for one-on-one assistance with meals and a Speech Language Pathologist (SLP) evaluation, these were not implemented. Observations showed Resident 79 was not assisted during meals, and their requests for diet changes were not addressed. The facility's failure to follow through with RD recommendations and obtain necessary evaluations contributed to the resident's continued weight loss. Resident 83, admitted with a fractured hip and malnutrition, also experienced significant weight loss, losing 17.24% of their body weight in less than four months. Observations revealed that Resident 83's meals were placed out of reach, and they received no assistance during mealtimes. Despite being identified as at risk for malnutrition, the facility did not consistently obtain weights or follow up on nutritional interventions. The lack of staff assistance and failure to monitor the resident's nutritional status contributed to their continued weight loss. Interviews with staff revealed systemic issues in processing RD recommendations and obtaining necessary evaluations. Staff members were unaware of the need for SLP evaluations, and there was a lack of communication regarding weight monitoring and nutritional interventions. The Director of Nursing Services acknowledged that RD recommendations should have been treated as orders, but the facility struggled with obtaining SLP services. These deficiencies in care and communication led to the residents' significant weight loss and nutritional dissatisfaction.
Failure to Protect Resident from Verbal and Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and physical abuse. Resident 1, who had severe cognitive impairment and required extensive assistance for personal hygiene, was subjected to aggressive behavior by Staff D, a Nursing Assistant. On the evening of 04/28/2024, Staff D grabbed Resident 1's arm aggressively, causing pain, and screamed profanity at the resident while providing personal care. This incident was witnessed by Staff C, another Nursing Assistant, who reported the abuse immediately to the charge nurse. Resident 1 complained of wrist pain and received pain medication following the incident. An X-ray of the wrist was ordered, and the results were negative for any injury. During interviews, Resident 1 confirmed the abuse and expressed that it was not right for anyone to do that. Staff D denied the allegations, while Staff C corroborated the resident's account of the incident. The facility's policy on abuse, neglect, and exploitation, dated 09/20/2023, mandates the prohibition and prevention of abuse to protect the health, welfare, and rights of each resident. Despite this policy, the facility failed to prevent the abuse, leading to a deficiency in protecting the resident's rights.
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A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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