Gig Harbor Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Gig Harbor, Washington.
- Location
- 3309 45th Street Court Northwest, Gig Harbor, Washington 98335
- CMS Provider Number
- 505436
- Inspections on file
- 45
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Gig Harbor Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple cardiac conditions, muscle weakness, unsteadiness, and a recent AICD placement reported that an RN told them to transfer and clean themself in the bathroom and stated they would have to do it themself or stay there forever. A CNA later found the resident in the bathroom, was told about the RN’s statements, and learned the resident had transferred and cleaned themself despite pain and left arm restrictions, but the CNA only informed the oncoming CNA and did not notify a supervisor because the resident asked them not to. Another CNA subsequently learned of the allegation and reported it to a nurse, but by then the facility’s policy and regulatory requirements for immediate reporting of abuse allegations to management and state authorities had already been violated.
A resident with dementia and moderate cognitive impairment, who ambulated independently on a locked unit, was taken by the hand into another resident’s room and had their breasts touched inappropriately by a severely cognitively impaired resident with dementia, aphasia, and a history of sexually inappropriate behaviors toward staff. Despite multiple documented incidents of this behavior, the facility did not timely add specific interventions to the behavior care plan, and when 1:1 supervision was later ordered, CNAs did not consistently maintain line-of-sight observation, allowing the resident to move out of visual range and into their room with the door closed. Staff interviews showed awareness of the sexually inappropriate behaviors but a lack of clear, pre-existing care plan guidance on how to manage them.
Staff failed to immediately report a witnessed incident of resident-to-resident sexual abuse involving two cognitively impaired residents, one with dementia and anxiety and the other with dementia, aphasia, and a cognitive communication deficit. A CNA discovered one resident in another’s room being touched on the breasts and notified an LPN, who documented an alert report but did not promptly notify the administrator, state agency, or police as required by facility policy and state guidelines. The incident was not reported to the state agency until the following day, well beyond the required two-hour reporting timeframe, despite staff interviews indicating they understood abuse should be reported immediately to supervisors and the DSHS hotline.
The facility did not provide timely emergency care or complete required post-fall monitoring for three residents who experienced falls, including a resident on anticoagulants who suffered a head injury and was not promptly sent for medical evaluation, resulting in serious harm. Documentation of alert charting was also incomplete or missing for multiple falls, despite staff and policy expectations.
Two residents with cognitive impairment did not consistently receive the correct size of briefs due to supply shortages, resulting in discomfort and inadequate containment of urine. Staff confirmed that brief shortages led to the use of incorrect sizes or delays in obtaining supplies, and the administrator was unaware of the need for daily supply order approvals.
A resident with a positive TB screening and inconclusive chest x-rays was not managed according to infection control standards, as the care plan was not updated, the local health jurisdiction was not promptly notified, and appropriate precautions were not clearly implemented or documented. Staff were uncertain about the correct type of precautions, and there was no systematic monitoring or intervention for possible TB exposure among staff or other residents.
The facility did not provide enough nursing staff to meet residents' needs, leading to missed showers, delayed call light responses, and a high number of falls. A resident dependent on staff for transfers was left in bed for several days without basic hygiene care, while another went weeks without a shower or hair wash. Staff reported caring for up to 15 residents at a time and struggling to complete care tasks, especially on weekends.
A resident with moderate cognitive impairment received an antibiotic that was not ordered, after a nurse failed to enter a verbal order into the electronic system, did not administer the medication as prescribed, and used another resident's discontinued medication. Required documentation for a change in condition was also not completed, and the medication was not pulled from the automated dispensing system as expected.
A resident with severe cognitive impairment and a recent hip surgery experienced a fall that was not reported or investigated at the time of the incident. The responsible nurse failed to notify management or implement risk management procedures, and the event was only discovered after the resident developed acute hip pain, leading to a delayed investigation that identified a dislocated hip arthroplasty.
A resident with anemia, who was cognitively intact, was physically harmed when a CNA abruptly pushed their wheelchair, causing knee injury and pain. The CNA, already suspended due to multiple abuse allegations, acted after expressing frustration at the resident's pace. The incident was reported about a week later, and the facility's investigation confirmed the CNA's involvement.
A resident with chronic pain was left without a fentanyl patch for 59 hours due to the facility's failure to ensure medication availability and obtain an alternative prescription. Despite severe pain reports, staff did not utilize available resources or contact the provider for a substitute, leading to significant discomfort for the resident.
Two residents experienced falls due to inadequate supervision and failure to follow care plans requiring two-person assistance during bed mobility. One resident sustained injuries requiring hospital evaluation, while the other had an assisted fall with no injuries. The root cause was identified as staff not adhering to the care plans.
The facility failed to implement effective infection control measures, leading to a widespread outbreak of respiratory illness among residents. Despite recommendations, the medical director did not fully follow CDC guidelines, resulting in delayed testing and treatment. Staff frequently neglected PPE protocols, and shared equipment was not sanitized properly, further contributing to the spread of infection.
The facility's QAPI program failed to self-identify and sustain corrections for deficiencies, leading to repeated and widespread issues. The DNS and Administrator acknowledged the need for improvement in the QAPI process. Deficiencies included infection control, residents' rights, and care planning.
Two residents in an LTC facility experienced unaddressed grievances, one involving a disruptive roommate and the other missing personal property. Despite expressing concerns to staff, no grievance forms were filed, and the facility's grievance logs showed no records of these issues.
The facility failed to provide written notification of transfer reasons to two residents hospitalized, as required by regulations. One resident with a history of stroke and atrial fibrillation was transferred without written notice, and another with a below-knee amputation and diabetes was also sent to the hospital without written notification. Staff confirmed that while verbal notifications were made, written documentation was not provided.
The facility failed to properly screen residents with mental health disorders for additional supports using the PASRR process. Four residents with diagnoses such as depression, anxiety disorder, and bipolar disorder were not referred for necessary PASRR level two evaluations, despite indications. Interviews with staff confirmed these oversights did not meet expectations.
The facility failed to conduct timely care conferences for four residents, as required by policy. Despite being able to communicate their needs, these residents had not participated in care conferences within the expected timeframes, with the last conferences occurring several months prior. Staff interviews confirmed that the facility was behind on scheduling these conferences, which are expected to occur quarterly.
The facility failed to provide adequate restorative care for three residents, leading to deficiencies in maintaining or improving their range of motion. One resident with arthritis and spinal stenosis was not included in a restorative program despite recommendations. Another resident with a hand contracture did not receive necessary interventions, and a third resident with hemiplegia lacked a care plan for ROM. Staff interviews confirmed the absence of a restorative program due to staffing issues.
The facility failed to consistently document pre and post dialysis assessments and maintain communication with the dialysis center for two residents requiring dialysis. Incomplete records and missing information were noted, and staff interviews confirmed that the documentation did not meet expectations.
The facility failed to use nonpharmacological interventions (NPI) before administering PRN pain medications for three residents, leading to a deficiency in medication management. A resident with an amputation and depression received PRN pain medication multiple times without documented NPI. Another resident with bipolar disorder and COPD received acetaminophen for pain without NPI documentation. A third resident with a history of amputation and diabetes also received PRN acetaminophen without NPIs being attempted. Staff interviews confirmed the lack of adherence to the protocol.
A medication error rate exceeding five percent was identified when an LPN administered metoclopramide and 12 other medications to a resident at incorrect times, contrary to the provider's orders. The medications were given at 9:19 AM instead of the specified times of 7:00 AM and 8:00 AM. The DON confirmed that the expectation for correct timing was not met.
The facility failed to properly store and label medications, with unsupervised medications left on a nurses' station counter and incomplete temperature logs for medication storage refrigerators. Medication carts contained undated or expired medications, and staff acknowledged these deficiencies. The DON confirmed that medications should be secured and monitored appropriately.
The facility failed to ensure residents understood arbitration agreements, leading to a deficiency in informed consent. A resident with hemiplegia and cognitive deficits, another with bipolar disorder, and a third with dementia signed agreements without understanding them. Staff relied on judgment to assess residents' ability to sign, resulting in inadequate handling of arbitration agreements.
The facility failed to implement an effective Antibiotic Stewardship Program, leading to inappropriate antibiotic use for several residents. The infection preventionist did not review antibiotic utilization daily, and provider orders lacked specific indications for use. This oversight placed residents at risk for adverse outcomes. Staff acknowledged the failure to document reasons for antibiotic use, which did not meet facility expectations.
A resident receiving duloxetine for depression did not receive information on the risks and benefits, nor was consent obtained, as required by facility protocol. Interviews with staff confirmed this oversight, which did not meet the facility's expectations.
A resident with paraplegia and cognitive communication deficit reported verbal mistreatment by staff, including accusations and inappropriate questioning, which was witnessed by other staff members. The facility's incident report lacked proper documentation, and the Administrator initially failed to recognize the incident as abuse, contrary to the facility's abuse prevention policy.
A resident with paraplegia and cognitive communication deficit reported an incident where a staff member accused them of theft and gang involvement, which was not documented or reported by the facility. The Administrator later acknowledged the oversight, recognizing the need for state reporting as per policy.
A facility failed to report and investigate an allegation of abuse involving a resident who felt unsafe due to another resident's behavior. The incident was reported to a receptionist but was not documented or investigated, as confirmed by the DNS.
The facility failed to accurately complete MDS assessments for two residents, leading to potential risks for unmet care needs. One resident was not coded for corrective lenses despite having new prescription glasses, and another resident's antibiotic therapy and continuous oxygen use were not accurately reflected in the MDS. Staff interviews confirmed the inaccuracies.
The facility failed to develop and implement comprehensive care plans for four residents, leading to unmet care needs. A resident with arthritis and spinal stenosis lacked a care plan for mobility interventions, while another with a hand contracture had no plan for restorative nursing or therapy devices. A third resident with hemiplegia had no range of motion interventions, and a fourth with sepsis had no care plan for their PICC line or antibiotic therapy. Staff interviews confirmed the absence of necessary care plans.
A resident with muscle weakness and difficulty walking did not receive scheduled showers and facial hair removal, as documented inaccurately by staff. Observations showed the resident with long facial hair, and interviews revealed discrepancies in care documentation, with staff acknowledging the inaccuracies and failure to meet scheduled care requirements.
The facility failed to follow provider orders for two residents, leading to missed dressing changes and undocumented orthostatic blood pressure readings. Additionally, a resident experienced improper wheelchair positioning, which was not addressed despite staff awareness. These deficiencies were acknowledged by the facility's nursing leadership.
A resident with a history of stroke, diabetes, and kidney failure required new glasses due to nearsightedness. Despite a physician's request for eye care services in March, the facility failed to follow up adequately, resulting in unmet vision needs. An appointment was initially scheduled but rescheduled due to the optometrist's unavailability, with no further documented attempts to reschedule.
A resident with a leg fracture and muscle weakness did not receive adequate continence care due to a lack of proper care plan updates. Despite therapy's recommendation for two-person assistance for toileting, the care plan only included a one-person assist with a bedpan. This led to the resident experiencing incontinence as staff were unable to provide timely assistance.
The facility failed to provide correct nutrition and implement dietary and fluid restrictions for several residents. A resident with kidney disease did not receive a low-salt diet as recommended. Another resident with a gastrostomy tube received less nutritional formula than ordered, resulting in weight loss. Additionally, a resident dependent on artificial nutrition received insufficient formula, and a resident with kidney failure had no fluid restriction orders despite medical recommendations. The DNS acknowledged these deficiencies.
A resident with heart failure, endocarditis, and kidney failure requiring dialysis was found with a CPAP machine that lacked proper care instructions in their EHR. The resident reported difficulty in getting aides to add water to the machine, and the water chamber was observed to contain unclear water with particles. The DON acknowledged the failure to monitor and initiate care plans for personal CPAP machines.
A facility failed to provide necessary social services to a resident after a traumatic event involving a roommate's visitor's arrest. The resident, with a history of leg fracture and diabetes, expressed feeling unsafe and ignored, with no follow-up from social services despite the facility's policy requiring such actions. Staff interviews confirmed a lack of awareness and follow-up on the resident's emotional needs.
The facility failed to monitor behaviors for two residents on psychotropic medications, risking adverse effects and diminished quality of life. One resident with anxiety and PTSD was not monitored for medication effectiveness, while another with anxiety and depression lacked behavior monitoring orders in the MAR. The DON acknowledged these deficiencies.
The facility failed to monitor and address high temperatures in the South Clean Utility Fridge, with numerous instances recorded above 40 degrees without corrective action. Staff interviews revealed a lack of communication and action, as the maintenance department was unaware of the issue despite the fridge being monitored by housekeeping and kitchen staff.
A resident with severe cognitive impairment and under hospice care was inappropriately restrained by two staff members during a COVID-19 test. One staff member held the resident in a choke hold while the other administered the nasal swab, despite the resident's visible distress and attempts to refuse. The incident was witnessed and confirmed as abuse by both an outside agency staff member and an LPN from the facility.
A resident who sustained a head injury after a fall did not receive timely medical care as per facility policy. Despite profuse bleeding from a head wound, the RN administered first aid and notified the provider, who did not issue new orders. Four hours later, after the resident expressed feeling unwell, the RN called 911 for emergency transfer. Staff interviews confirmed that the standard of care for such injuries was not initially followed.
The facility failed to administer prescribed medications and perform necessary wound care for three residents, leading to severe health complications. One resident was hospitalized in septic shock due to incomplete antibiotic therapy, another had a surgical wound left untreated for seven weeks, and a third experienced delays in infection diagnosis and treatment, worsening psychiatric symptoms.
The facility failed to properly assess or re-assess two residents for elopement risk and did not update their care plans with necessary interventions. One resident eloped and was found at home, while another attempted to exit through an employee door. Elopement drills were not conducted as required.
Failure to Timely Report Resident’s Abuse Allegation Involving Required Assistance With Toileting
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal and potential physical abuse involving one resident. The facility’s abuse policy, revised 10/20/2022, required all alleged violations involving abuse to be reported immediately, but not later than two hours after the allegation was made, to the administrator or designee and to state officials, including the state survey agency and adult protective services. The Nursing Home Guidelines (Purple Book) also required staff-to-resident allegations to be reported to the DSHS Hotline, logged within five days, and reported to police or 911. Resident 1, who had diagnoses including myocardial infarction, sepsis, unsteadiness on feet, muscle weakness, cardiomyopathy, and a recently placed AICD with instructions not to use the left arm, was moderately cognitively impaired per the 5-day MDS. On 03/07/2026, a facility incident investigation documented that an RN (Staff F) assisted the resident to the bathroom and told the resident they needed to transfer themself to and from the toilet, and when the resident asked if Staff F would return to help them off the toilet, Staff F stated the resident would have to transfer themself or stay there forever. Later that evening, a CNA (Staff E) answered the resident’s call light and found the resident in the bathroom; the resident reported they had already transferred and cleaned themself because Staff F had told them to do it themself or stay there forever. Staff E reported this concern only to the oncoming CNA at shift change and did not notify a supervisor, stating they did not report the allegation because the resident asked them not to. The next day, another CNA (Staff G) documented that the resident reported significant left arm pain and disclosed the prior day’s allegation, which Staff G then reported to their supervisor. Interviews confirmed that Staff E had recently received abuse training, including instruction to report all allegations of abuse and to report them within two hours to the abuse coordinator and/or supervisor, and that abuse should be reported even if a resident requests that it not be. The facility failed to follow its own policy and regulatory requirements for immediate reporting of an abuse allegation when Staff E did not escalate the resident’s report beyond informing the oncoming CNA.
Failure to Prevent Sexual Abuse and Timely Address Escalating Sexually Inappropriate Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from sexual abuse and to timely implement appropriate interventions for a resident with escalating sexually inappropriate behaviors. Facility policy on abuse required immediate assessment and protection of residents following any allegation or observation of abuse, as well as prompt revision of the care plan with interventions to minimize recurrence. Despite this, the facility did not act in accordance with its policy when confronted with repeated sexually inappropriate behaviors by one resident toward staff, which preceded an incident of sexual contact with another resident. Resident 1 was admitted with dementia and anxiety disorder, was moderately cognitively impaired per the MDS, and resided on a locked unit due to wandering and exit seeking. Resident 1 was able to ambulate independently without assistive devices. On the date of the incident, Resident 1 was found in another resident’s room and reported that the other resident had taken them by the hand into the room and touched their breasts inappropriately. Resident 1 later stated they did not want to be touched and could not understand why the other resident had touched them. Staff interviews confirmed that Resident 1 had been led into the other resident’s room and touched on the breasts. Resident 2, who had dementia, aphasia, and a cognitive communication deficit and was severely cognitively impaired per the MDS, had documented sexually inappropriate behaviors toward staff on multiple days, including touching a CNA inappropriately, motioning a CNA to get into bed, rubbing a social worker’s arm and directing them toward the bed, and exposing their genitals to a CNA. Despite these documented behaviors, Resident 2’s behavior care plan did not include interventions for sexually inappropriate behaviors until after the incident involving Resident 1. One-to-one supervision was initiated the following day, and observations showed that even after this was ordered, staff did not consistently maintain line-of-sight supervision, allowing Resident 2 to move out of visual range and into their room with the door closed. Staff interviews indicated that some staff were aware of Resident 2’s sexually inappropriate behaviors but did not have clear guidance or care plan interventions to manage these behaviors prior to the substantiated incident of sexual abuse involving Resident 1.
Failure to Timely Report Witnessed Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to immediately report a witnessed incident of sexual abuse between residents to the state agency and other required authorities. Facility policy on abuse required that all alleged violations involving abuse be reported immediately, but no later than two hours after the allegation was made, to the administrator or designee and to officials including the state survey agency and adult protective services. The Nursing Home Guidelines (Purple Book) further specified that resident-to-resident sexual abuse/assault incidents must be reported to the DSHS hotline, logged within five days, and that police or 911 be called. Resident 1, who had dementia and anxiety disorder and was assessed as moderately cognitively impaired, was admitted on a specified date. Resident 2, who had dementia, aphasia, and a cognitive communication deficit and was assessed as severely cognitively impaired, was also admitted on a specified date. On 02/02/2026 at 11:45 AM, an incident report documented that Resident 1 was touched inappropriately by Resident 2. A progress note at 12:45 PM the same day showed that a CNA found Resident 1 in Resident 2’s room being touched on the breasts by Resident 2 and notified the nurse, who then wrote an alert report to inform managers of the incident. However, the state agency report showed the incident was not reported until 02/03/2026 at 10:42 AM, outside the required two-hour timeframe. Incident investigation documentation showed the nurse did not immediately report the inappropriate touching to the administrator, state agency, or police, despite being a mandated reporter. During interviews, multiple CNAs, LPNs, and an RN described that abuse should be reported promptly to supervisors and the DSHS hotline, and the Administrator and DNS later stated they only became aware of the incident the following morning while reviewing progress notes and that the incident should have been reported immediately to leadership, DSHS, and the police within two hours.
Failure to Provide Timely Emergency Care and Post-Fall Monitoring
Penalty
Summary
The facility failed to provide timely emergency services and thorough documentation for three residents who experienced falls, resulting in a deficiency related to quality of care. One resident, who was on a blood thinning medication, suffered an unwitnessed fall with a head injury. Despite having a laceration above the eye and being at high risk for intracranial bleeding, the resident was not sent for immediate medical evaluation. Instead, the resident was monitored in the facility, and only after a significant change in condition, including delayed response and unequal pupils, was the resident transferred to the emergency department. Hospital records confirmed a large subdural hematoma requiring emergency surgery, and the resident was later placed on comfort care. For two other residents who experienced falls, the facility's response was inconsistent. Both residents were not on blood thinners but were sent to the emergency department for evaluation after their falls, one with a head laceration and the other with head pain. However, the facility failed to complete required alert charting and post-fall monitoring every shift for 72 hours as outlined in facility policy. Documentation was missing or incomplete for multiple falls, and alert charting was not consistently performed as expected by facility leadership. Interviews with staff confirmed that the expectation was for alert charting to be completed every shift for 72 hours following a fall, but this was not consistently done. The deficiency was further supported by a review of facility policies and external clinical guidelines, which emphasize the need for rapid assessment and intervention for residents on anticoagulants who sustain head injuries. The lack of timely emergency response and incomplete documentation placed residents at risk for medical complications and delayed care.
Failure to Consistently Provide Appropriate Toileting Supplies
Penalty
Summary
The facility failed to consistently provide necessary toileting supplies, specifically briefs, for two residents with moderate cognitive impairment who required staff assistance for toileting hygiene. One resident reported that the facility had run out of their size of brief on three occasions since admission, resulting in the use of smaller briefs that were uncomfortable and did not adequately contain urine, leading to leakage. Another resident stated that staff sometimes used larger briefs when the correct size was unavailable, which did not always prevent wetness. Both residents were able to communicate their needs, and their experiences were corroborated by staff interviews. Staff, including a CNA and Central Supply personnel, confirmed that the facility occasionally ran out of briefs and would substitute with different sizes or obtain supplies from a sister facility, sometimes with delays of up to 12 hours. The administrator was unaware of the need for daily approval of supply orders and acknowledged that the facility should not have been running out of briefs. These actions and inactions resulted in residents not consistently receiving appropriate toileting supplies, as required.
Failure to Implement Proper Infection Control for Suspected Tuberculosis Case
Penalty
Summary
The facility failed to follow infection control standards in the management of a resident suspected of having tuberculosis (TB). According to the facility's own policy, residents with suspected or confirmed TB should be immediately placed on droplet precautions pending transfer, and only admitted if the facility is equipped with a private airborne infection isolation room. The resident in question had a positive PPD test and subsequent positive QuantiFERON gold test, with chest x-rays that could not rule out TB. Despite these findings, the care plan was not updated to reflect the suspicion of TB, the initiation of droplet precautions, or the treatment for pneumonia. The facility did not notify the local health jurisdiction (LHJ) promptly after the positive PPD test, waiting six days before making contact. Staff interviews revealed uncertainty about the correct type of precautions for TB, with the Director of Nursing Services (DNS) acknowledging that airborne precautions are typically required for TB, not droplet precautions as stated in the facility's policy. There was also a lack of documentation and timely communication with the LHJ regarding the resident's status and the facility's actions. Additionally, the facility did not implement interventions for possible TB exposure among staff or other residents, relying instead on verbal communication for monitoring signs and symptoms. The care plan was not reviewed or updated at key points when new information about the resident's condition became available. These lapses in infection control practices and communication placed residents, staff, and visitors at risk for contracting and spreading infections.
Insufficient Staffing Resulting in Unmet Resident Care Needs and Increased Falls
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents across three of four halls, resulting in unmet care needs and increased risk of falls. Review of facility records showed that a significant percentage of residents required assistance with activities of daily living, such as bathing, dressing, transferring, and toileting. Despite policies stating that staffing levels were reviewed daily and adjusted as needed, incident logs revealed a high number of resident falls over several months. Interviews with staff indicated that CNAs were often responsible for caring for up to 15 residents at a time, making it difficult to complete necessary care tasks, especially on weekends when staffing was lower. Staff also reported having to stay late to finish tasks and being frequently asked to cover open shifts. Observations and interviews with residents further highlighted the impact of insufficient staffing. One resident, who was dependent on two staff for transfers and had recently been diagnosed with pneumonia, reported not receiving scheduled showers, not being out of bed for six days, and not having their teeth brushed. Another resident stated they had not had a shower for at least two weeks and had not had their hair washed in about a month. Staff interviews confirmed that administrative nursing staff were counted in the nursing hours per patient day (PPD), but these staff were not always available on weekends. The deficiency was cited under WAC 388-97-1080 (1) and 1090 (1).
Failure to Prevent Significant Medication Error Due to Improper Order Entry and Administration
Penalty
Summary
A significant medication error occurred when a nurse failed to enter a provider's verbal order for an antibiotic (Rocephin 1 gm IM) into the electronic medication administration system (Point Click Care) and did not administer the medication as ordered. Instead, the nurse administered Ceftriaxone 2 gm/Dextrose 50 ml via the clysis system, which was not ordered for the resident. Additionally, the nurse used medication that was prescribed for another resident, which had been discontinued and was awaiting return to the pharmacy. The nurse also failed to complete the required documentation for a change in condition and did not place the resident on alert charting as required by facility policy. The resident involved was moderately cognitively impaired and had multiple diagnoses. Review of the resident's medication administration records showed no antibiotic order was present at the time of administration. The facility's policies required that all medication orders, especially verbal orders, be immediately and accurately recorded in the resident's medical record, including all necessary details such as drug name, strength, dosage, route, and frequency. The nurse did not follow these procedures, resulting in the administration of an unprescribed medication and lack of proper documentation.
Failure to Promptly Investigate and Report Resident Fall
Penalty
Summary
The facility failed to conduct a prompt and thorough investigation following a fall experienced by a resident who was assessed as severely cognitively impaired and had recently undergone surgical repair for a right hip dislocation. The fall, which occurred on 04/06/2025, was not reported by the responsible licensed nurse at the time of the incident, and nurse management was not notified. Risk management procedures and immediate interventions were not implemented as required by facility policy. The incident only came to light when the resident developed new onset pain, prompting an investigation on 04/14/2025, which revealed a dislocation of the right hip arthroplasty without acute fracture. Record review and staff interviews confirmed that the facility's policy for investigating and reporting accidents and incidents was not followed. The nurse supervisor/charge nurse did not promptly report the accident to the administrator or initiate and document an investigation at the time of the fall. The lack of timely notification and intervention was acknowledged by the Director of Nursing Services, who stated that a thorough investigation should have been conducted and documented immediately after the fall.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A resident, assessed as cognitively intact and admitted with anemia, experienced physical harm when a Certified Nursing Assistant (CNA) abruptly moved the resident's wheelchair while the resident was self-propelling from the dining room to their room. The CNA reportedly told the resident they were moving too slowly and needed to be passed, then pushed the wheelchair, causing the resident's knee to hit the side of the chair. The resident experienced immediate pain and swelling in the knee, which was later evaluated by x-ray and determined to have no injury, with swelling expected to resolve on its own. The resident did not report the incident immediately, waiting about a week before informing facility staff. The facility's investigation documented that the CNA involved had been identified in three separate abuse allegations recently. At the time the incident was reported, the CNA was already suspended pending a decision from the corporate Human Resources department regarding termination. The facility's abuse policy defines abuse as the willful infliction of injury or punishment resulting in physical harm, pain, or mental anguish, and requires that residents be protected from such actions.
Failure to Provide Adequate Pain Management
Penalty
Summary
The facility failed to ensure the availability of pain medications and did not obtain a provider's order for an alternative pain medication of similar strength for a resident experiencing chronic pain. Resident 1, who was admitted with chronic pain due to lumbar spine stenosis and degenerative disc disease, was prescribed a fentanyl transdermal patch to be applied every 72 hours. However, the Medication Administration Record (MAR) indicated that the patch was not in place for three consecutive shifts, and a new patch was not applied until 59 hours later, leaving the resident without adequate pain management. During this period, Resident 1 reported severe pain, rating it as a 10 on the pain scale, and expressed discomfort due to the absence of the fentanyl patch. Nursing notes documented that the resident had a difficult night without the patch and that the pharmacy was delayed in sending a new one. Despite the availability of pain patches in the Cubex and the option to contact the provider for an alternative medication, the facility staff did not take appropriate actions to manage the resident's pain effectively. This oversight resulted in the resident experiencing significant pain and discomfort.
Inadequate Supervision Leads to Falls in Residents
Penalty
Summary
The facility failed to provide adequate supervision and assistance during bed mobility care for two residents, leading to falls and injuries. Resident 1, who was admitted with multiple diagnoses and required substantial assistance with activities of daily living, experienced a fall from bed when a single staff member attempted to provide care alone, despite the care plan requiring two caregivers. This incident resulted in Resident 1 sustaining injuries that required hospital evaluation. The root cause was identified as inadequate staffing during in-bed care. Similarly, Resident 2, who was receiving hospice services and required substantial assistance, also experienced a fall during care. The care plan for Resident 2 specified the need for two staff members during care due to the resident's fear of rolling off the bed. However, the staff failed to adhere to this plan, resulting in an assisted fall. Although no injuries were noted, the root cause was again identified as the failure to follow the care plan requiring two-person assistance.
Inadequate Infection Control and Outbreak Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, leading to the transmission of a communicable disease among residents. The facility did not implement transmission-based precautions (TBP) in a timely manner for residents exhibiting symptoms of respiratory illness. Specifically, residents were not tested for influenza or COVID-19, nor were they placed on droplet precautions or administered antiviral medications like Tamiflu as per the facility's outbreak protocols. This failure resulted in several residents being hospitalized with complications such as pneumonia, sepsis, and acute kidney injury. The facility's outbreak management was inadequate, as evidenced by the lack of timely communication and action from the infection preventionist and medical director. Despite recommendations from the local health jurisdiction to follow CDC guidelines for influenza outbreak management, the medical director chose not to implement these recommendations fully, opting instead to provide antiviral treatment only to symptomatic residents. This decision contributed to the spread of the illness, affecting a significant portion of the resident population. Additionally, the facility did not adhere to proper transmission-based precautions and enhanced barrier precautions. Observations revealed that staff frequently entered rooms without appropriate personal protective equipment (PPE), failed to sanitize shared equipment between uses, and did not follow hand hygiene protocols. The laundry process also lacked proper sanitation, with visible debris and grime on washing machine gaskets not being cleaned between loads. These lapses in infection control practices placed residents, staff, and visitors at increased risk of exposure to communicable diseases.
Failure in QAPI Program Leads to Repeated Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) program effectively self-identified deficiencies and developed or implemented effective plans of action to sustain corrections for previously identified deficiencies. This failure led to repeated deficiencies, a pattern of deficiencies, widespread deficiencies, and a pattern of actual harm that placed residents at repeated risk for unmet needs. During interviews, the Director of Nursing Services (DNS) acknowledged being informed of infection control issues upon taking over the position in July 2024, but expected these issues to have been resolved by then. The DNS admitted that improvements could be made in the QAPI process to reduce repeated deficiencies. The facility conducted QAPI meetings but failed to self-identify deficiencies, recognize unsustained corrections of previously identified deficiencies, or make timely revisions to action plans. The Administrator admitted to being aware of some improvements but not others and acknowledged the need for better engagement with the QAPI process. The report lists numerous deficiencies, including issues related to residents' rights, grievances, abuse and neglect, reporting of alleged violations, care planning, and infection control, among others. These deficiencies were not effectively addressed or sustained, leading to repeated citations and harm.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to properly address grievances for two residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal. Resident 14, who has bipolar disorder and COPD, expressed increased anxiety and dissatisfaction due to a disruptive roommate. Despite multiple progress notes indicating Resident 14's distress and dissatisfaction with the offered solution of earplugs, no grievance was filed, and the Social Services Director was unaware of the situation. The Administrator acknowledged that a grievance should have been initiated, and the resident should have been offered a room change or the first available room. Similarly, Resident 66, who has a left below-knee amputation and diabetes, reported missing personal property, specifically two jackets, to various staff members, including a nurse aide, a nurse, and laundry staff. Despite these reports, no grievance form was completed, and the grievance logs showed no record of the missing items. The Administrator confirmed that the expectation was for staff to assist residents with grievance forms for missing items, but this was not done for Resident 66.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of the reason for transfer or discharge to the resident or responsible party for two residents who were hospitalized. Resident 38, who had a history of stroke, high blood pressure, and paroxysmal atrial fibrillation, was transferred to the hospital on 11/29/2024. The electronic health records showed no documentation of a written notice being provided to Resident 38 or their responsible party regarding the transfer. Staff interviews revealed that while verbal notifications were made, there was no written documentation provided. Similarly, Resident 66, who had diagnoses including a left below-knee amputation, infection, and diabetes, was sent to the hospital for evaluation on 08/22/2024. There was no documentation found indicating that the resident or their representative was notified in writing of the reason for the transfer. Staff interviews confirmed that written notices were not provided to residents or their representatives for hospital transfers, which is a requirement under the relevant regulations.
Failure in PASRR Screening for Mental Health Disorders
Penalty
Summary
The facility failed to ensure that residents with mental health disorders were properly screened for additional mental health supports using the Preadmission Screening and Resident Review (PASRR) process. Specifically, four residents with diagnoses of depression, anxiety disorder, and bipolar disorder were not referred for a PASRR level two evaluation despite indications that such referrals were necessary. For instance, Resident 53, who was admitted with a diagnosis of depression, had a PASRR level one indicating the need for a level two referral, which was not completed. Similarly, Resident 5, with diagnoses including anxiety disorder, depression, and bipolar disorder, had serious mental illness indicators on their PASRR level one but was not referred for a level two evaluation. Additionally, Resident 8, who was readmitted with anxiety disorder and depression, was not referred for a PASRR level two evaluation despite the presence of mood disorder indicators. Resident 66, admitted with a diagnosis of depression and receiving antidepressant medication, was not marked for serious mental illness on the PASRR level one, and no level two evaluation was conducted. Interviews with the Social Services Director and the Administrator confirmed that these oversights did not meet the facility's expectations for mental health screening and referral processes.
Failure to Conduct Timely Care Conferences
Penalty
Summary
The facility failed to conduct timely care conferences with residents or their responsible parties for four of the seventeen sampled residents, specifically Residents 17, 35, 47, and 65. This deficiency was identified through interviews and record reviews, which revealed that these residents had not participated in care conferences within the expected timeframes. Resident 17, who was able to communicate their needs, had not attended a care conference since July 2024, despite being readmitted to the facility. Similarly, Resident 35, also capable of expressing their needs, last attended a care conference in March 2024. Resident 47, who was admitted with chronic pain and dementia, had their last care conference in April 2024, and Resident 65, who could also communicate their needs, had not attended a care conference since May 2024. Interviews with facility staff, including the Social Services Director and the Administrator, confirmed that the facility's policy was to offer care conferences upon admission and quarterly thereafter. However, the Social Services Director admitted that they were behind on scheduling these conferences for long-term residents. The Administrator reiterated the expectation for quarterly care conferences, indicating a lapse in adherence to the facility's care planning procedures. This failure to conduct timely care conferences placed the residents at risk for unmet needs and a diminished quality of life, as they were not adequately involved or informed about their care plans.
Deficiency in Restorative Care for Residents
Penalty
Summary
The facility failed to provide adequate care and services to maintain or improve the range of motion (ROM) for three residents, leading to a deficiency in their care. Resident 17, who had arthritis, muscle weakness, and spinal stenosis, was not included in a restorative nursing program despite recommendations from a physical therapy evaluation. The resident's care plan lacked interventions for maintaining lower extremity function, and the last documented restorative program progress note was dated several months prior. Staff interviews confirmed that Resident 17 should have been on a restorative program to maintain mobility. Resident 35, who had a contracture of the right hand and other mobility issues, did not receive restorative nursing services. Observations showed the resident was unable to use a therapy device independently, and there were no care plan interventions for managing the contracture. Staff interviews revealed a lack of awareness and application of necessary devices, and the Director of Rehabilitation acknowledged the absence of a care plan to protect the resident's hand and prevent further contracture. Resident 20, diagnosed with right-side hemiplegia and osteoarthritis, also did not receive appropriate restorative care. The resident's care plan lacked interventions for ROM, and a previous focus on managing contractures was resolved without explanation. Observations indicated that necessary equipment, such as foot drop boots, was not being used, and staff interviews confirmed the discontinuation of the restorative program due to staffing issues. The Director of Rehabilitation noted the need for a restorative program to maintain residents' functional levels post-therapy.
Incomplete Dialysis Documentation and Communication
Penalty
Summary
The facility failed to consistently conduct and document pre and post dialysis assessments and ensure ongoing communication with the dialysis center for two residents requiring dialysis. Resident 65, who had a history of stroke, diabetes, and kidney failure, was readmitted to the facility and required dialysis three times a week. However, the dialysis communication records for several dates in December 2024 were incomplete, with missing information and signatures. Interviews with the Unit Manager and Director of Nursing Services confirmed that the records did not meet expectations and should have been completed. Similarly, Resident 66, diagnosed with diabetes and end-stage kidney disease, also required dialysis three times a week. The dialysis communication forms for late November and early December 2024 were found to have blank sections that should have been completed by facility staff and the dialysis center. Interviews with a Licensed Practical Nurse and the Director of Nursing Services revealed that the forms were expected to be filled out accurately, and if the dialysis center did not complete their section, the staff should have contacted them to fill in the information or documented it in a progress note.
Failure to Implement Nonpharmacological Interventions Before PRN Pain Medications
Penalty
Summary
The facility failed to implement nonpharmacological interventions (NPI) before administering as-needed (PRN) pain medications for three residents, leading to a deficiency in medication management. Resident 53, who was admitted with an acquired absence of the right leg above the knee and depression, received PRN pain medication 16 times over two months without any documented NPI. Staff interviews confirmed that NPIs were not provided as required, which did not meet the facility's expectations. Similarly, Resident 14, diagnosed with bipolar disorder and chronic obstructive pulmonary disease, received 18 doses of acetaminophen for pain without NPI documentation, despite the absence of an elevated temperature. Resident 66, with a history of left below-knee amputation and diabetes, also received PRN acetaminophen without NPIs being attempted, as indicated by the medication administration record. Staff interviews corroborated the lack of adherence to the protocol of using NPIs before administering PRN pain medications.
Medication Administration Timing Error
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, as evidenced by 13 errors in 31 opportunities during medication administration for one of the sampled residents. Specifically, a Licensed Practical Nurse (LPN) administered metoclopramide and 12 other medications to a resident at incorrect times, contrary to the provider's orders. The metoclopramide was ordered to be given at 7:00 AM with meals, and the other medications were to be administered at 8:00 AM. However, the LPN administered all medications at 9:19 AM. The Director of Nursing Services acknowledged that the expectation was for nurses to follow the correct time of administration, which did not occur in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications across multiple areas, including three medication carts and two medication rooms. Medications belonging to a resident were left unsupervised on the North Nurses' Station counter, which included packets of Seroquel and Tamsulosin. Staff X, an LPN, acknowledged that these medications should have been locked away. Additionally, the temperature logs for the medication storage refrigerators in both the South and North medication rooms were incomplete, with numerous undocumented temperature checks for November 2024. Staff J, the Resident Care Manager, confirmed that the temperature should have been documented by the assigned nurses. Further observations revealed issues with medication carts. The Run 3 medication cart contained a bottle of atropine sulfate without a date of opening or label, and refresh eye drops that were not dated when opened. The Peak 1 medication cart had expired insulin, and the Run 4 medication cart had multiple eye drops that were either not dated or potentially expired. Staff members, including RNs and LPNs, acknowledged these deficiencies. The Director of Nursing Services confirmed that medication refrigerators should be monitored for temperature twice a day and that multidose medications should be dated when opened and discarded when expired. The Director also stated that all medications should be secured behind a lock and not left unsupervised.
Failure to Ensure Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to adequately explain and ensure understanding of arbitration agreements for three residents, leading to a deficiency in informed consent. Resident 75, who was admitted with hemiplegia, hemiparesis, and a cognitive communication deficit, signed an arbitration agreement without a date and later stated they did not understand what it was. They recalled being too sick to sign legal documents at the time of admission. Similarly, Resident 14, diagnosed with bipolar disorder and a cognitive communication deficit, signed the agreement without a date and later expressed a lack of understanding of the document, stating they were not in a condition to sign documents upon admission. Resident 31, with dementia and a cognitive communication deficit, signed and dated the arbitration agreement but also lacked understanding of its implications. Interviews with facility staff revealed that the arbitration agreements were presented with admission paperwork, and the staff relied on their judgment to determine if residents could sign their own documents. Staff T, the Admission Director, acknowledged that the previous admissions coordinator did not adequately complete their duties, including the handling of arbitration agreements. Staff A, the Administrator, confirmed that the admission staff assessed residents' ability to sign documents based on their perceived level of confusion. This oversight placed residents at risk of forfeiting their right to a jury trial and seeking restitution for facility errors.
Failure in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program, which is crucial for promoting appropriate antibiotic use, reducing unnecessary antibiotic use, and decreasing antibiotic resistance. The deficiency was identified through interviews and record reviews, revealing that the facility did not ensure criteria were met for antibiotic use and did not include indications for use or type of infection in provider orders for six of ten sampled residents. This oversight placed residents at risk for potential adverse outcomes associated with inappropriate and unnecessary antibiotic use. The facility's policy required the infection preventionist to review antibiotic utilization daily, but this was not effectively carried out. Specific cases highlighted include Resident 9, who was prescribed antibiotics without being included in the infection control line listing, and Resident 26, who was treated for a urinary tract infection without sufficient evidence or culture results. Staff interviews revealed that orders should have included specific indications for use, but this was not consistently done. The infection preventionist and Director of Nursing Services acknowledged the failure to review and log new antibiotics daily, as well as the lack of documentation for the reason for antibiotic use, which did not meet the facility's expectations.
Failure to Obtain Consent for Antidepressant Use
Penalty
Summary
The facility failed to provide necessary information and obtain consent for the use of an antidepressant medication for one resident, identified as Resident 53. Resident 53, who was admitted with a diagnosis of acquired absence of the right leg above the knee and depression, was receiving duloxetine daily for depression. However, the electronic health record (EHR) review revealed that the risks and benefits of duloxetine were not communicated to the resident, and consent for its use was not obtained. Interviews with the Unit Manager and the Director of Nursing Services confirmed that the facility's protocol required nursing staff to provide information on risks and benefits and obtain signed consent before starting an antidepressant, which was not done in this case, failing to meet the facility's expectations.
Failure to Prevent Verbal Abuse of a Resident
Penalty
Summary
The facility failed to ensure an environment free from verbal abuse for a resident, identified as Resident 45, who was reviewed for abuse. Resident 45, who has paraplegia and a cognitive communication deficit, reported an incident where a staff member accused them of buying all the potato chips from a vending machine and questioned them about being in a gang and breaking into the staff member's car. This incident was witnessed by other staff members who laughed at the resident. The resident reported feeling verbally mistreated and was visibly upset, as noted in a progress note dated 11/17/2024. The facility's incident report lacked documentation of findings, actions taken, and witness accounts. During an interview, the Administrator acknowledged speaking with Resident 45 but did not initially identify the complaint as an allegation of abuse. The Administrator later recognized the need to classify the incident as such after reviewing the progress note. The facility's policy on abuse prevention, dated April 2023, mandates the protection of residents from abuse by anyone, including facility staff, but this policy was not effectively implemented in this case.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to identify and report an allegation of abuse involving a resident, referred to as Resident 45, who was admitted with diagnoses including paraplegia and cognitive communication deficit. Resident 45 was capable of communicating their needs and reported an incident where a staff member accused them of buying all the potato chips from a vending machine and questioned them about being in a gang and breaking into the staff member's car. This incident, which occurred in the presence of other staff members who laughed at the resident, was reported by Resident 45 to a staff member. Despite the report, the facility's Accident and Incident Log for the relevant period did not include any documentation of this allegation. The Administrator, identified as Staff A, acknowledged having spoken to Resident 45 but did not recognize the complaint as an allegation of abuse initially. Staff A later admitted that the incident should have been reported to the state, as per the facility's Abuse Prevention Program policy, which mandates reporting any allegations of abuse within required timeframes.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly report allegations of abuse for one of the sampled residents, Resident 85, which placed residents at risk of repeated potential abuse, neglect, or mistreatment, and a diminished quality of life. Resident 85, who was admitted with diagnoses including a fracture of the right lower leg, injury of the right ankle, and diabetes, expressed feeling unsafe after an incident involving a male resident walking and yelling in the hallway early in the morning. Resident 85 reported the incident to Staff U, a receptionist, but the incident was not documented in the facility's incident log for November or December 2024. Staff U mentioned they thought they reported the occurrence but could not recall to whom. Staff B, the DNS, confirmed that the incident was not reported and investigated in a timely manner to rule out abuse, which did not meet the facility's expectations.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, leading to potential risks for unmet care needs. Resident 69, who was admitted with systemic lupus erythematosus and depression, was inaccurately assessed as having adequate vision without corrective lenses. However, it was revealed through interviews and record reviews that the resident had received new prescription glasses in June 2024, which was not reflected in the MDS completed on 09/03/2024. The MDS Coordinator admitted to not observing the resident with glasses and acknowledged the need for modification of the MDS. Resident 346, admitted with sepsis, a local infection, and COPD, was also inaccurately assessed. The admission MDS failed to code the resident's antibiotic therapy and continuous oxygen use correctly. Observations and record reviews showed the resident was receiving intravenous antibiotic therapy and continuous oxygen at 2 liters per minute, yet the MDS was coded for intermittent oxygen use and did not reflect the high-risk medication. The MDS Coordinator and the Director of Nursing Services both confirmed the inaccuracies in the coding for Resident 346's MDS.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to unmet care needs and potential negative outcomes. Resident 17, who was readmitted with arthritis, muscle weakness, and spinal stenosis, utilized a wheelchair and was dependent on staff for transfers. However, there was no care plan addressing restorative nursing programs or interventions for range of motion to maintain function related to impaired mobility. Similarly, Resident 35, with a contracture of the right hand and muscle weakness, did not have a care plan for restorative nursing programs or interventions for the use of a therapy carrot to manage the contracture. Resident 20, admitted with right side hemiplegia and osteoarthritis, required extensive assistance with activities of daily living and had both upper and lower extremity impairments. Despite these needs, there was no intervention for range of motion related to the extremity impairment in the care plan. Staff interviews revealed that the facility did not have a restorative nursing program in place, and the expectation was that mobility and range of motion should have been addressed in the care plan. Resident 346, admitted with sepsis and a local infection, had a PICC line in place for intravenous antibiotic therapy. However, there was no active care plan for the PICC line or for managing the sepsis. Staff interviews confirmed the absence of a care plan for the antibiotics, IV line, or infection, which should have been addressed. The deficiencies highlight a lack of individualized care planning for residents with specific medical needs, as required by regulations.
Inaccurate Documentation and Inadequate ADL Care for Resident
Penalty
Summary
The facility failed to provide and accurately document necessary care and services for a resident, specifically in relation to scheduled showers and facial hair removal. Resident 35, who was readmitted to the facility with conditions including contracture of the right hand, muscle weakness, and difficulty in walking, required partial assistance with showering twice a week. However, observations over several days showed the resident with long facial hair, and the resident reported not receiving showers as scheduled. The resident's electronic health records indicated inconsistencies in documentation, with records showing both a lack of showers on scheduled days and inaccurate entries suggesting daily showers. Interviews with staff revealed further discrepancies in the documentation and care provided. Staff Z, a CNA, confirmed the resident's shower schedule but noted that the documentation inaccurately reflected the resident receiving showers multiple times a day. Staff AA, an RN, acknowledged the resident's request for facial hair removal and the inaccuracies in the shower documentation. The Director of Nursing Services also recognized the documentation errors, noting that the resident did not receive showers twice a week as scheduled, and that documenting 'Not applicable' on a scheduled shower day was not acceptable.
Deficiencies in Following Provider Orders and Wheelchair Positioning
Penalty
Summary
The facility failed to follow provider's orders for two residents, leading to deficiencies in care. Resident 66, who was admitted with a left below-knee amputation, infection, and diabetes, did not receive daily dressing changes as ordered by the provider. The resident reported that the dressing changes were missed on multiple occasions, and staff failed to document or communicate the missed care to subsequent shifts. This lack of adherence to the care plan was acknowledged by the facility's nursing leadership as not meeting expectations. Resident 8, who was readmitted with anxiety disorder, depression, and paroxysmal atrial fibrillation, had orders for monthly orthostatic blood pressure measurements. However, the facility failed to document the standing blood pressure readings in the electronic health record, despite staff initials indicating the task was completed. The Unit Manager and Director of Nursing Services confirmed the absence of documentation and acknowledged that the expected procedures were not followed. Resident 17, who utilized a wheelchair for mobility due to arthritis, muscle weakness, and spinal stenosis, experienced issues with improper wheelchair positioning. The resident reported that the footrests did not fit correctly, and they were unable to maintain proper positioning, leading to discomfort. Despite being aware of the issue, staff did not document or address the need for a reassessment of the wheelchair fit. The Director of Rehabilitation confirmed the inappropriate positioning and the need for a therapy referral, which had not been obtained.
Failure to Provide Timely Vision Services for a Resident
Penalty
Summary
The facility failed to provide necessary vision services for a resident, identified as Resident 65, who was reviewed for communication sensory needs. Resident 65, who had a history of stroke, diabetes, and kidney failure, expressed the need for new glasses due to nearsightedness and had informed the staff about this need approximately a month prior to the interview conducted on 12/05/2024. The resident's electronic health record indicated that a request for eye care services was completed and signed by the attending physician on 03/25/2024. Despite the request being made, there was no follow-up documentation in the resident's electronic health record regarding the eye care referral. The Social Services Director confirmed that an appointment was initially scheduled for August 2024 but was rescheduled to September 2024 due to the optometrist's unavailability. However, there was no documentation of further attempts to reschedule the appointment. The Administrator acknowledged that the resident's vision issues should have been addressed back in March 2024, indicating a failure to meet the facility's expectations.
Failure to Provide Adequate Continence Care
Penalty
Summary
The facility failed to provide necessary care and assistance to maintain continence for Resident 394, who was admitted with a fracture of the left leg, asthma, and muscle weakness. The resident was able to communicate their needs and required assistance to move out of bed. Despite therapy recommendations for a two-person assistance for toileting, the care plan only included a one-person assist with a bedpan and lacked specific instructions for toileting services. This oversight led to the resident being unable to receive timely assistance, resulting in episodes of incontinence. On one occasion, the resident reported being fully soiled by the time staff arrived to assist them. The resident also mentioned that therapy had previously assisted them to use the toilet and indicated that two strong staff members could help with the transfer. However, a weekend charge nurse stopped the staff from assisting the resident, citing that it was not allowed. The Director of Nursing Services acknowledged that the nursing department failed to update the care plan with therapy's instructions, which did not meet the facility's expectations.
Failure to Implement Dietary and Fluid Recommendations
Penalty
Summary
The facility failed to ensure that residents received the correct amounts of supplemental nutrition and that diet recommendations and fluid restrictions were implemented. Resident 19, who had diagnoses including kidney disease and heart failure, reported that the facility did not follow their provider's dietary and fluid recommendations. The resident was offered foods high in sodium, contrary to the provider's order for a low-salt diet and specific fluid intake. The Director of Nursing Services (DNS) acknowledged that the recommendations were not forwarded to the provider, which did not meet the facility's expectations. Resident 34, diagnosed with conditions such as hemiplegia and malnutrition, required a specific amount of nutritional formula via a gastrostomy tube. However, the medication administration record (MAR) showed that the resident received less than the ordered amount on multiple occasions, leading to a weight loss of 10 pounds over 60 days. The Resident Care Manager (RCM) and DNS confirmed that the resident did not receive the ordered nutrition, which was below the facility's standards. Resident 81, with diagnoses including cerebral infarction and diabetes, was dependent on staff for nutrition via an artificial route. The MAR indicated that the resident received only one carton of Jevity formula instead of the ordered two cartons on several occasions. The DNS stated that this was due to a nurse's error. Additionally, Resident 74, who had heart failure and kidney failure, was supposed to be on a fluid restriction as per their renal doctor's recommendation. However, there were no orders or instructions on fluid restriction in the resident's care plan, which the DNS admitted did not meet expectations.
Failure to Provide Proper Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide respiratory care according to professional standards of practice for a resident who was reviewed for respiratory care. Resident 74, who was admitted with diagnoses of heart failure, endocarditis, and kidney failure requiring dialysis, was observed with a CPAP machine next to them. The resident expressed that the aides were reluctant to add water to the machine, and it was difficult to get a nurse's assistance. The resident's electronic health record (EHR) lacked any order or care plan regarding the CPAP machine or instructions for its care. An observation revealed the CPAP machine's water chamber contained unclear water with floating white/grayish particles. The Assistant Director of Nursing acknowledged the issue and initiated cleaning. The Director of Nursing Services stated that nurses were expected to monitor personal CPAP machines and initiate orders and care plans, which was not done in this case.
Failure to Provide Social Services After Traumatic Event
Penalty
Summary
The facility failed to provide medically related social services to Resident 85, who was involved in a traumatic experience in their room. Resident 85, who was admitted with a fracture of the right lower leg, injury of the right ankle, and diabetes, expressed feeling unsafe and mentally exhausted after a male resident approached their room and a previous incident where their roommate's visitor was arrested for attempted murder in front of them. Despite these events, Resident 85 reported that staff did not check on their well-being or provide emotional support, leading to feelings of being ignored. Interviews with facility staff revealed a lack of awareness and follow-up regarding Resident 85's emotional needs. The Social Service Director was unaware of the resident's concerns, and the Director of Nursing Services acknowledged the arrest event as stressful, expecting social services to provide follow-up, which did not occur. The facility's policy required social services to identify emotional needs and maintain individualized care plans, but this was not adhered to, resulting in unmet needs and diminished quality of life for Resident 85.
Failure to Monitor Behaviors for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor behaviors for two residents who were prescribed psychotropic medications, which are intended to affect mental status. Resident 57, who was admitted with anxiety and post-traumatic stress disorder, was observed sitting in a dark room and expressed having night terrors. Despite being administered multiple antidepressant and antianxiety medications, there was no behavior monitoring in place to assess the effectiveness of these medications or the behaviors experienced by the resident. The Director of Nursing Services acknowledged the absence of behavior monitors, which did not meet the facility's expectations. Similarly, Resident 8, who was readmitted with anxiety disorder and depression, received antidepressant and antipsychotic medications without corresponding behavior monitoring orders documented in the medication administration record (MAR) for a specific period. An existing order to monitor behaviors did not specify the reason, and the Unit Manager confirmed that behavior monitoring related to the use of these medications was not conducted as required. The Director of Nursing Services also confirmed that the behavior monitoring for Resident 8 did not meet expectations, as it should have been documented in the MAR.
Failure to Monitor Refrigerator Temperatures
Penalty
Summary
The facility failed to monitor refrigerator temperatures and take corrective action for the South Clean Utility Fridge, which was one of three resident refrigerators reviewed. Observations on December 10, 2024, revealed that the temperature logs for November and December 2024 were posted on the fridge, indicating that the refrigerator temperature should not exceed 40 degrees. However, the review of the logs showed that in November 2024, 11 of 31 AM temperatures and 16 of 31 PM temperatures were recorded above 40 degrees, with no comments made for these temperatures. Similarly, in December 2024, 3 of 10 AM temperatures and 1 of 10 PM temperatures were recorded above 40 degrees, again with no comments made. Interviews with staff revealed a lack of communication and action regarding the temperature issues. The Dietary Manager stated that the fridge was monitored by housekeeping staff, and the kitchen staff was responsible for ensuring correct temperatures. The Environmental Services Director confirmed that they monitored the fridge Monday through Friday and would notify maintenance if temperatures were too high. However, the Maintenance Assistant was unaware of any temperature issues, indicating a breakdown in communication. The Administrator acknowledged that the monitoring did not meet expectations, as temperatures above 40 degrees should have been reported to maintenance.
Resident Subjected to Inappropriate Physical Restraint During COVID-19 Test
Penalty
Summary
The facility failed to ensure a resident was free from physical restraints, which is a violation of their Abuse Prevention Program policy. The incident involved a resident with severe cognitive impairment, dementia, and other mental health issues, who was dependent on staff for daily living activities and was under hospice care. During a COVID-19 test, two staff members were observed restraining the resident inappropriately. One staff member held the resident in a choke hold while the other administered the nasal swab, despite the resident's visible distress and attempts to refuse the procedure. The incident was witnessed by both an outside agency staff member and a licensed practical nurse (LPN) from the facility. The LPN observed the resident struggling and noted their face was bright red, indicating distress. The LPN instructed the staff to stop the procedure. The Director of Nursing Services and the facility administrator both confirmed the incident was substantiated as abuse, as the resident's right to refuse was not respected, and the use of physical restraint was inappropriate.
Failure to Provide Timely Medical Care After Resident Fall
Penalty
Summary
The facility failed to provide timely medical care for a resident who sustained a head injury after a fall. According to the facility's policy on managing falls and fall risk, immediate medical treatment should be obtained if there is evidence of injury. However, after the resident fell and sustained a 3-centimeter vertical wound on the back of the head that bled profusely, the registered nurse administered first aid and notified the guardian and provider. Despite the bleeding, the provider did not issue new orders and planned to see the wound later that day. The resident's vital signs were documented as within normal limits. Four hours after the fall, a family member requested an emergency transfer to the hospital, but the RN initially explained that the situation was being monitored and did not appear to be an emergency. However, when the resident expressed feeling unwell, the RN agreed to call 911, and the resident was transferred to the hospital for emergency evaluation. Interviews with staff, including the Director of Nursing Services, indicated that the standard of care for a head injury with bleeding should involve immediate assessment, first aid, physician notification, and calling 911 for emergency transfer, which was not initially followed in this case.
Failure to Administer Medications and Perform Wound Care
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice. For Resident 1, the facility did not administer the prescribed IV Zosyn antibiotic on multiple occasions and failed to document or notify the physician about the resident's adverse reactions and refusals. This led to Resident 1 being admitted to the hospital in septic shock due to incomplete antibiotic therapy. Additionally, the facility did not follow up on a faxed order for a new antibiotic, resulting in further delays in treatment. Resident 2's surgical wound care was inadequately managed. The facility did not document or perform the necessary wound assessments and dressing changes as per the hospital discharge orders. Despite Resident 2's allergy to adhesive tape, the original dressing was left unchanged for seven weeks, leading to complications. The facility staff failed to communicate with the surgeon to obtain appropriate wound care orders and did not address the resident's refusal of care effectively. For Resident 3, the facility did not carry out the psychiatrist's recommendation for lab work to test for infection, nor did they notify the primary care provider about the recommendation. When a physician later ordered a urinalysis to evaluate for a possible UTI, the order was not executed promptly, and the nursing staff was unaware of the pending order. This lack of coordination and communication resulted in delays in diagnosing and treating potential infections, exacerbating Resident 3's psychiatric symptoms.
Failure to Assess and Mitigate Elopement Risk
Penalty
Summary
The facility failed to ensure that two residents were properly assessed or re-assessed for elopement risk and that their care plans were updated to include interventions to mitigate or prevent elopement. Resident 1, who had diagnoses including rib fractures, alcohol abuse, and alcohol withdrawal, exhibited exit-seeking behavior and was found wandering multiple times. Despite these behaviors, the resident was not reassessed for elopement risk, and the care plan was not updated. Eventually, Resident 1 eloped from the facility and was found at home with a spouse who was unable to care for them. The facility's Elopement Risk Binder did not contain an information sheet with a photo for Resident 1, and staff had not conducted elopement drills as required by the facility's policy. Resident 2, diagnosed with Alzheimer's disease, was initially assessed as not at risk for elopement. However, the resident's care plan indicated a risk for wandering, and subsequent assessments documented increased wandering behavior. Despite these changes, the resident was not reassessed for elopement risk, and the care plan was not updated with new interventions. Resident 2 was moved from an alarmed unit to an unalarmed unit due to a change in medical condition, and was later found attempting to exit the facility through an employee door. The Director of Nursing Services acknowledged that a reassessment and care plan update should have been conducted at the time of the resident's change in condition. Interviews with facility staff revealed that elopement drills had not been conducted monthly as required by the facility's policy. The Director of Nursing and the Administrator both indicated that the facility's policy was to develop a care plan based on the risk for elopement and to place resident information sheets with photos in the Elopement Risk Binder. However, these steps were not followed for the residents in question, leading to the deficiencies noted in the report.
Latest citations in Washington
A resident with cerebral palsy and a court-appointed guardian experienced multiple episodes of nausea, vomiting, loose stools, abdominal discomfort, fatigue, and later refusal of meals and medications, leading to changes in the care plan including close monitoring, lab testing, and IV fluid administration. Despite a facility policy recognizing court-appointed guardians as resident representatives with decision-making authority, staff did not document any notification to the guardian during these changes in condition or treatment decisions. The guardian reported not being contacted when the resident stopped eating or developed stomach issues and felt the facility did not respect the guardianship, while the DON acknowledged there were multiple missed opportunities to notify the guardian of the resident’s change from baseline.
A resident with depression, anxiety, moderate cognitive impairment, and urinary incontinence, care-planned for q2h checks and assistance with toileting, was found by a visitor to be soaking wet, unusually agitated, and reporting they had been told to wait to be changed and referred to with a derogatory remark. The visitor filed a written grievance alleging abuse/neglect related to delayed incontinence care and removal of the resident’s tablet as a consequence. Although an incident report noted that the matter was reported to the state and that the resident was not soaking wet, a CNA who actually changed the resident later reported the resident’s brief, pants, wheelchair, and socks were soaked and that the resident was acting timid and repeatedly saying they had to sit for five minutes, but this CNA was never interviewed. The DON acknowledged not investigating the resident’s behavior or interviewing this CNA, and the grievance official acknowledged the facility did not fully investigate or communicate findings and resolution to the complainant, resulting in a failure to follow the facility’s grievance policy.
A resident with dementia, respiratory failure, and heart failure developed new shortness of breath with an O2 sat of 90%, and a physician ordered transfer to the ED for tx and eval. An RN completed an SBAR, notified the MD and family, and reported to the oncoming nurse that the resident needed ED transfer and that paramedics should be contacted, then left the facility. Instead of calling 911 for this emergent respiratory distress, staff arranged non-emergent transport through a contracted ambulance service, resulting in the resident remaining at the facility for several hours without pickup until the dispatcher later instructed staff to call 911. The DON stated that 911 is expected to be used for emergent conditions and the contracted service only for non-emergent transport.
A resident with anoxic brain injury, dysarthria, and documented lack of decisional capacity alleged physical abuse and expressed fear of their identified representative, yet social services only reported the allegation to the state and did not complete an incident report, revise the care plan, or implement protective interventions. The same representative continued to be treated as the resident’s decision-maker and visited frequently, with staff noting suspicious odors of foreign substances and concerns about possible illicit substance use. Psychiatry later documented concern that the representative was providing illicit substances, and the resident was subsequently hospitalized for altered mental status and overdose, after which the representative was banned. Key staff, including the DON, unit manager, and administrator/abuse coordinator, were unaware of the initial abuse allegation, and social services did not timely explore or clarify legal decision-making authority or alternative representation for the resident.
A resident with severe cognitive impairment, osteoarthritis, and spinal spondylosis, care planned for 2-person Hoyer transfers, was being moved by two CNAs using a mechanical lift when one corner loop of the sling became disengaged, causing the resident to fall about four feet, strike the floor and the lift, and sustain head abrasion, multiple rib fractures, and lumbar vertebral fractures. Facility policy required staff to verify secure sling attachment, examine hooks, clips, fasteners, and strap stability, and ensure the sling bar was sound before lifting, but during this transfer the sling loop detached despite staff believing it was properly fastened and hearing it click into place; post-incident assessment showed the loop had come loose, the sling appeared in good condition, and a CNA later reported thinking one of the round metal disks on the lift might have been slightly loose, while maintenance logs documented no prior concerns with the lifts or slings.
The facility failed to revise and individualize care plans to reflect current needs and preferences for multiple residents, including one cognitively intact resident with hemiplegia, hemiparesis, and mononeuropathy who had bilateral shoulder surgery and could not tolerate BP measurements on the upper arms but preferred forearm readings. Despite repeatedly informing staff, this preference was not documented in the care plan or Kardex, and direct care staff and the RN/UM were unaware of it. Another cognitively intact resident with hemiplegia, contractures, and weakness reported they were supposed to get out of bed for two hours daily, but some NACs did not know this, even though the MAR/TAR contained an order to document times up and back to bed. The surveyors concluded that care plans were not accurately revised for several residents, placing them at risk for unidentified and unmet care needs and diminished quality of life.
Surveyors found that two residents with hemiplegia, hemiparesis, weakness, and contractures did not receive restorative nursing services, including ROM exercises and splint/brace or orthotic assistance, after therapy discharge. Although PT and OT discharge summaries documented established restorative ROM and transfer programs, recommended PROM to affected extremities, and recommended splint/brace use and assistance with orthotic wear, these recommendations were not entered as restorative referrals in the EHR. As a result, the residents’ care plans and records showed no restorative programs, and both residents reported that therapy and restorative exercises had stopped, while the DON, rehab director, and MDS coordinator confirmed they were unaware of and had not implemented the recommended restorative services.
A resident with cancer, cognitive impairment, and declining strength experienced multiple unwitnessed falls, most occurring while attempting to toilet or move toward the bathroom, culminating in a fractured ankle requiring ED treatment. Although assessments identified fall and incontinence risks and the facility’s policy required individualized interventions, the comprehensive care plan lacked a toileting plan and did not include several interventions that were discussed in incident investigations, such as consistent wheelchair placement and frequent rounding for bathroom assistance. Staff reported relying on verbal reminders and education to use the call light, despite acknowledging the resident’s impulsivity and failure to call for help, and the resident’s bed remained furthest from the bathroom while repeated bathroom-related falls occurred without the trend being recognized or addressed in the care plan.
A resident with a history of acute urinary retention and acute kidney injury had a Foley catheter deemed permanent by the hospital, with instructions that it not be removed in the SNF. At a later urology visit, the catheter was removed, and the resident returned with no new orders documented. Facility staff did not document bladder assessments, post-void residuals, or urine output, and CNA documentation showed the resident did not void that evening. Over the next day, the resident had vomiting, poor intake, altered level of consciousness, tachycardia, hypotension, and no documented wet briefs. A bladder scan eventually showed more than 2000–2500 mL of retained urine, and a new catheter drained a large volume. The resident and a roommate reported moaning, crying out in pain, and repeatedly alerting staff that the resident was not urinating and that the catheter was not draining, while nurses documented catheter care when no catheter was in place and later had to flush and replace the catheter due to continued complaints.
Surveyors found that nurses and nurse aides did not consistently administer medications according to professional standards and facility policy. Multiple residents reported that agency nurses were slow with medications, did not fully follow instructions, and often gave routine meds late. Observations showed an LPN administering expired Humalog/Lispro insulin well past the scheduled time, an LPN giving several scheduled meds (including Tizanidine) late and all at once, and an RN attempting to give sliding-scale insulin nearly two hours late, which a resident refused after already eating. Another resident received Methocarbamol two hours late after questioning the RN, and a resident on scheduled Tramadol had doses given without timely documentation, with a discrepancy between the narcotic count and pills remaining. These events demonstrated failures in timely administration, use of non-expired medications, and immediate, accurate MAR and narcotic documentation.
Failure to Notify Court-Appointed Guardian of Resident’s Clinical Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court-appointed guardian of significant clinical changes and care decisions, contrary to its own policy and state requirements. The facility’s policy on Resident Representatives, revised 02/2021, states that a resident representative includes a court-appointed guardian or conservator and that the facility treats the representative’s decisions as those of the resident to the extent delegated or required by the court. Resident 1, admitted with cerebral palsy, had a Superior Court guardianship letter dated 02/07/2025 indicating a guardian of person and conservator of the estate with full authority, identifying Collateral Contact 1 (CC1) as the guardian. Despite this, multiple clinical events and changes in condition were documented without any corresponding documentation that CC1 was notified. Progress notes and provider notes show that Resident 1 experienced an episode of nausea and vomiting, frequent loose stools, abdominal discomfort, bloating, worsening fatigue, generalized weakness, and later refusal of meals and medications over at least a 24-hour period, with observations that the resident appeared frailer, more fatigued, and had no energy or interest to talk. The provider developed care plans including close monitoring for deterioration, sending stool to the lab, and later initiating IV fluids for rehydration, with a plan to call family/POA for discussion. However, there was no documentation that the guardian was notified at any of these points, including when IV fluids were started. CC1 reported that they were not contacted when the resident stopped eating or developed stomach issues, and expressed that the facility did not respect their guardianship and that involvement in care planning took too long. The DON confirmed on record review that there were many opportunities to notify the guardian when the resident’s condition changed from baseline and that there was no evidence staff did so.
Failure to Thoroughly Investigate and Resolve Resident Grievance Regarding Incontinence Care and Staff Conduct
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve a grievance alleging neglect and disrespect toward a resident, as required by its grievance policy. The resident had depression, anxiety, moderate cognitive impairment, occasional urinary incontinence, and required moderate assistance with toileting, with a care plan directing staff to check the resident every two hours, ask about toileting needs, and ensure they were clean and dry. A collateral contact reported arriving to visit the resident and finding them soaking wet and agitated, with behavior that was not typical for the resident. The collateral contact documented in a written grievance that the resident’s tablet was off, the resident appeared upset, and the resident reported being told they had to wait five minutes to be changed and that staff would change their “nasty *ss” in five minutes, leading the collateral contact to believe the resident had been given a consequence of no tablet and sitting in wet clothes, which they characterized as abuse/neglect and requested immediate removal of the responsible staff and a report filed. The facility documented receipt of the grievance and created an incident report indicating the matter was reported to the state agency, and that the unit manager interviewed the collateral contact and the resident, with the resident described as confused and denying being soaking wet. The incident report stated that a different nursing assistant was assigned to assist with the brief change and that the unit manager believed the resident was not soaking wet, and that the resident and collateral contact were satisfied when they left the room. However, a CNA who actually changed the resident reported that the resident’s brief was soaked through their pants onto the wheelchair and their socks were soaked, and that the resident was timid, repeatedly saying they had to sit for five minutes, and not acting like themselves; this CNA stated they were never interviewed or asked about the grievance or the resident’s condition. The DON acknowledged not interviewing this CNA or investigating the resident’s behavior and why they were upset, and the unit manager did not recall whether the collateral contact was present during follow-up and did not believe they followed up with the collateral contact regarding the grievance. The administrator, identified as the Grievance Official, stated the facility should have thoroughly investigated the grievance and discussed findings and resolution with the collateral contact, indicating the grievance process was not fully carried out in accordance with policy and WAC 388-97-0460.
Failure to Obtain Timely Emergency Transport for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to obtain timely emergency medical services for a resident experiencing new-onset respiratory distress. The resident had dementia, respiratory failure, and heart failure, with severe cognitive impairment and a need for substantial assistance with activities of daily living. On the day the resident was sent to the hospital, a collateral contact observed the resident having difficulty breathing, appearing unable to get enough air, and looking as if they were sleeping or unconscious, and reported this to staff with a request to contact the doctor. An SBAR Communication Form documented that the resident was experiencing shortness of breath that had not occurred before, with an oxygen saturation of 90%. The physician was notified and ordered the resident sent to the emergency department for treatment and evaluation, and the collateral contact was notified shortly thereafter. Progress notes later documented that, despite the order for emergency department transfer, the resident was still awaiting pickup by Olympic transportation several hours later, with no estimated time of arrival. At approximately 3:30 AM, the dispatcher informed the facility that they could not provide transportation and instructed that 911 be called; only then was 911 contacted and the resident transported to the hospital via ambulance for respiratory distress. The RN caring for the resident stated they completed the SBAR, notified the physician and family, and at the end of their shift reported to the oncoming nurse that the resident needed to be sent to the emergency department for respiratory distress and that paramedics should be contacted, then left assuming 911 would be called. The DON stated that staff are expected to contact 911 for emergent conditions such as shortness of breath or respiratory distress, and that Olympic Ambulance is used only for non-emergent transport.
Failure to Provide Social Service Advocacy After Abuse Allegation and Questionable Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medically-related social services and advocacy for a resident following an allegation of abuse and concerns about the resident’s representative. The resident had an anoxic brain injury, dysarthria, moderate cognitive impairment, and was dependent on staff for activities of daily living. A hospital palliative care note documented that the resident lacked decisional capacity, had no DPOA, that the legal next of kin (CC4) did not want to be part of care decisions, and that care decisions were being deferred to another contact (CC5). CC5 accompanied the resident on admission, signed admission forms, and was listed as the primary contact in the medical record profile. On a date in February, during communication therapy, the resident reported that CC5 had done something to them, pounded their hands on their chest, recalled being hit in the back of the head by an unknown person, and stated they were sometimes afraid of CC5. A social services staff member reported this allegation to the state agency but did not complete a facility incident report, did not initiate care plan changes or interventions, and took no further action. CC5 continued to be treated as the resident’s representative, and progress notes documented CC5 at the bedside on multiple dates, including an entry noting the room smelled like foreign substances and that CC5 was seen waking the resident and then asking the nurse to administer pain medications. A psychiatry note later documented concern that CC5 was providing the resident with illicit substances and stated it would be prudent for the resident to identify a POA. Subsequently, the resident was found unresponsive, transported to the hospital, and later readmitted after altered mental status and overdose, with a provider note stating that CC5 posed a significant danger to the resident and was banned from visiting. After readmission, staff attempted to contact CC4 for consent to treat but initially reached someone who stated they were not CC4. The social service director acknowledged that, beyond reporting the initial allegation, no additional interventions were implemented, that CC5 continued to be used as the resident’s representative after the allegation, and that they had not explored legal authority for decision making following the abuse allegation or concerns about substances. The social service assistant reported they did not speak with the resident about the hospital stay or CC5 and did not complete an incident report or care plan changes after the allegation. The unit manager and DON were unaware of the initial abuse allegation, and the administrator, who served as abuse coordinator, also stated they were unaware of the allegation and that an investigation should have been initiated and a representative for the resident investigated at a minimum.
Injury from Mechanical Lift Sling Detachment During Transfer
Penalty
Summary
The facility failed to ensure a safe mechanical lift transfer when a resident was being moved with a Hoyer lift and sling, resulting in a fall and injury. Facility policy for using a mechanical lifting machine required staff to securely attach sling straps to the sling bar according to manufacturer’s instructions, double-check the security of the sling attachment before lifting, examine all hooks, clips, or fasteners, check strap stability, and ensure the sling bar was securely attached and sound. Despite these requirements, during a transfer for dinner, two CNAs placed the sling under the resident, attached the loops at each corner of the sling to the lift, and raised the resident off the bed into the space between the bed and wheelchair when the bottom left corner of the sling became disengaged from the lift. The resident involved had multiple diagnoses including osteoarthritis, cervical and thoracic spondylosis, and Alzheimer’s disease, with the Minimum Data Set documenting severely impaired cognitive skills for daily decision-making. The resident’s care plan required the assistance of two staff during Hoyer lift transfers. During the transfer, the resident fell approximately four feet, landing on her buttocks, bouncing, and then falling backward and striking her head on the leg of the Hoyer lift. Hospital records documented that the resident sustained an abrasion to the back of the head, fractures of the 6th, 7th, 8th, and 10th ribs, and fractures of the 1st and 2nd lumbar vertebra. Staff interviews and observations showed that staff believed the sling loops had been securely fastened and reported hearing the loops click into place before lifting. One CNA stated that they had barely lifted the resident off the bed when the bottom left loop became disconnected and the resident fell. Another CNA reported being shocked and unable to figure out what had happened. A nurse who assessed the resident and then examined the equipment after the fall noted that one of the loops of the sling had become disengaged but stated the sling appeared to be in good condition. During a later demonstration, a CNA indicated she thought one of the round metal disks on the lift might have been a little loose. Maintenance logs for Hoyer slings and lifts for the preceding months documented no concerns with the slings or lifts, and the DON acknowledged expecting a citation due to the resident’s injury from the fall.
Failure to Revise Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize comprehensive care plans to reflect residents’ current needs and preferences, as required by its own care planning policy. For one resident with hemiplegia, hemiparesis following cerebrovascular disease, and mononeuropathy of the upper limb, the admission MDS showed intact cognition and upper extremity impairment. This resident reported having bilateral shoulder surgery and an inability to tolerate blood pressure measurements on the upper arms due to pain, and stated a preference for BP measurements on the forearms. The resident reported having informed multiple nursing staff of this preference, but staff continued to place the cuff on the upper arms. Review of the resident’s care plan and Kardex showed no interventions or instructions regarding forearm BP cuff placement. A NAC confirmed they were unaware of the preference until the resident told them directly and that this instruction was not documented in the Kardex. The RN/Unit Manager, who stated they were responsible for revising and reviewing care plans when there were changes, also confirmed they were not aware of the resident’s preference and that it should have been updated in the care plan. Another resident, readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, contracture of the left hand, and weakness, was cognitively intact and required maximum assistance for bed mobility per a quarterly MDS. This resident stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care requirement. Review of the resident’s March 2026 MAR/TAR showed an order to document the time the resident got up and the time they returned to bed daily. The report states that, overall, the facility failed to revise care plans accurately to reflect residents’ needs for three of four residents reviewed for care plan revision, placing them at risk for unidentified and unmet care needs and a diminished quality of life.
Failure to Implement Restorative Nursing and Splint/Brace Programs After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services, including range of motion (ROM) exercises and splint/brace assistance, to maintain or prevent decline in mobility and contractures for two residents with significant motor impairments. The facility’s undated Restorative Nursing Services policy stated that residents would receive restorative care as needed to achieve and maintain optimal functioning and that residents may initiate a restorative program upon discharge from rehabilitative care. Despite this, surveyors found that residents with documented hemiplegia, hemiparesis, weakness, and contractures were not placed on restorative programs and had no restorative interventions documented in their electronic health records (EHRs). Resident 1 was admitted with hemiplegia and hemiparesis following cerebrovascular disease, a left lower leg fracture, and weakness, and the admission MDS showed intact cognition, moderate assistance needs for bed mobility and transfers, and one-sided upper and lower extremity impairment. During observation, the resident was seen lying in bed with a bent inward left forearm and hand and reported no longer receiving therapy or nursing-assisted exercises. The care plan initiated in January showed no restorative services, and the care plan history and EHR contained no restorative nursing interventions. However, the PT discharge summary from February documented that restorative ROM and transfer programs had been established and trained, including PROM to the left upper and lower extremities and stand-by assist with transfers, and the OT discharge summary recommended a splint/brace to prevent contracture. The OT stated that the splint/brace was not tried due to lack of time before insurance was discontinued, and both the Director of Rehab and the MDS coordinator confirmed there was no restorative referral in the EHR and they were unaware of the recommendations. Resident 2 was readmitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, a left-hand contracture, and weakness, and the quarterly MDS showed intact cognition, maximum assistance needs for bed mobility, total assistance for transfers, bilateral upper and lower extremity impairment, and no therapy or restorative programs. The resident reported that therapy had been discontinued months earlier and that no restorative staff were assisting with exercises. The care plan and EHR showed no restorative services. OT evaluation documented left upper extremity ROM impairment, a left-hand contracture, and prior use of a left orthotic to manage flexion tone, and the OT discharge summary recommended restorative care and assistance with donning/doffing the orthotic. The PT discharge summary recommended restorative programs if Medicaid Part B services did not continue. The Director of Rehab confirmed therapy was discontinued and that restorative nursing programs were recommended, but both the Director of Rehab and the MDS coordinator stated there were no restorative referrals in the EHR after readmission, and the MDS coordinator confirmed the resident had no restorative programs since readmission.
Failure to Implement Effective Fall and Toileting Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, identify fall trends, and implement progressive, resident-centered interventions for a resident with multiple falls and declining strength. The facility’s own Falls and Fall Risk Management policy required staff to identify interventions related to residents’ specific risks and causes to prevent falls and minimize complications. The resident’s Care Area Assessment identified cancer-related risks for pain, falls, and ADL decline, and stated that falls and urinary incontinence would be addressed in the care plan with an objective of improvement and risk minimization. However, the comprehensive care plan did not include a urinary or ADL care plan and contained no toileting plan, despite the resident’s identified risks and prior fall history. Over a series of falls, the resident repeatedly fell while attempting to toilet or move toward the bathroom, yet the facility did not recognize or address this pattern in its investigations or care planning. The resident had multiple unwitnessed falls: next to the bed while getting up to use the restroom, in the bathroom while standing to use the toilet, and near or in the bathroom on several occasions. Incident investigations and post-fall assessments documented environmental factors such as clutter, items on the floor, water on the floor, and issues with footwear, as well as the resident’s increasing weakness, impulsivity, poor safety awareness, and poor insight into limitations. Interventions documented in investigations and risk reviews included encouraging use of the front-wheeled walker, keeping the wheelchair and walker accessible, ensuring proper footwear and non-skid socks, and providing resident education on safe transfers, ambulation, and assistive device use. However, several of these planned interventions, including placement of the wheelchair and frequent rounding/toileting assistance, were not added to or reflected in the care plan as stated. Staff interviews further showed that the resident frequently fell while trying to go to the bathroom and that staff relied on verbal education and reminders to use the call light, even though the resident often did not use it. Staff acknowledged the resident’s impulsivity and tendency to get up independently despite instructions, and one staff member stated that nursing assistants were verbally instructed to offer bathroom assistance, but this intervention was not documented in the care plan. The resident’s bed remained the one furthest from the bathroom throughout the stay, and none of the facility’s investigations identified the trend of bathroom-related falls or addressed toileting options in the care plan. Ultimately, the resident sustained a left ankle fracture after another bathroom-related fall, requiring transfer to the emergency department for evaluation and treatment, and later records documented additional fractures and a decline in condition. The surveyors concluded that the facility’s failures placed residents at risk of repeated falls and injuries.
Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Medication Administration Delays, Documentation Errors, and Use of Expired Insulin
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff with appropriate competencies and skill sets to administer medications according to professional standards of practice, facility policy, and prescriber orders. The facility’s medication administration policy required medications to be given as prescribed, in accordance with manufacturers’ specifications and good nursing principles, with no expired medications used, and doses administered within 60 minutes of the scheduled time and documented immediately after administration. Multiple residents reported that agency nurses often gave medications late, did not read full instructions, or were slow in bringing medications, and that routinely scheduled medications were not consistently provided without residents having to ask. Surveyors observed several specific medication administration failures. For a resident with diabetes, an LPN drew up and administered Humalog/Lispro insulin from a multi-dose vial that had been opened and dated “02/16” with no year, making it expired per policy, and administered the dose nearly 1 hour and 45 minutes after it was due. Another resident with care plan instructions to receive medications as ordered had multiple scheduled medications (Gabapentin, Oxybutynin, Baclofen, and Tizanidine) that were ordered at specific times throughout the day; the LPN was observed administering all four together and acknowledged that at least one (Tizanidine) was late, while the resident reported that receiving them together at that time was typical and not at their request. For another diabetic resident, an RN checked blood sugar and prepared sliding scale Humalog/Lispro insulin almost two hours after the scheduled time; the resident refused the insulin, stating they had already finished lunch. Additional deficiencies were identified with other residents’ pain and scheduled medications. One resident with a pain care plan and an order for Methocarbamol four times daily at set times approached the cart requesting Methocarbamol and Tylenol; the RN initially stated the Methocarbamol had already been given, but then administered it two hours after it was due when the resident pointed out the scheduled timing. For another resident with a risk for pain care plan and Tramadol ordered three times daily at specific times, an LPN retrieved a PRN pain medication while the electronic record showed no 8:00 AM medications documented; the LPN stated they had given them but had not yet documented. Later, an RN prepared the 2:00 PM Tramadol dose, and review of the narcotic count showed a discrepancy between the number of pills documented and the number remaining in the card. The RN stated they had given the 8:00 AM Tramadol but had not signed it out, then signed out both the 8:00 AM and 2:00 PM doses at that time. Residents interviewed consistently reported that medications were sometimes or frequently late, that agency nurses did not always follow instructions, and that they often had to request medications that were routinely scheduled.
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