Grays Harbor Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Aberdeen, Washington.
- Location
- 920 Anderson Drive, Aberdeen, Washington 98520
- CMS Provider Number
- 505016
- Inspections on file
- 29
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Grays Harbor Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and ADL needs had a care plan stating that staff would provide bathing assistance, but the plan did not reflect the documented arrangement and preference for the resident’s spouse to perform showers. Progress notes indicated the spouse would be present on shower days to assist, and the resident reported that staff did not shower him while admitted. An LPN and the RN care manager confirmed the spouse insisted on providing showers and did not want staff involved, yet there was no documented orientation of the spouse to the shower room and no completed safety assessment, despite acknowledged fall risk. The Administrator later stated that the spouse-provided showers were not sanctioned and that the required safety assessment for showering had not been completed.
A resident who required assistance with ADLs and had moderate cognitive impairment was care planned for OT involvement and had physician orders for OT evaluation and treatment two times per week. The resident received only an initial OT evaluation, with no follow-up treatment sessions provided, and reported not recalling working with therapy staff. The rehab director confirmed the lack of ongoing OT services and noted reliance on part-time and PRN OT staff while therapy positions were being advertised.
A resident with severe cognitive impairment and an order for continuous oxygen therapy was observed without oxygen in use; the concentrator was off, the nasal cannula was not applied, and the oxygen tank on the wheelchair was empty. Both an LPN and the DON confirmed the resident was not receiving oxygen as ordered, and no changes to the physician's order had been made.
A resident with mild cognitive impairment had a physician-ordered UA that was not collected for three days after the order was placed. Nursing staff documented waiting for the sample, and interviews with the DON and other nurses confirmed that the delay was due to the order not being properly scheduled in the electronic medical record, resulting in the UA not being collected within the expected timeframe.
The facility failed to assist residents with completing advance directives (AD) and maintaining Durable Power of Attorney (DPOA) documentation. Several residents, including those with cognitive impairments, did not have their ADs properly documented in their electronic health records (EHRs). Staff acknowledged that ADs were not adequately addressed, and POLST forms were mistakenly used as substitutes, leading to a lack of proper AD documentation.
A facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident, who was moderately cognitively impaired, before the end of Medicare-covered services. Although a Notice of Medicare Non-Coverage (NOMNC) was provided, the SNF ABN, which details potential financial liability, was not given, as confirmed by the Social Services Director.
A facility failed to obtain consent and a physician's order for bed rails for a moderately cognitively impaired resident. Observations showed the resident with bed rails installed, but the electronic health record lacked the necessary documentation. Staff confirmed the oversight, acknowledging the failure to follow the facility's process.
A facility failed to complete a timely Level II PASRR referral for a resident with depression and anxiety. The initial Level I PASRR did not reflect the resident's diagnoses, and the necessary referral was delayed by over eight months. The Social Services Director admitted to missing the step, and the DON was aware of the oversight.
The facility failed to initiate bowel interventions for two residents who did not have bowel movements for extended periods, contrary to the facility's bowel management policy. Additionally, a resident requiring urology and vascular consultations did not have these appointments arranged, as there was no system in place to track and follow up on specialist referrals. Staff interviews confirmed the absence of documentation and a clear process for managing these referrals.
A resident with moderate cognitive impairment was found with loose bed rails, creating a gap between the mattress and rail. The resident struggled to use the rail for mobility, and staff interviews revealed a lack of timely reporting and maintenance checks. The maintenance director confirmed the need for tightening the rails.
Failure to Implement and Document ADL Care Plan for Resident Showering by Family
Penalty
Summary
The deficiency involves the facility’s failure to implement and update a complete, individualized ADL care plan and corresponding interventions for a resident whose wife was providing showers. Facility policy titled "Quality of Life" required development and implementation of care plans and interventions to maintain, improve, or prevent avoidable decline in ADLs based on assessed needs, goals, and preferences. The resident was admitted with moderate cognitive impairment and required assistance with ADLs. The 5‑day admission MDS documented these needs, and the ADL care plan initiated the day before the MDS specified that one staff member would provide bathing/showering assistance as needed. However, the care plan did not document the resident’s or wife’s preference for the wife to provide showers. Progress notes documented that the wife would do the resident’s laundry and would be present in the evenings to shower him on his shower days. The resident later stated that while he was in the facility, staff did not shower him and that his wife assisted him instead. An LPN and the Residential Care Manager/RN both reported that the wife was insistent on showering the resident and did not want staff involved, and the RN acknowledged there was no documentation of any orientation to the shower room for the wife. The RN also acknowledged a fall risk associated with family members showering residents. The Administrator stated she learned after the fact that the wife had been showering the resident, that this was not sanctioned by the facility, and that an assessment to verify safety with showering, which should have been completed, was not done for this resident.
Failure to Provide Ordered Occupational Therapy Services
Penalty
Summary
Failure to provide specialized rehabilitative services occurred when a resident with physician orders for occupational therapy (OT) evaluation and treatment did not receive ordered OT services beyond the initial evaluation. The resident was admitted with needs for assistance with activities of daily living (ADLs) and was documented as moderately cognitively impaired on the 5-day admission MDS. The resident’s fall risk care plan included an intervention to refer to OT as needed per orders, and physician orders dated 02/24/2026 specified OT evaluation and treatment as indicated. The Director of Rehabilitation Services reported that OT was ordered two times per week and confirmed that the resident was evaluated for OT on 02/25/2026 but did not receive any subsequent OT treatments. The resident also stated he did not recall working with therapy staff while admitted. Facility staff reported that there was no full-time occupational therapist on staff and that OT coverage was being provided by a part-time weekend therapist and PRN COTAs, with ongoing efforts to recruit additional therapy staff.
Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
A resident who was admitted to the facility with severe cognitive impairment had physician orders and a care plan in place for continuous oxygen therapy at 2 liters per minute via nasal cannula for dyspnea. Despite these orders, during an observation, the resident was found in bed without oxygen in use; the oxygen concentrator was turned off and the nasal cannula was not applied. Additionally, the oxygen tank attached to the resident's wheelchair was empty. Interviews with facility staff revealed a lack of awareness regarding any changes to the resident's oxygen orders, and upon review, staff confirmed that the order for continuous oxygen therapy remained in effect. Both the LPN and the DON acknowledged that the resident was not receiving oxygen as prescribed at the time of observation, and the DON confirmed that the expectation was for the resident to have oxygen applied at all times per the current orders.
Delayed Collection of Physician-Ordered Urinalysis
Penalty
Summary
The facility failed to ensure the timely completion of a physician-ordered urinalysis (UA) for one resident. The resident, who was mildly cognitively impaired, had a physician's order for a UA with culture and sensitivity if indicated. The order, dated 07/18/2025, did not specify collection instructions. Nursing documentation on the same day noted that staff were awaiting a urine sample from the resident. The UA was not collected until 07/21/2025, three days after the order was placed, and was then sent to the lab. Interviews with facility staff revealed that standard practice was to collect UAs within the same shift or within 24 hours of the order. Staff indicated that a three-day delay in collection was not considered timely. The Director of Nursing identified that the order was entered but not scheduled in the electronic medical record, which prevented the system from alerting nurses to complete the lab. This resulted in the UA not being collected in a timely manner as required.
Failure to Properly Document and Assist with Advance Directives
Penalty
Summary
The facility failed to have procedures in place to assist residents with completing advance directives (AD) and obtaining and maintaining Durable Power of Attorney (DPOA) documentation. This deficiency was identified for five residents who were part of a sample review. The facility's policy required that upon admission, residents should be informed of their right to establish advance directives and be provided assistance if needed. However, the facility did not adhere to this policy, as evidenced by the lack of documentation in the residents' electronic health records (EHR) regarding discussions or assistance offered for ADs. Several residents, including those who were moderately cognitively impaired, did not have their ADs properly documented or maintained in their EHRs. Staff members, including the Social Services Director and the Director of Nursing Services, acknowledged that ADs were not being adequately addressed and that POLST forms were mistakenly used as substitutes for ADs. This misunderstanding led to the absence of proper AD documentation for the residents, placing them at risk of not having their healthcare preferences honored.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide a resident with the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), which is necessary to inform residents of their potential financial liability when Medicare services are ending. Resident 34, who was moderately cognitively impaired and admitted with diagnoses including abnormalities of gait and mobility, was issued a Notice of Medicare Non-Coverage (NOMNC) on 01/31/2025, indicating that skilled nursing services would end on 02/02/2025. However, the SNF ABN, which should have been provided before the last covered day to explain the financial implications of continuing care, was not issued to the resident or their representative. This oversight was confirmed by the Social Services Director during an interview on 03/19/2025.
Failure to Obtain Consent and Physician's Order for Bed Rails
Penalty
Summary
The facility failed to obtain consent and a physician's order for the use of physical restraints, specifically bed rails, for a resident identified as moderately cognitively impaired. The resident was admitted to the facility and had an assessment indicating the use of assist rails for bed mobility. However, observations on multiple occasions revealed the resident lying in bed with quarter bed rails installed, without any documented consent or physician's order in the resident's electronic health record. Staff interviews confirmed the oversight, with the Unit Manager and LPN acknowledging the absence of necessary consent and physician orders for the bed rails. The Director of Nursing also stated that it was expected for consent and physician orders to be obtained prior to the installation of bed rails, indicating a failure to follow the facility's established process for this resident.
Failure to Complete Timely PASRR Level II Referral
Penalty
Summary
The facility failed to accurately complete a Level I Pre-Admission Screening and Resident Review (PASRR) and ensure a referral for a Level II evaluation for one of the sampled residents. This resident was admitted with diagnoses of depression and anxiety, and the initial Level I PASRR did not reflect these diagnoses. Despite being prescribed Duloxetine for depressive symptoms, the necessary Level II referral was not completed until over eight months after admission. Staff F, the Social Services Director, acknowledged missing the step of sending off the Level II referral within the required timeframe. The Director of Nursing Services was aware of the oversight and expected PASRR processes to be followed according to facility policy.
Failure to Initiate Bowel Protocol and Arrange Consultations
Penalty
Summary
The facility failed to initiate bowel interventions for two residents, identified as Resident 18 and Resident 42, who were reviewed for bowel management. According to the facility's bowel management policy, residents who do not have a bowel movement for more than three days should be assessed and the bowel protocol should be initiated. Resident 18 did not have a bowel movement for over 81 hours, and Resident 42 did not have a bowel movement for over 128 hours. Despite these extended periods without bowel movements, the bowel protocol was not initiated for either resident, as confirmed by the lack of documentation in their Medication Administration Reports (MARs). Additionally, the facility failed to arrange necessary consultations for Resident 55, who was reviewed for physician orders for urology and vascular consults. Resident 55 was admitted with an indwelling foley catheter, and a urology consult was ordered to address urinary retention. Furthermore, a vascular consult was ordered following the discovery of a full-thickness wound and moderate stenosis in the resident's lower extremities. However, there was no documentation to confirm that these consultations were scheduled, and staff members were unable to verify if the appointments had been arranged. Interviews with staff members revealed a lack of a clear process for tracking and following up on specialist referrals. Staff members, including unit managers and the Director of Nursing Services, acknowledged the absence of a system to ensure that referrals were completed and appointments were scheduled. This lack of organization and documentation contributed to the failure to provide timely and appropriate care for the residents involved.
Failure to Securely Fasten Bed Rails
Penalty
Summary
The facility failed to ensure that bed rails were securely fastened and without gaps between the mattress and bed rail for a resident reviewed for accident hazards. The resident, who was moderately cognitively impaired, was observed with loose bed rails on both sides of the bed. The right bed rail was leaning outward and had significant movement, with a noticeable gap between the mattress and the rail, where a box of tissues had fallen. The left bed rail also exhibited movement. The resident expressed difficulty using the loose rail to get in and out of bed and to move around, indicating that the rail had been loose for a long time. Staff interviews revealed that maintenance was responsible for installing and checking bed rails, with checks scheduled twice a year. However, the staff did not report any current issues with bed rails, and the maintenance director confirmed that the rails needed tightening after observing the resident's bed. The Director of Nursing stated that staff should report loose bed rails through the electronic work order system, TELS, and expected that bed rails would be maintained properly.
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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