Hallmark Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Federal Way, Washington.
- Location
- 32300 First Avenue South, Federal Way, Washington 98003
- CMS Provider Number
- 505313
- Inspections on file
- 30
- Latest survey
- May 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Hallmark Manor during CMS and state inspections, most recent first.
Staff did not provide required written transfer notifications, bed hold policies, or call reports to the receiving hospital for several residents transferred to acute care. In some cases, residents or their representatives were not informed of the transfer or their rights, and documentation of these actions was missing. The facility also failed to notify the LTCO and medical providers as required.
Hazardous chemicals and sharps were found unsecured in multiple areas, including shower rooms and storage rooms, with doors left open or unlocked and no staff present. Items such as cleaning agents, razors, and scissors were accessible to residents, and staff confirmed these should have been secured according to facility policy.
A resident was discharged to an adult family home without being provided the required Notification of Medicare Non-Coverage (NOMNC) prior to discharge. Documentation confirmed the discharge was planned, but the NOMNC letter was not issued, as verified by the Social Service Director.
Multiple resident rooms lacked personal items or décor, with some rooms noted to have strong odors and inadequate lighting that persisted despite being reported. Weight scales in both shower rooms were found to be rusted, with staff confirming the potential for resident contact with rust. These deficiencies were observed and confirmed through staff and resident interviews, indicating a failure to maintain a safe, clean, and homelike environment.
A resident experienced multiple declines in condition, including increased confusion, immobility, refusal of food and fluids, and was placed on hospice care. Despite these changes, staff did not complete a Significant Change in Status Assessment (SCSA) as required, as confirmed by record review and staff interviews.
Surveyors found that the facility failed to accurately complete MDS assessments for two residents: one resident's fall was not documented in the MDS despite being recorded in progress notes, and another resident's discharge was incorrectly coded as a hospital transfer instead of a discharge to home, as confirmed by staff and records.
The facility did not ensure that PASRR Level 2 evaluations were obtained for several residents with serious mental illness, as required after positive Level 1 screenings or new mental health diagnoses. Documentation and staff interviews revealed that referrals were either not made or not followed up on, resulting in missing or incomplete evaluations for residents with conditions such as depression, anxiety, and psychotic disorders.
A resident who had agreed to Palliative care services did not have a Palliative care plan developed, as confirmed by record review and DON interview. This omission was not in accordance with facility policy requiring timely, person-centered care plans.
The facility did not consistently conduct or document quarterly care conferences for three residents, including one with diabetes and mental health conditions, another in a persistent vegetative state, and a third without memory impairment. Additionally, care plans were not revised as required for two residents: one with respiratory failure whose care plan was not updated after discontinuing oxygen, and another with complex medical needs whose care plan lacked interventions for repeated refusals to be weighed. Staff interviews confirmed inconsistent processes for care conferences and care plan updates.
The facility did not obtain or clarify necessary physician orders for bed rails and blood sugar parameters for a resident with diabetes, failed to follow medication administration parameters for a resident with hypertension, and did not ensure blood pressure checks were performed before administering a diuretic to another resident, as required by physician orders. Staff interviews confirmed these deficiencies.
Staff failed to provide necessary ADL assistance and supervision for three dependent residents, including leaving a resident in a wheelchair for extended periods, not providing nail and foot care for a diabetic resident, and not supervising a hospice resident during meals as required by care plans and facility policy.
The facility failed to obtain required lab tests before administering medications for cholesterol, uric acid, and thyroid conditions, did not consistently observe or report changes in condition such as edema or infection in two residents, and did not administer pain medications as ordered for a resident with chronic pain. These actions resulted in residents receiving medications without proper monitoring and experiencing unaddressed changes in their health status.
Staff did not consistently assist residents with meals, offer or document meal replacements when less than 50% of meals were consumed, or follow dietary restrictions for residents with special needs. In several cases, residents were left without appropriate food options or assistance, and required weight monitoring was not performed or documented as ordered.
The facility did not complete ongoing monitoring or quarterly evaluations for bed rail use for three residents, despite physician orders and care plans indicating the use of bilateral bed rails. Observations and record reviews confirmed the absence of required documentation, and the DON acknowledged that evaluations were not performed as expected.
The facility did not ensure that monthly pharmacist Medication Regimen Reviews (MRRs) and their recommendations were consistently documented in resident records or acted upon in a timely manner. For two residents receiving multiple medications, pharmacist recommendations regarding medication adjustments and necessary blood work were not acknowledged, not included in records, and not addressed for extended periods, contrary to facility policy.
A resident with a history of skin infection was administered an antibiotic for an extended period without a documented stop date or duration, despite pharmacy recommendations and facility policy requiring clarification. The antibiotic was given twice daily for nearly two months, with no evidence of provider follow-up or care plan documentation, and the Infection Preventionist was unaware of the ongoing therapy.
Surveyors found that medications, including inhalers and prescription drugs, were not properly labeled or securely stored. Opened inhalers lacked open dates, a bottle of vitamins was left at a resident's bedside without proper authorization, and a prescription medication was found unsecured in an unlocked cabinet. Staff interviews confirmed these practices did not meet required protocols.
Several residents were served unappetizing green eggs and were not offered alternate meal options when they refused or disliked the food. Staff acknowledged the issue with the eggs and confirmed that the process for offering substitutes was not consistently followed, resulting in dissatisfaction and inadequate meal intake for some residents.
Staff did not follow infection control protocols when providing care to a resident with a feeding tube, including failing to perform hand hygiene after glove removal and not donning a gown as required by EBP signage. These lapses were confirmed by both the staff involved and the DON.
The facility employed a Dietary Manager without the necessary ServSafe Manager Certification and failed to register them for the Certified Dietary Manager course, risking inadequate dietary services for residents.
The facility failed to maintain food safety and hygiene standards, risking residents' health. Observations showed improper food temperature checks, cross-contamination, inadequate hand hygiene, and delayed meal service. Unlabeled, undated, and expired foods were found in storage, with fruit flies and unclean vents adding to unsanitary conditions. The administrator acknowledged these issues.
A resident at severe risk of pressure sores developed a significant wound due to inadequate care and oversight. After a cast was removed, the facility failed to update the care plan for skin checks and brace use, leading to a deep tissue injury and exposed bone. The wound progressed to gangrene, necessitating hospital treatment and amputation. Staff interviews revealed a lack of communication and care plan updates post-cast removal.
The facility failed to obtain physician orders for COVID-19 testing for six residents and did not document test results for three residents during a COVID-19 outbreak. Staff interviews revealed a misunderstanding about the implementation of standing orders for testing.
The facility failed to respond to abuse allegations in a timely manner for two residents. One resident experienced verbal abuse from a CNA, which was not reported to administrative staff until four days later, allowing the CNA to continue working. Another resident reported an incident of physical abuse, but it was not properly documented or investigated.
Failure to Provide Required Transfer Notifications, Bed Hold Policies, and Communication During Resident Transfers
Penalty
Summary
Facility staff failed to provide required written transfer notifications, bed hold policies, and call reports to the receiving hospital for multiple residents who were transferred to acute care hospitals. For several residents, there was no documentation that written transfer notices were given to the residents or their representatives at the time of transfer, nor were copies of these notices found in the residents' records. In some cases, residents or their representatives reported not receiving timely notification or explanation regarding the transfer, and staff interviews confirmed that these notifications were not provided as required. Additionally, the facility did not consistently offer or document bed hold policies to residents or their representatives during hospital transfers. In instances where residents declined bed holds, the forms lacked a witness staff signature to verify verbal consent. The facility also failed to document that staff called and reported the residents' medical status to the receiving hospital at the time of transfer for several residents, as expected for continuity of care. The report further notes that the Office of the State Long Term Care Ombudsman (LTCO) was not notified for certain resident transfers, and in one case, the resident's medical provider was not notified of a discharge. Staff interviews confirmed these omissions, and staff acknowledged the importance of these notifications and documentation for resident safety and informed decision-making. The deficiencies were identified through record reviews and staff and resident representative interviews.
Unsecured Chemicals and Sharps in Resident Areas
Penalty
Summary
Multiple unsecured areas containing hazardous chemicals and sharps were observed throughout the facility, including the north and south units, soiled laundry room, and central supply room. On several occasions, doors to shower rooms, utility rooms, and storage areas were found propped open or unlocked with no staff present. Inside these areas, chemical cleaning agents, razors, scissors, and other potentially dangerous items were accessible to residents. Cabinets intended to secure these items were also found unlocked or lacking locks altogether. Staff interviews confirmed that these items should have been secured and that the rooms should have remained locked for resident safety. Facility policies required chemicals and sharps to be stored out of residents' reach and never left unattended. Despite these policies, observations revealed that chemicals, razors, and other hazardous items were left within reach in unlocked or unattended rooms. Staff acknowledged the failure to secure these items, citing broken locks and lack of cabinet locks as contributing factors. These actions and inactions resulted in the facility failing to maintain a safe environment free from accident hazards, as required by regulation.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a required Notification of Medicare Non-Coverage (NOMNC) to a resident who was admitted and later discharged to an adult family home. Record review showed no evidence that the NOMNC letter was given to the resident prior to discharge, despite the discharge being planned and documented in social services notes. During an interview, the Social Service Director confirmed that the NOMNC letter was not provided to the resident before discharge, as required by regulation.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents as required by its own policy. Observations revealed that several resident rooms in the South Wing lacked any personal items or décor, with blank walls and, in one instance, a strong odor of urine and a bedside commode containing urine. Another room was noted to be dark, with no functioning hallway light for at least two days, despite the resident reporting the issue to staff. Staff interviews confirmed awareness of these environmental deficiencies, including the lack of personalization and lighting issues, but indicated that corrective measures had not yet been implemented. Additionally, both the North and South Wings had weight scales in the shower rooms that were visibly rusted, with rust present on the ramps and safety rails, and rust dust observed on the floor. Staff acknowledged that residents could come into contact with the rust and that the equipment should be repaired or replaced. These conditions were observed during multiple site visits and confirmed through staff and resident interviews, demonstrating a failure to maintain a clean and safe environment as outlined in facility policy.
Failure to Complete Significant Change Assessment for Resident on Hospice
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days of determining a significant change in condition for a resident who was reviewed following their death. Record review showed that the resident experienced a series of health declines, including increased confusion, becoming bedridden, dropping blood pressure, discontinuation of blood pressure medications, development of a new pressure ulcer, refusal of food and fluids due to difficulty swallowing, and increased pain. The resident's representative requested comfort care, and a physician order for hospice services was implemented. Despite these documented changes and the initiation of hospice care, there was no evidence that a SCSA was completed as required by the Resident Assessment Instrument (RAI) Manual. Interviews with the DON and MDS Nurse confirmed that the resident had multiple changes in condition and that a SCSA should have been completed prior to the resident's death, but it was not done. This failure was identified during the review of the resident's records and staff interviews.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one resident, the quarterly MDS indicated no falls during the assessment period, despite documentation in the nursing progress notes that the resident had experienced a fall while attempting to retrieve clothing without staff assistance. The MDS Coordinator confirmed that the fall should have been captured in the MDS, but it was not, resulting in an inaccurate assessment. For another resident, the MDS was coded as a discharge to an acute care hospital, while health records and staff interviews confirmed that the resident was actually discharged home per physician orders. The MDS Coordinator acknowledged the error, stating that the MDS should have been coded as a discharge to home/community. These inaccuracies in the MDS assessments were identified through observation, interview, and record review, and were not in accordance with the facility's policy to follow the Resident Assessment Instrument guidelines.
Failure to Obtain Required PASRR Level 2 Evaluations for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) Level 2 comprehensive evaluations were obtained for five out of nine residents reviewed who had indications of serious mental illness (SMI). According to facility policy, a positive PASRR Level 1 screen for SMI requires a referral for a Level 2 evaluation, which should be conducted prior to admission or upon identification of new SMI diagnoses. For several residents, documentation showed either a referral for a Level 2 evaluation was made but not followed up on, or no referral was made at all despite the presence of SMI diagnoses such as depression, anxiety, psychotic disorder, and schizophrenia. In one case, a resident was referred for a Level 2 evaluation after a change in condition, but there was no evidence in the records that the evaluation was obtained or that follow-up occurred, even months after the referral. Interviews with facility staff confirmed that there was no established process for tracking or following up on PASRR Level 2 referrals to ensure completion. Staff acknowledged that residents with SMI should have been referred for Level 2 evaluations and that these evaluations are important for ensuring appropriate mental health care. Record reviews for the affected residents showed missing or incomplete PASRR Level 2 documentation, and in some cases, no updated PASRR Level 1 was completed after new mental health diagnoses were identified. These actions and omissions resulted in the facility not obtaining required PASRR Level 2 determinations for residents with SMI.
Failure to Develop Palliative Care Plan for Resident
Penalty
Summary
The facility failed to develop a Palliative care plan for one resident who was reviewed for closed records. According to the health records, a physician's progress note documented that the resident's representative had agreed to Palliative care services, but there was no corresponding Palliative care plan in the resident's file. The Director of Nursing confirmed during an interview that a Palliative care plan was not present and acknowledged that one should have been developed to guide staff in providing comfort-focused interventions at the end of life. This deficiency was identified through record review and staff interview, and was found to be inconsistent with the facility's policy requiring timely, person-centered care plans involving the resident or their representative.
Failure to Conduct Quarterly Care Conferences and Revise Care Plans
Penalty
Summary
The facility failed to conduct and document quarterly care conferences for three residents and did not ensure care plans were revised as required for two residents. For one resident with diabetes, anxiety, and depression, there was no documentation of a care conference for over two and a half years, despite a note indicating the resident declined a quarterly conference at one point, with no evidence of further offers or follow-up. Another resident in a persistent vegetative state had only a single documented attempt to schedule a care conference with their representative, with no further follow-up. A third resident, who had no memory impairment, reported not being offered or having a care conference since admission, and records confirmed no such documentation except for a single declined offer, with no further attempts noted. Additionally, the facility did not revise care plans as required for two residents. One resident with respiratory failure had a care plan that continued to include oxygen supplementation and monitoring, even after supplemental oxygen was discontinued, which was not updated in the care plan and could cause confusion. Another resident with multiple complex diagnoses, including heart failure and risk for malnutrition, repeatedly refused to be weighed as ordered by the physician. The care plan for this resident did not include specific interventions to address refusals to be weighed, nor did it document staff efforts to obtain the resident's weight, despite ongoing refusals and the importance of weight monitoring for medication management. Interviews with facility staff confirmed that the process for providing quarterly care conferences was inconsistent and not fully implemented, with some disciplines no longer attending care conferences as expected. Staff also acknowledged that care plans were not always updated to reflect changes in residents' needs or to include specific interventions for care refusals, as required by facility policy and regulatory standards.
Failure to Obtain and Follow Physician Orders for Bed Rails, Blood Sugar, and Medication Administration
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for three residents. For one resident with diabetes, there was a lack of physician orders specifying blood sugar parameters for when to notify the physician of dangerously low levels, despite the resident receiving injectable medication for blood sugar control. Additionally, this same resident had bilateral bed rails in use without a corresponding physician order. Staff interviews confirmed that these orders were missing and acknowledged the importance of having them in place. Another resident with hypertension received blood pressure medication outside of the prescribed parameters, as staff administered the medication even when the resident's systolic blood pressure was below the threshold specified in the physician's order. For a third resident, a physician order for a diuretic included instructions to check blood pressure prior to administration, but these instructions were not transferred to the medication administration record, resulting in staff not checking blood pressure as required. Staff interviews confirmed these deficiencies and the need for clarification of orders.
Failure to Provide Required ADL Assistance and Supervision
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were dependent on staff support. One resident, who was moderately cognitively impaired and required total assistance for transfers, was observed repeatedly left in their wheelchair for extended periods, including while asleep, without being assisted back to bed as requested by their representative. Staff interviews confirmed that the resident was routinely kept in their wheelchair after breakfast until the afternoon, despite expectations that staff should assist residents to lie down if they were asleep in their wheelchair. Another resident, dependent on staff for bathing, dressing, and personal hygiene due to impaired balance and diabetes, reported that staff did not provide nail care, did not offer washcloths for personal hygiene, and did not remove their socks for weeks. Observations confirmed the resident had long, cracked toenails and dry, discolored skin on their feet, with one leg more swollen than the other. Staff interviews revealed that refusals of care were not documented, and the resident was not referred to the podiatrist for diabetic foot care as required, nor was there evidence of proper communication among staff regarding the resident's needs. A third resident, who had recently transitioned to hospice care and required supervision while eating, was observed multiple times with meal trays but without staff supervision during meals. On one occasion, the resident was heard coughing while eating alone, and staff did not provide the required supervision. Staff interviews indicated a lack of awareness of the resident's current care plan, with some staff believing only setup assistance was needed, despite documentation requiring supervision. These failures were contrary to the facility's own ADL policy and placed residents at risk for unmet care needs.
Failure to Ensure Lab Monitoring, Change of Condition Reporting, and Pain Medication Administration
Penalty
Summary
The facility failed to ensure appropriate laboratory testing and monitoring for several residents receiving medications that require such oversight. One resident was prescribed cholesterol-lowering and uric acid-lowering medications without any documented lab results for cholesterol or uric acid levels, and there was no diagnosis related to high uric acid. Staff acknowledged that these labs should have been obtained prior to medication administration. Another resident with hypothyroidism received daily thyroid hormone replacement without documentation of a Thyroid Stimulating Hormone (TSH) test to monitor therapy effectiveness. The facility also failed to observe and report changes in condition for residents at risk. One resident with diabetes and a history of heart failure reported that staff did not remove their socks or check their legs for swelling, resulting in undetected edema for three weeks. Another resident dependent on dialysis had redness, swelling, and pain in their right hand, which staff failed to notice or report during routine care, despite care plans instructing staff to monitor for such changes. Additionally, the facility did not administer pain medications as ordered for a resident with a history of vertebral fracture and chronic pain. The resident received a lower dose of pain medication than prescribed on multiple occasions, and a pain patch was not applied as soon as it was available, contrary to physician orders. Staff interviews confirmed that medication administration did not follow the prescribed pain management protocol.
Failure to Provide Adequate Nutrition, Meal Replacements, and Weight Monitoring
Penalty
Summary
Staff failed to provide adequate nutritional care and meal replacements for multiple residents who consumed less than 50% of their meals. In one instance, a resident who was unable to feed themselves was left with a meal tray and not assisted until nearly an hour later, by which time the food was cold. The resident consumed less than 10% of the meal, and staff did not offer or document a meal replacement, contrary to facility policy. Staff interviews confirmed that meal replacements should be offered and documented when residents consume less than half of their meal, but this was not done. Another resident with diagnoses including morbid obesity, heart failure, and malnutrition, and who was lactose intolerant and diabetic, frequently refused facility meals. Staff offered inappropriate snacks such as milk and high-sugar items, despite knowing the resident's dietary restrictions. When the resident refused meals, staff did not consistently offer suitable meal alternatives or ensure that outside food was properly stored, as required by facility policy. Staff interviews revealed uncertainty about the provision of supplements and the storage of outside food. A third resident, at risk for malnutrition and with dysphagia, had physician orders for regular weight monitoring. Staff failed to obtain and accurately document weights as ordered, with several entries missing or marked as refused without evidence of alternative attempts. Staff acknowledged the failure to follow physician orders and the need for alternative weighing methods for residents who refuse care. These deficiencies in nutritional care, meal replacement, and weight monitoring were observed and confirmed through staff interviews and record reviews.
Failure to Monitor Bed Rail Use According to Policy
Penalty
Summary
The facility failed to ensure ongoing monitoring of bed rail use for three residents who were reviewed for accident hazards. Observations showed that these residents had bilateral bed rails in use, despite their Minimum Data Set (MDS) assessments indicating that bed rails were not in use. Physician orders and care plans were present for bed rail use, but there was no documentation of ongoing monitoring or quarterly evaluations as required by facility policy. The policy specified that evaluation for bed rail use should be completed at least quarterly and with any change of condition. Record reviews for each resident confirmed the absence of documentation regarding ongoing monitoring of bed rail use. During an interview, the Director of Nursing acknowledged that the required quarterly evaluations for bed rail use had not been completed. This lack of monitoring was identified through observation, record review, and staff interview, and was cited as a failure to meet professional standards of practice.
Failure to Document and Act on Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were consistently added to resident records and that the pharmacist's recommendations were reviewed and acted upon in a timely manner. For one resident, who was receiving multiple medications including antipsychotics, antidepressants, anticoagulants, antiplatelets, blood sugar control, and antiseizure medications, the pharmacist recommended routine blood work related to a cancer treatment medication. This recommendation was not acknowledged, not included in the resident's record, and not acted upon or discussed with the physician for over five months. Additionally, other MRRs for this resident were missing from the record, with only a few months' reports present. For another resident, who was also on several medications such as antianxiety, antidepressants, water pills, and antiplatelets, the pharmacist made recommendations to consider reducing certain medications based on blood test results. These recommendations were not documented as reviewed or addressed by staff, and were not included in the resident's record. The recommendations were not acted upon until more than two months after they were made. Staff interviews confirmed that the MRRs were not followed up on, not implemented, and not included in the residents' records as required by facility policy.
Failure to Clarify and Monitor Antibiotic Therapy Duration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications, specifically regarding the continued use of an antibiotic for a chronic lower leg skin infection. The resident, who had a history of urinary tract infections and skin infection, was started on an antibiotic with a physician order that directed staff to follow up with the provider regarding the infection. However, the order did not specify a stop date or duration for the antibiotic therapy. A pharmacy medication review identified the missing stop date and duration, noting the increased risk associated with prolonged use, and recommended that the intended duration or stop date be documented. Despite this, there was no evidence that the facility provided this information or clarified the order with the provider. Medication Administration Records showed the resident received the antibiotic twice daily for nearly two months without documented reassessment or clarification of the ongoing need. Progress notes did not indicate that the provider was notified to address the missing stop date or duration. Interviews with the Infection Preventionist revealed a lack of awareness regarding the resident’s ongoing antibiotic therapy and a failure to follow up as required by the physician’s order. The antibiotic usage was also not documented on the care plan, and both nursing staff and the Infection Preventionist did not ensure appropriate follow-up with the provider.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the proper storage and labeling of medications across several areas of the facility. On one medication cart, three opened inhaler medications were found without open dates, despite staff acknowledging that inhalers should be dated upon opening and discarded after 30 days. Additionally, an opened bottle of vitamins with remaining tablets was found at a resident's bedside in one room, which staff confirmed should not occur without a physician order and proper storage. The resident in question denied knowledge of the vitamins, and staff confirmed that medications at bedside require a resident assessment, physician order, and secure storage. Further, in the 600 Hall, the shower room door was found propped open and unattended, with an overhead cabinet left unlocked containing a prescription medication labeled for a resident. Staff confirmed that such medications should be secured in the medication cart and not left accessible in an unlocked cabinet. These observations demonstrate lapses in medication management protocols, including failure to label, secure, and properly store medications as required.
Unappetizing Meals and Lack of Alternate Food Options
Penalty
Summary
The facility failed to serve meals that were appetizing in appearance and palatable, as well as to offer alternate meal options to residents who refused or disliked the food provided. Multiple residents reported dissatisfaction with the taste and appearance of their meals, specifically noting that the scrambled eggs served at breakfast were green and unappetizing. Observations confirmed that several residents did not eat the eggs, and staff acknowledged that the eggs had turned green after being placed on the steam table due to a substitute egg product being used. Staff also admitted to serving the eggs despite their appearance and stated that residents were not offered alternative meal options when they refused the food. Interviews with residents revealed that some did not receive enough food and relied on family to bring in outside meals, while others left portions of their meals uneaten due to poor quality or unappealing presentation. Staff interviews further confirmed that the process for offering alternate meals was not consistently followed, and that communication with residents regarding food-related issues was lacking. The facility's own policy required staff to offer substitutes of similar nutritive value when a resident refused a meal, but this was not implemented as observed and reported.
Failure to Follow Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow established infection control practices during the care of a resident requiring enhanced barrier precautions (EBP). Specifically, a Certified Nursing Assistant provided personal care to a resident with a feeding tube, removed soiled gloves, did not perform hand hygiene, left the room to obtain new gloves, and returned to the resident's room without performing hand hygiene before donning clean gloves. This action was observed during the provision of incontinence care. Additionally, a Registered Nurse prepared and administered feeding and medications through the resident's feeding tube without donning a gown, as required by the EBP signage and facility policy. The nurse acknowledged forgetting to wear the gown, which was expected for all staff when working with the resident's feeding tube. The Director of Nursing confirmed that staff are expected to perform hand hygiene before and after resident care and to follow EBP signage, including gowning up when directed.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the designated Dietary Manager, referred to as Staff C, possessed the necessary training and qualifications required for the role. Staff C was employed on 08/07/2024, but did not have the ServSafe Manager Certification, which verifies sufficient food safety knowledge to protect the public from foodborne illness, as required for employment. Additionally, Staff C was not registered for the Certified Dietary Manager (CDM) course, which is essential for managing food service operations and ensuring food safety in a healthcare facility. This deficiency was identified through interviews and record reviews, placing all residents at risk of receiving dietary services from staff lacking the required competencies and skills.
Food Safety and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, placing all 92 residents at risk of foodborne illness and poor nutritional intake. Observations revealed that food temperatures were not checked before serving, with hot foods like pork sausage and eggs being served at temperatures within the danger zone, which allows rapid bacterial growth. Staff members were unaware of the required temperature standards, and no temperature logs were maintained for the meals served on the observed dates. Cross-contamination was observed when a dietary manager placed cracked eggshells on top of whole eggs, and an energy drink spilled onto a carton of eggs. Hand hygiene practices were inadequate, with staff failing to wash hands properly after sneezing or touching potentially contaminated surfaces. Additionally, meal service was delayed, with trays leaving the kitchen later than the posted times, further compromising food safety. Food storage practices were also deficient, with unlabeled, undated, and expired foods found in the walk-in refrigerator. The presence of fruit flies in the dry storage room and unclean kitchen vents added to the unsanitary conditions. The administrator acknowledged these issues, stating that kitchen staff were expected to maintain cleanliness and adhere to food safety protocols.
Failure to Prevent Pressure Ulcer Leads to Severe Harm
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of an avoidable pressure ulcer for a resident, leading to significant harm. The resident, who was at severe risk of developing pressure sores, had a hard cast on their right lower extremity due to a surgically repaired ankle fracture. Despite being assessed as at risk, the care plan was not updated after the cast was removed, and the resident was transitioned to a lace-up brace. The facility did not perform adequate skin checks or clarify with the orthopedic provider about the brace's use and the need for range of motion exercises. The resident developed a deep tissue injury and an open wound on their right foot, which was attributed to pressure from their preferred lying position. The wound was not identified until it had progressed significantly, resulting in exposed bone and gangrene. The facility's investigation noted that the resident always had their leg wrapped, and staff did not remove the brace for skin checks, leading to the oversight of the developing wound. Interviews with staff revealed a lack of communication and understanding regarding the resident's care needs post-cast removal. The Director of Nursing acknowledged that the care plan was not revised to include necessary skin checks after the cast was removed. The resident's condition deteriorated to the point of requiring hospital treatment and an above-the-knee amputation due to the severity of the wound.
Failure to Obtain Physician Orders and Document COVID-19 Test Results
Penalty
Summary
The facility failed to obtain laboratory services according to professional standards of practice for eight residents reviewed for COVID-19 testing. Specifically, the facility did not obtain physician orders (POs) for COVID-19 testing for six residents and failed to document the results of the testing for three residents. This deficiency was identified during a COVID-19 outbreak in the facility, which began on April 20, 2024. The Director of Nursing (Staff B) confirmed that the facility was conducting COVID-19 testing twice a week during the outbreak, but the necessary POs were not in place for several residents, and test results were not consistently documented. For Resident 1, there were no POs for COVID-19 testing, although tests were performed on multiple dates with negative results. Resident 2 also lacked POs but had multiple tests performed, with one positive result leading to transmission-based precautions. Resident 3 and Resident 4 had no POs but had tests performed with varying results. Resident 5 had a change of condition and was diagnosed with COVID-19 in the emergency room, but the facility did not document the test results upon return. Resident 6 had a PO for a test that was not documented as done, and another test was performed without an associated PO. Residents 7 and 8 had POs for tests, but the results were not documented. Staff interviews revealed a misunderstanding about the implementation of standing orders for COVID-19 testing.
Failure to Respond to Abuse Allegations in a Timely Manner
Penalty
Summary
The facility failed to respond to abuse allegations in a timely manner for two residents. For Resident 1, the incident occurred when a CNA verbally abused the resident during a night shift. The abuse was reported by another CNA to a nurse after the shift ended, but neither the reporting CNA nor the nurse followed up or reported the allegation to the administrative staff until four days later. During this period, the alleged perpetrator continued to work with residents. The facility only assessed Resident 1 for injury and notified their family and physician four days after the incident was reported. The CNA involved was eventually suspended and terminated, but not before working additional shifts. For Resident 8, the resident reported an incident where a man grabbed them from behind, placed them on the ground, and pulled down their shorts. This incident was documented in a behavior note, but no report was made in the incident reporting log, and the Director of Nursing was not made aware of the allegation. The staff's response was limited to reorienting the resident and offering them a cup of coffee and a quiet space. The Director of Nursing acknowledged that the staff did not follow the proper process for reporting and investigating the allegation.
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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