Heartwood Extended Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Tacoma, Washington.
- Location
- 1649 East 72nd, Tacoma, Washington 98404
- CMS Provider Number
- 505326
- Inspections on file
- 34
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Heartwood Extended Healthcare during CMS and state inspections, most recent first.
A resident with CHF and morbid obesity was not accurately weighed as required, with staff documenting repeated identical weights and failing to re-attempt weights after refusals. Logistical barriers and possible inaccurate documentation were identified, and a significant weight gain was observed during the survey, indicating a failure to properly assess and manage the resident's CHF.
A facility failed to inform a resident of the risks/benefits and obtain consent for an antidepressant medication. The resident, admitted with a spine fracture, quadriplegia, and depression, was receiving the medication without documented consent. Staff confirmed the oversight, acknowledging the protocol to provide such information and obtain consent was not followed.
A resident with multiple health conditions expressed dissatisfaction when staff disposed of personal condiments without prior notice or agreement. The resident, who could communicate needs, was not informed of the facility's food policy beforehand. Despite the resident's concerns, no grievance was filed, contrary to the facility's protocol.
A facility failed to assess the use of a low bed as a restraint for a resident with hemiplegia and hemiparesis, who was at risk for falls and required staff assistance for mobility. The resident's care plan included a low bed intervention, but the necessary consent, assessment, order, and care plan were not in place, as acknowledged by the DON.
A facility failed to provide a resident with written notification of a hospital transfer. The resident, diagnosed with polyneuropathy and bipolar disorder, was transferred without receiving the required notice. Interviews with the DON and Administrator confirmed the oversight, as the EHR lacked documentation of the notice.
A facility failed to provide a written bed hold notice to a resident with polyneuropathy and bipolar disorder during their hospital transfer. The resident's electronic health record lacked documentation of a bed hold offer, confirmed by the Business Office Manager. The Administrator noted that bed holds should be done at transfer or within 24 hours, but this was not followed, risking the resident's awareness of their bed hold rights.
The facility failed to accurately complete comprehensive assessments for three residents, leading to discrepancies in their medical records. A resident's pressure ulcers were misrecorded, another's dental and respiratory conditions were inaccurately documented, and a third resident's discharge was incorrectly coded. Staff confirmed these inaccuracies, indicating a failure to meet expected standards.
The facility failed to conduct timely care planning meetings for a resident with respiratory failure, paraplegia, and depression. The resident, dependent on staff for daily activities, did not recall a recent care conference, and records showed the last offer was several months prior. Staff interviews confirmed the expectation of quarterly care conferences, but the date of the last meeting could not be located.
A resident was discharged without a complete discharge summary, lacking an overview of their stay, a final status summary, and necessary signatures. The resident, diagnosed with multiple sclerosis, dementia, and receiving hospice care, was discharged home without these critical documents. Staff interviews confirmed the discharge process was not completed as expected.
The facility failed to provide necessary positioning devices for a resident with multiple health issues, and did not follow bowel management protocols for two residents. The resident did not receive a required boot and splint, and staff were unaware of the orders. Additionally, two residents experienced lapses in bowel movement documentation and protocol adherence, leading to unaddressed constipation issues.
A facility failed to ensure a resident received appropriate care to maintain or improve range of motion (ROM), leading to a risk of worsening mobility and contractures. Despite a referral for a resting hand splint and exercises, the resident did not receive the necessary assistance, and the care plan lacked interventions for splint/brace assistance. Interviews with staff revealed a lack of follow-up on the referral, contrary to the expectations of the DON.
The facility failed to secure hazardous items in a shower room and did not implement fall interventions for a high-risk resident. Observations showed unsecured razors and nail clippers in an unlocked shower room, contrary to staff expectations. Additionally, a resident identified as a high fall risk did not have recommended safety measures, such as a fall mat and a low, locked bed, in place.
The facility failed to administer nutritional supplements as recommended for a resident with significant weight loss and did not follow fluid restrictions for two residents with critical health conditions. The Registered Dietician's recommendations for supplements were not fully implemented, and fluid intake documentation was missing for residents on fluid restrictions, as confirmed by staff interviews.
A resident with multiple health conditions was using oxygen without a physician's order or a care plan in place. Staff interviews confirmed that oxygen services should be provided per provider's orders and monitored, which was not done, leading to a deficiency in respiratory care.
A facility failed to conduct consistent pain assessments for a resident receiving oxycodone for chronic pain. Despite frequent changes in medication orders, the last pain assessment was documented in early January, with no further assessments conducted. The resident had multiple health conditions and was dependent on staff for daily activities. The DON noted a shortage of care managers, leading to LNs being responsible for pain assessments.
A facility failed to provide dialysis care consistent with professional standards for a resident with end-stage renal disease. The facility's policy required documentation of dialysis care, but records showed inconsistent documentation of pre- and post-dialysis evaluations. Staff interviews confirmed that the process was not followed as expected, placing the resident at risk for substandard care.
A facility failed to limit a PRN psychotropic medication for a resident to 14 days, as required by policy. The resident, with multiple health conditions including anxiety and depression, had an indefinite order for clonazepam without documented rationale for extension. Staff acknowledged the oversight and stated the expectation for provider documentation.
A resident with respiratory issues and broken teeth did not receive routine dental services, as observed during a survey. The resident's care plan did not address the dental issues, and staff interviews confirmed that a dental appointment should have been made. The DON acknowledged the deficiency in dental care.
The facility failed to maintain effective infection control practices, as staff did not consistently use PPE according to Enhanced Barrier Precautions for a resident with a PEG and catheter. Additionally, respiratory care equipment for another resident was improperly stored on the floor. These actions increased the risk of infection transmission.
A resident reported rough care by a CNA, leading to the CNA's dismissal. Later, the resident felt retaliated against by other CNAs, but this was not reported or investigated as required. Staff interviews confirmed the incident should have been reported and investigated due to potential psychosocial harm.
The facility did not post actual nursing staffing hours daily for 30 days, preventing residents and visitors from knowing the available nursing staff. The policy required daily posting of staffing data, but reviews showed missing facility names and adjustments for absences. Interviews revealed a lack of awareness and expectation about posting actual hours worked.
A resident was discharged from a facility with a zero balance, yet over-payments were made post-discharge, resulting in a credit of $4,363.44 that was not refunded nearly a year later. Automatic withdrawals were made from the resident's bank account without a located authorization form, and staff confirmed the refund should have been issued within 30 days.
A facility failed to provide appropriate care for a resident with a urinary catheter and bowel incontinence. The resident did not have physician orders for catheter use, nor a care plan for catheter care and monitoring. The facility also failed to continue the resident's established bowel program from the hospital. Improper catheter care was observed, and the Director of Nursing confirmed the absence of necessary orders and care plans, placing the resident at risk for infections and diminished quality of care.
The facility did not accurately assess and develop/implement a care plan for a resident with chronic heart failure and lung disease, leading to unmonitored weight gain and fluid volume overload, resulting in respiratory failure and emergency hospitalization. Additionally, the facility failed to consistently monitor and document bowel movements for two residents, leading to delayed interventions for constipation despite having bowel management protocols in place.
The facility failed to accurately assess 7 residents, leading to deficiencies in their care plans. Errors included incorrect coding of falls, dental status, weight changes, mental health history, and medical conditions. These inaccuracies impacted the development of comprehensive care plans, potentially risking unmet needs and diminished quality of care.
The facility failed to develop, implement, and update person-centered comprehensive care plans for six residents, leading to unmet care needs and potential risks. Issues included missing care plans for depression, catheter care, and bowel management, as well as outdated and conflicting information in care plans for various medical conditions.
The facility failed to meet professional standards of practice in medication administration, vital sign monitoring, physician orders, insulin administration, weight monitoring, and heart failure care, placing residents at risk of medical complications.
The facility failed to accommodate resident food preferences, affecting four residents. One resident with a pineapple allergy was served pineapple, and others did not receive their preferred breakfast items. Staff cited shortages and lack of preparation as reasons for the failure.
The facility failed to follow preplanned menus and serve appropriate portion sizes for three residents. Due to running out of bread and 2% milk, the cook served donuts and low-fat milk instead. Additionally, overcooked eggs led to incorrect portion sizes being served.
The facility failed to include the Arbitration Agreement in the admission packets for four residents. Interviews revealed that residents did not recall receiving information about the optional Arbitration Agreement, and staff confirmed that the packet attachments were not up to date.
The facility failed to include documentation of the Arbitration Agreement for four residents. The Admission Agreement indicated that residents acknowledged receiving the Arbitration Agreement, but it was missing from the admission packets. Staff confirmed that the documentation had only recently been provided and needed to be updated.
The facility failed to maintain an effective infection prevention and control program, with incomplete infection data collection and analysis for February and March 2024. Additionally, staff did not follow proper isolation precautions, including improper use of PPE and lack of hand hygiene, placing residents and staff at risk.
The facility failed to implement an effective Antibiotic Stewardship Program, leading to inappropriate and unnecessary antibiotic use for four residents. Interviews revealed a lack of awareness and oversight regarding infection criteria and lab result reviews, placing residents at risk for adverse outcomes.
The facility failed to ensure food was prepared and served according to professional standards, placing residents at risk. Observations revealed improper thawing and handling of food, failure to take temperatures of hot foods, and leaving cooked chicken unrefrigerated for an extended period. Staff acknowledged these practices did not meet expectations.
The facility failed to ensure residents had access to their personal funds during evenings and weekends. A resident reported not having a lock box and had to keep funds in their room due to the lack of access after business hours. Interviews with staff confirmed this issue, which was attributed to a recent petty cash audit, violating residents' rights to manage their financial affairs.
The facility failed to protect the privacy of two residents during care activities. One resident was exposed to the hallway due to an improperly closed door and curtain, while another resident's privacy was breached when a staff member entered the room without knocking and left the door open during a wound care procedure.
A resident experienced significant weight gain, loss of mobility, and increased depression, but the facility failed to conduct a timely Significant Change in Status Assessment (SCSA) within the required 14 days. The resident's care plan was not updated to reflect these changes, leading to unmet care needs and diminished quality of life.
The facility failed to conduct timely and routine care planning conferences for three residents, leading to unmet needs and lack of involvement in their care plans. Staff confirmed deficiencies in documentation and scheduling of these conferences.
The facility failed to provide adequate ADLs and hygiene care for several residents, leading to unmet care needs and poor hygiene. Observations revealed unclean teeth, uncombed hair, and inadequate toileting assistance, with staff interviews confirming these deficiencies.
The facility failed to provide resident-centered activity programs that incorporated the interests, hobbies, and cultural preferences of the residents. Four residents were observed to have activity care plans that lacked individualized preferences, leading to social isolation, boredom, and a diminished quality of life.
The facility failed to provide a safe environment and adequate supervision for three residents and two smoking areas. One resident was observed smoking unsupervised in the parking lot despite a history of unsafe smoking behaviors. Another resident was found vaping in their room, against the facility's policy. Additionally, the facility grounds were littered with cigarette butts, and there were no proper receptacles for disposal. A resident who experienced a fall did not have their care plan updated with new interventions to prevent future falls.
The facility failed to ensure that two residents with urinary catheters received care consistent with professional standards. One resident did not receive routine catheter care, and the catheter tubing was not secured, leading to potential risks. Another resident experienced issues with catheter draining and leaking, with no proper care directives in place. Staff interviews revealed inconsistencies in catheter care practices and documentation.
The facility failed to provide and accurately document pain medication for a resident with osteoarthritis, leading to inconsistencies in pain management. The resident did not receive a scheduled topical anti-inflammatory gel and had no documentation of acetaminophen administration over several days. Staff interviews confirmed expectations for accurate documentation and administration were not met.
The facility failed to provide adequate hemodialysis (HD) services for a resident, as evidenced by incomplete or missing Dialysis Transfer Forms and inconsistent communication with the HD center. This placed the resident at risk for unmet care needs and medical complications.
The facility failed to provide Influenza and Pneumococcal vaccines for two residents. One resident's record showed a signed consent form without indication of consent or declination, and the vaccines were not administered. Another resident's record had a signed consent form for the influenza vaccine and an incomplete form for the pneumococcal vaccine, with no vaccines administered. The DON stated that residents should be educated on and offered the vaccines upon admission, with forms fully completed and vaccines administered if consented to.
The facility failed to offer and follow-up on the completion of COVID-19 immunizations for two residents. One resident had no record of receiving the vaccine despite a signed consent form, and another resident, due for a booster, had not received it despite consenting. The DON stated that vaccines should be offered and administered upon admission if consented.
Failure to Accurately Monitor and Document CHF Management
Penalty
Summary
The facility failed to accurately assess and manage the diagnosis of congestive heart failure (CHF) for one resident with a history of morbid obesity and recent hospitalization for acute CHF exacerbation. Upon admission, the resident was alert, oriented, and able to communicate needs. Hospital discharge instructions and provider progress notes indicated the need for daily or at least weekly weight monitoring to assess for fluid retention, a critical aspect of CHF management. However, the facility order only specified weekly weights, and documentation showed repeated identical weights over several weeks, with no evidence that actual weights were obtained. When the resident refused a weight, there were no documented re-attempts to obtain it, and staff interviews revealed logistical barriers to weighing the resident, such as equipment incompatibility and resident discomfort with the Hoyer lift. The resident reported not being weighed for an extended period and expressed understanding of the importance of weight monitoring for CHF. Further review and interviews indicated that staff may have been copying and pasting previous weights rather than obtaining accurate measurements, as the documented weights remained unchanged week after week. The Director of Nursing confirmed that staff should continue to attempt to obtain weights after refusals and that weight monitoring protocols should be adjusted based on stability. The Administrator acknowledged the likelihood of inaccurate documentation. An observed weight obtained during the survey showed a significant increase from the resident's hospital discharge weight, and a previously obtained weight referenced by the resident was not documented in the medical record.
Failure to Obtain Consent for Antidepressant Use
Penalty
Summary
The facility failed to provide necessary information and obtain consent for the use of a psychotropic medication for one resident, identified as Resident 72, who was part of a sample of five residents reviewed for unnecessary medications. Resident 72 was admitted with diagnoses including a spine fracture, quadriplegia, and depression, and was capable of communicating their needs. The electronic health record indicated that Resident 72 was receiving an antidepressant medication as of February 2025. However, there was no documentation showing that the resident had been informed of the risks and benefits of the medication or had given consent for its use. Interviews with Staff K, a Staff Development/LPN, and Staff B, the Director of Nursing Services, confirmed that the facility's protocol required providing risks/benefits information and obtaining consent for antidepressant use upon admission, but this had not been done for Resident 72.
Failure to Address Resident Grievance on Personal Property
Penalty
Summary
The facility failed to properly handle a grievance for a resident concerning personal property, specifically condiments purchased by a family member. Resident 67, who has a medical history including contracture of the right hand, muscle weakness, congestive heart failure, and chronic kidney disease, expressed dissatisfaction when staff disposed of these items without prior notice or agreement. The resident was able to communicate their needs and stated they were not informed of the facility's food policy before the disposal. Despite the resident's expressed concerns, no grievance was filed in the facility's grievance log for the month in question. The facility's administrator acknowledged that staff are expected to initiate grievances for resident concerns, indicating a lapse in following this protocol.
Failure to Assess Use of Low Bed as Restraint
Penalty
Summary
The facility failed to conduct an assessment for the use of a low bed for a resident, identified as Resident 39, who was reviewed for the use of physical restraints. Resident 39 was admitted with diagnoses including hemiplegia and hemiparesis, and was assessed to be at risk for falls, requiring staff assistance for mobility. Observations on two separate occasions showed the resident lying on a bed that was lowered to the floor. The resident's care plan included an intervention to place the bed in a low position, initiated in August 2022. However, during an interview, the Director of Nursing Services acknowledged that a low bed could be considered a restraint and should have had consent, assessment, order, and care plan, which were lacking for this resident, not meeting the facility's expectations.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of the reason for hospital transfer to Resident 291 or their responsible party. This deficiency was identified during a review of the electronic health record (EHR) and interviews with facility staff. Resident 291, who was admitted to the facility with diagnoses including polyneuropathy and bipolar disorder, was transferred to the hospital on 02/08/2025. However, the EHR lacked documentation that a notice of transfer was provided to the resident or their representative. During interviews, both the Director of Nursing Services and the Administrator acknowledged that the resident or their representative did not receive the required written notice of transfer, which was expected to be provided at the time of transfer.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to Resident 291 at the time of their transfer to the hospital, which is a requirement under WAC 388-97-0120 (4). Resident 291, who was admitted to the facility with diagnoses including polyneuropathy and bipolar disorder, was hospitalized, but there was no documentation in the electronic health record indicating that a bed hold was offered. During interviews, the Business Office Manager confirmed that neither the resident nor their representative was offered a bed hold, and the Administrator stated that the expectation was for bed holds to be done at the time of transfer or within 24 hours. This oversight placed the resident at risk of not being informed about their right to hold their bed during hospitalization, potentially affecting their quality of life.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to accurately complete the comprehensive assessments for three residents, leading to discrepancies in their medical records. Resident 79 was admitted with two pressure ulcers, but the admission Minimum Data Set (MDS) inaccurately recorded these ulcers as acquired in the facility. Staff interviews confirmed the inaccuracy, with both the Staff Development/Licensed Practical Nurse and the Director of Nursing Services acknowledging the error. This misrepresentation in the MDS could potentially affect the care planning and treatment provided to the resident. Resident 18's admission MDS inaccurately documented the resident's dental and respiratory conditions. Despite having broken natural teeth and using oxygen, the MDS indicated no broken teeth and no use of oxygen. Similarly, Resident 88's significant change/discharge MDS inaccurately coded the discharge as unplanned, contrary to the electronic health record. The MDS Nurse and the Director of Nursing Services confirmed these inaccuracies, indicating a failure to meet the expected standards for accurate resident assessments.
Failure to Conduct Timely Care Planning Meetings
Penalty
Summary
The facility failed to conduct timely care planning meetings with residents or their responsible parties, specifically for Resident 31, who was one of the two sampled residents reviewed for care planning. Resident 31, who was readmitted to the facility with diagnoses including respiratory failure, paraplegia, and depression, was dependent on staff for activities of daily living and able to communicate needs. Despite this, Resident 31 did not recall having a recent care conference, and the electronic health record indicated that the last care conference offered was on 06/08/2024. Interviews with the Social Service Director and the Administrator confirmed that care conferences were expected to be held quarterly, but they could not locate the date of the last care conference for Resident 31, indicating a failure to meet these expectations.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a complete discharge summary for Resident 88, who was discharged home without the necessary documentation. The discharge summary was supposed to include a recapitulation of the resident's stay, a final summary of the resident's status, and the resident and/or their representative's signature. Resident 88, who had been readmitted to the facility with diagnoses including multiple sclerosis, dementia, and hospice services, was discharged without these critical components. Interviews with staff revealed that the discharge process was not completed as expected, with the Director of Nursing Services acknowledging the oversight.
Deficiencies in Positioning and Bowel Management
Penalty
Summary
The facility failed to ensure proper positioning and mobility interventions for Resident 17, who had multiple diagnoses including heart and lung disease, diabetes, anxiety, depression, and muscle weakness. The resident was dependent on staff for activities of daily living and required a Prevalon boot for their left foot while in bed, as well as an elbow splint for a contracture. Despite these requirements, the resident reported never receiving the necessary devices, and staff interviews revealed a lack of awareness or follow-through on the orders for these interventions. The medical records staff had received an order for an orthotics referral but were unsure if it had been refused due to expense or lack of insurance, and there was no documentation of refusal in the resident's electronic health record. The facility also failed to consistently monitor and document bowel movements and implement the bowel program for Residents 4 and 82. Resident 4, who had Alzheimer's disease and was unable to communicate needs, had no bowel movements documented over a four-day period, and no medication was administered per the bowel protocol. Similarly, Resident 82, who had cirrhosis of the liver and was able to communicate needs, had extended periods without documented bowel movements, and no laxative medications were administered according to the protocol. Staff interviews confirmed that the facility did not meet expectations for bowel management documentation for these residents.
Failure to Provide ROM Care for Resident
Penalty
Summary
The facility failed to provide appropriate care and services to maintain or improve the range of motion (ROM) for a resident, identified as Resident 67, who was at risk for worsening mobility and developing contractures. Resident 67 was admitted with diagnoses including contracture of the right hand, muscle weakness, congestive heart failure, and chronic kidney disease. Despite a provider note dated 11/22/2025 recommending a referral for a resting hand splint and hand/finger exercises, the resident reported not receiving the splint and was observed with slightly bent fingers. The resident's care plan lacked interventions for a restorative nursing program for splint/brace assistance. Interviews with facility staff revealed a lack of follow-up on the referral for the splint. Staff W, a Restorative Nursing Aide, confirmed that Resident 67 was not receiving splint assistance services. Staff D, an LPN/Care Coordinator, acknowledged that the nursing staff should have followed up on the referral but did not. The Director of Nursing Services, Staff B, stated that the expectation was for the referral to be followed up on in a timely manner, which did not occur.
Failure to Secure Hazardous Items and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure that the resident environments were free from accident hazards, specifically in the 200 Hall shower room. Observations on multiple dates revealed that the shower room was unlocked, and items such as an electric razor, disposable razors, and nail clippers were unsecured inside. Interviews with staff confirmed that these items should have been locked away, either in the medication cart or a cupboard within the shower room, but were not. This oversight placed residents at risk of accessing dangerous items. Additionally, the facility did not implement fall interventions for Resident 67, who was identified as a high fall risk due to factors such as poor safety awareness, generalized weakness, and impaired mobility. Despite a provider's note recommending the use of a fall mat and ensuring the bed was in a low and locked position, observations showed that these interventions were not in place. Interviews with staff indicated that the provider's recommendations were not followed, which did not meet the facility's expectations.
Failure to Administer Nutritional Supplements and Follow Fluid Restrictions
Penalty
Summary
The facility failed to administer the Registered Dietician's (RD) recommendations for Resident 31, who was readmitted with diagnoses including respiratory failure, paraplegia, and depression. The RD recommended Arginaid and Medpass 2.0 supplements due to a significant weight loss of 10%. However, the electronic health record (EHR) showed that while there was a provider's order for Arginaid, it was not administered until February 11, 2025, and there was no order for Medpass 2.0. The Director of Nursing Services acknowledged that the Arginaid should have been administered as ordered and documented on the medication administration records (MARs). Additionally, the facility failed to follow fluid restrictions for Residents 18 and 82. Resident 18, with conditions including end-stage renal disease and heart failure, was on a fluid restriction of 1500 ml per day, but the MARs did not document the amount of fluid consumed. Similarly, Resident 82, with diagnoses including cirrhosis and heart failure, had a fluid restriction order of 1500 ml per day, but the documentation was missing. Staff interviews revealed that the process required documentation of fluid intake, which was not met, as confirmed by the Director of Nursing Services.
Failure to Provide Ordered Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 18, by not having a physician's order or a care plan for the use of oxygen. Resident 18, who was admitted with diagnoses including end-stage renal disease, acute respiratory failure, chronic obstructive pulmonary disease, and cirrhosis of the liver, was observed using oxygen without a provider's order. The resident stated that the oxygen made it easier to breathe. However, a review of the electronic health record showed no provider's orders for oxygen use, and there was no care plan directing staff on its use. Interviews with staff confirmed that oxygen services should be provided per provider's orders, monitored each shift, and care planned, which was not done in this case.
Failure in Conducting Pain Assessments for Resident
Penalty
Summary
The facility failed to ensure proper pain management for a resident, identified as Resident 9, who was receiving as-needed pain medication, specifically oxycodone. The deficiency was identified through interviews and record reviews, which revealed that the facility staff did not conduct consistent pain assessments for the resident. Despite having a care plan that required pain assessments, the last documented pain assessment was conducted on January 9, 2025, and no further assessments were performed even though the resident's medication orders were frequently changed throughout January and February 2025. Resident 9 was admitted with multiple health conditions, including chronic pain, spinal stenosis, bipolar disorder, muscle weakness, anxiety, and depression. The resident was dependent on staff for daily living activities and could communicate their needs. The Director of Nursing Services acknowledged the expectation for care managers to conduct pain assessments but noted a shortage of care managers, leading to licensed nurses being tasked with this responsibility. However, the lack of ongoing pain assessments after the initial evaluation contributed to the deficiency in pain management for Resident 9.
Inadequate Dialysis Care Documentation for a Resident
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for Resident 18, who was diagnosed with end-stage renal disease, among other conditions. The facility's policy required documentation of dialysis care, including the location of the catheter, condition of the dressing, and observations post-dialysis. However, the electronic health record showed only one post-dialysis evaluation and three pre-dialysis evaluations were completed, indicating a lack of consistent documentation. Interviews with staff revealed that the process for completing pre- and post-dialysis evaluations was not followed as expected. Staff D, a Licensed Practical Nurse/Care Coordinator, acknowledged that the dialysis flow sheet was incomplete, and the Director of Nursing Services confirmed that Resident 18's dialysis care did not meet expectations. This deficiency placed the resident at risk for substandard dialysis care, injury, infection, and diminished quality of life.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication for a resident was limited to 14 days, as required by policy. The policy, dated July 2022, specified that psychotropic medications should not be prescribed or given on a PRN basis unless necessary for a diagnosed condition documented in the clinical record, and PRN orders should be limited to 14 days unless a rationale for extension is documented. However, Resident 9's electronic health record showed an order for clonazepam, a psychotropic medication used to treat anxiety, to be administered every 8 hours as needed with no end date, ordered as indefinite. No additional rationale was documented by the provider to extend the medication beyond 14 days. Resident 9 was admitted with multiple health conditions, including chronic pain, spinal stenosis, bipolar disorder, anxiety, and depression, and was dependent on staff for assistance with activities of daily living. The resident's care plan indicated a decline in mood due to anxiety, with interventions for staff to monitor and encourage the use of PRN medication. During interviews, staff members, including the Staff Development/Licensed Practical Nurse and the Director of Nursing Services, acknowledged the oversight and stated that the expectation would be for the provider to document a rationale for extending the psychotropic medication beyond 14 days.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for a resident, identified as Resident 18, who was admitted with acute respiratory failure and chronic obstructive pulmonary disease. Despite being able to communicate needs, Resident 18 had multiple broken teeth, which were observed during a visit. The resident expressed that the staff had not addressed the issue. The care plan, dated several months prior, did not include the resident's dental issues, and the clinical admission note confirmed the presence of broken teeth. A nutrition evaluation also noted obvious cavities and broken teeth. Interviews with staff revealed that a dental appointment should have been made and the oral status should have been included in the care plan. The Director of Nursing Services acknowledged that the dental care provided did not meet expectations.
Infection Control Deficiencies in PPE Use and Equipment Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not consistently applying Personal Protective Equipment (PPE) in accordance with Enhanced Barrier Precautions (EBP) for Resident 47. Despite clear signage indicating the need for gowns and gloves during high-contact care activities, staff members were observed entering the resident's room and performing tasks such as urine collection and catheter flushing without wearing the required gowns. Interviews with staff confirmed that they were aware of the requirements but failed to adhere to them, citing forgetfulness. Additionally, the facility did not ensure that respiratory care equipment for Resident 18 was stored in a clean and sanitary manner. Observations revealed that the nebulizer machine, mouthpiece, and oxygen tubing were placed on the floor, which is against the facility's expectations for maintaining sanitary conditions. Staff interviews confirmed that this practice did not meet the facility's standards, acknowledging that the equipment should not have been on the floor. These deficiencies in infection control practices placed residents and staff at risk for contracting and spreading infections. The failure to follow established protocols for PPE use and equipment storage compromised the safety and sanitary environment necessary to prevent the transmission of communicable diseases within the facility.
Failure to Investigate Allegations of Abuse and Retaliation
Penalty
Summary
The facility failed to identify and investigate allegations of abuse and neglect for one resident, referred to as Resident 56, which placed the resident at risk of continued abuse and a diminished quality of life. According to the facility's policy on abuse investigation and reporting, all reports of abuse, neglect, and related issues should be promptly reported to the appropriate authorities and thoroughly investigated. However, this protocol was not followed in the case of Resident 56. The resident, who was admitted with diagnoses including muscle weakness, anxiety, and depression, reported experiencing rough care from a CNA during a night shift. Although the CNA was no longer working at the facility following the incident, the resident later felt retaliated against by other CNAs, which was not properly reported or investigated. During interviews, it was revealed that Resident 56 had expressed concerns about potential retaliation to another CNA, Staff C, who did not report the incident as required. Staff D, a Licensed Practical Nurse and Care Coordinator, confirmed that the comment about potential retaliation was a reportable event that should have been investigated. Similarly, the Director of Nursing Services acknowledged that the incident should have been reported and investigated due to the potential for psychosocial harm. The failure to report and investigate these allegations was a clear deficiency in the facility's adherence to its own policies and regulatory requirements.
Failure to Post Actual Nursing Staffing Hours
Penalty
Summary
The facility failed to post the actual nursing staffing hours daily for a period of 30 days, which prevented residents, family members, and visitors from knowing the actual number of available nursing staff. The facility's policy, dated August 2022, required daily posting of nurse staffing data for each shift, including the number of nursing personnel providing direct care and the actual hours worked. However, an observation and record review on February 13, 2025, revealed that the staffing posting did not include the facility's name or adjustments for staff absences due to call-offs or illness, nor did it reconcile to show actual hours worked. Interviews with the Staffing Coordinator and the Administrator indicated a lack of awareness and expectation regarding the requirement to post actual hours worked daily.
Failure to Timely Refund Overpayments to Resident
Penalty
Summary
The facility failed to timely refund charges paid by a resident, identified as Resident 2, who was reviewed for misappropriation and personal funds. Resident 2 was admitted to the facility and later discharged to an Adult Family Home. Despite being discharged with a zero balance, over-payments were made after the discharge, resulting in a credit of $4,363.44 that was due to Resident 2. This credit was identified on a statement dated nearly a year after the discharge, yet the refund had not been issued. Interviews with facility staff revealed that the payments were consistent with the Department of Social and Health Services Award Letter of Participation, which determined Resident 2's share of the cost for room and board. These funds were collected through automatic withdrawals from Resident 2's bank account. However, the facility was unable to locate the authorization form signed by Resident 2 to access these finances. Staff confirmed that the over-payment should have been reimbursed within 30 days of discharge or identification of the overpayment, but this did not occur.
Deficient Care for Resident with Catheter and Bowel Incontinence
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter and bowel incontinence, as observed through a survey. The resident, who had a traumatic spinal cord problem affecting their arms, legs, bowel, and bladder, was admitted with a chronic indwelling Foley catheter and was dependent on staff for all activities of daily living. The facility did not obtain physician orders for the use of the catheter, nor did they develop or implement a care plan for catheter care and monitoring. Additionally, the facility did not continue the resident's established bowel program from the hospital, which included a high fiber-bulk forming laxative and a bowel stimulant suppository at night, instead administering the suppository in the morning contrary to the established program. The facility's failure to adhere to professional standards of care was further highlighted by the lack of a personalized bowel program in the resident's care plan. The resident's collateral contact reported improper catheter care, noting an overfilled urine leg bag and urine not draining properly. The Director of Nursing confirmed the absence of necessary physician orders and care plans for the catheter and acknowledged the failure to continue the resident's established bowel program. These deficiencies placed the resident at risk for infections, skin breakdown, constipation, and diminished quality of care.
Deficiencies in Chronic Heart and Bowel Management
Penalty
Summary
The facility failed to accurately assess and develop/implement a care plan for the management of chronic heart problems for Resident 51, who had a history of heart failure and chronic lung disease. Despite experiencing daily difficulty breathing and requiring non-invasive mechanical ventilation, Resident 51 was not routinely weighed or monitored for fluid volume overload. The resident's weight had significantly increased over a few months, indicating a potential fluid imbalance that went unnoticed. Additionally, the facility did not have a consistent plan in place for monitoring and managing Resident 51's edema and fluid status, leading to a delay in identifying and addressing the fluid volume overload that ultimately resulted in respiratory failure and emergency hospitalization. Furthermore, the facility failed to consistently monitor and document bowel movements for Residents 16 and 66, who experienced constipation during their stay. Despite having bowel management protocols in place, the staff did not effectively implement the orders for laxatives and enemas as needed for residents with prolonged constipation. This lack of adherence to the bowel management protocols resulted in delayed interventions for relieving constipation and addressing gastrointestinal issues for both residents. The inadequate monitoring and management of bowel movements for Residents 16 and 66 indicate a systemic issue in ensuring proper care and treatment for residents with gastrointestinal problems within the facility.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to accurately assess 7 of 20 sampled residents, leading to deficiencies in their care plans. Resident 27 had documented falls that were not correctly coded in their quarterly MDS, which was acknowledged by both the MDS Coordinator and the Director of Nursing Services. Resident 88's admission MDS inaccurately reflected their dental status, despite observations and dental visit documentation indicating broken and missing teeth. This discrepancy was also confirmed by the MDS Coordinator and the Director of Nursing Services. Resident 6's weight records showed significant weight gains that were not coded in their MDS, and their use of antidepressants was not properly documented. Additionally, Resident 6 reported dental issues that were not reflected in their assessments. Resident 9's MDS did not accurately reflect their mental health history, including developmental delay and bipolar disorder, which was confirmed as incorrect coding by the MDS Coordinator. Resident 51's MDS contained multiple coding errors related to their medical conditions, medications, and weight, which were not accurately documented. Resident 69's MDS inaccurately coded their physical impairments and medical conditions, which was acknowledged as an error by the MDS Coordinator. Lastly, Resident 72's admission MDS lacked information on their ADL abilities, despite the resident's report of not being assisted into a wheelchair when requested. These inaccuracies in the MDS assessments directly impacted the development of comprehensive care plans for the residents, leading to potential risks for unmet needs and diminished quality of care.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop, implement, and update person-centered comprehensive care plans (CP) for six residents, leading to unmet care needs and potential risks. For Resident 55, the facility did not create a care plan for depression despite a physician's order for anti-depressant medication. The Director of Nursing Services acknowledged this oversight during an interview. Resident 70, who required an indwelling supra-pubic urinary catheter, did not have a care plan for catheter care, and there were no orders for routine catheter care in the Treatment Administration Record. The resident reported not receiving catheter care, and staff interviews confirmed the absence of necessary care directives in the CP and Kardex. Resident 13's care plan for tobacco use was not updated to reflect multiple unsafe smoking incidents, and the Kardex lacked specific instructions for monitoring and managing these behaviors. Additionally, the Kardex did not provide clear directives for weight monitoring, diet, or meal locations. Resident 52's care plans contained outdated and conflicting information, with no updates for current medical conditions such as diabetes, seizures, and dental concerns. The leisure and trauma care plans were generic and not person-centered, and there were discrepancies between the care plans and the medications listed in the Medication Administration Record. Similar deficiencies were found for Residents 69 and 6. Resident 69's care plans for psychotropic and behavior management were not personalized, and there was no bowel management care plan despite the resident's incontinence and use of medications for constipation. Resident 6's care plans lacked person-centered information addressing dental concerns, nutrition, weight monitoring, preferences, activities, mood, and other medical needs. These failures in care planning placed the residents at risk for poor clinical outcomes and diminished quality of life.
Failure to Meet Professional Standards of Practice
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice for several critical areas, including anti-hypertensive medication administration, orthostatic vital signs, physician orders, insulin administration, injection site rotation, weight monitoring, edema monitoring, and care of patients with heart failure. For instance, Resident 16's blood pressure medication was administered multiple times despite their systolic blood pressure being below the hold parameter of 110, and the provider was not notified of consistently low blood pressures. Similarly, Resident 69's blood pressure medication was administered without documented hold parameters, and orthostatic vital signs were not properly recorded for multiple residents, including Resident 47 and Resident 69, who had identical blood pressure readings for different positions, indicating a failure in proper assessment and documentation. Resident 69 also did not receive a prescribed continuous glucose monitoring device, and their insulin administration records showed a lack of documentation for injection site rotation and failure to follow orders for blood sugar checks after meals. Additionally, there were instances where high blood sugar levels were not addressed according to the physician's orders, and the provider was not notified of critical blood sugar readings. This lack of adherence to prescribed care plans and monitoring protocols placed residents at risk of medical complications. The facility also failed to maintain accurate and updated physician orders for several residents. For example, Resident 70's wound care orders were not updated to reflect the current treatment recommendations from the wound care specialist. Furthermore, weight monitoring protocols were not followed for multiple residents, including Resident 52, who had no documented weights for several months despite being at risk for nutritional problems. Resident 51, who had a history of heart failure, was not weighed routinely, and their care plan did not include necessary monitoring for heart failure symptoms, leading to a significant weight gain and subsequent hospitalization for fluid volume overload.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to provide food that accommodated identified resident preferences, affecting four residents. Resident 22, who disliked tomatoes, was served tomato soup. Resident 6 reported that despite being asked about their food preferences, they were still served items they disliked. Resident 72, who had a pineapple allergy, was served pineapple and did not eat due to concerns about cross-contamination. These incidents indicate a failure to honor resident food preferences, potentially leading to weight loss, malnutrition, and diminished quality of life. During observations of the breakfast tray line, it was noted that Resident 3, who preferred a banana, was not provided one. Resident 62, who preferred two bowls of rice, received only one. Resident 301, who preferred rice, was served a donut, scrambled eggs, and ham instead. Resident 91, who preferred fresh fruit, was not provided any. Staff H, the cook, stated they were unable to accommodate these preferences due to running out of fresh fruit and not preparing enough rice. The Dietary Manager, Staff G, was unaware of the shortage of fresh fruit and expected that rice would be prepared to meet resident preferences. The Regional Director of Clinical Operations confirmed that it was the expectation to honor resident preferences.
Failure to Follow Preplanned Menus and Serve Appropriate Portion Sizes
Penalty
Summary
The facility failed to ensure preplanned menus were followed and the appropriate portion sizes were served according to the tray card for three residents. On the observed date, the preplanned breakfast menu included toast, scrambled eggs, ham, 2% milk, juice, and fruit. However, due to running out of bread and 2% milk, Staff H, the cook, served donuts and low-fat milk as alternatives. Additionally, the eggs were overcooked and not as fluffy as usual, which affected the portion sizes served to the residents. Resident 75, 76, and 92 were all supposed to receive double portions according to their breakfast tray cards. However, Staff H served single portions to Resident 75 and 92, and an incorrect combination of double and single portions to Resident 76. Staff H expressed concern about not having enough food to serve double portions due to the overcooked eggs. The Dietary Manager confirmed the issues with the food supply and acknowledged that the eggs were overcooked and unappetizing.
Failure to Include Arbitration Agreement in Admission Packets
Penalty
Summary
The facility failed to include documentation of the Arbitration Agreement in the admission packets for four residents (Residents 81, 87, 73, and 66). The Admission Agreement packet, dated May 2017, indicated that residents or their representatives would receive a copy of the Arbitration Agreement, be informed orally of its content, and have the opportunity to ask questions. However, the Arbitration Agreement was not included in the attachments for any of the reviewed residents. Interviews with the residents revealed that they did not recall receiving information about the optional Arbitration Agreement during their admission process. Staff interviews confirmed that the Admission Agreement information was discussed with residents upon admission, and they signed an acknowledgment of receipt of attachments. However, the Admissions Coordinator admitted that the optional Arbitration Agreement attachment was only recently provided to include in the Admission Agreement packet. The Administrator acknowledged that the packet attachments were not up to date and stated that the optional Arbitration Agreement would be added to the packet attachments moving forward.
Failure to Include Arbitration Agreement Documentation
Penalty
Summary
The facility failed to include documentation of the Arbitration Agreement to the resident and/or representative for four residents (Residents 81, 87, 73, and 66). The Admission Agreement for Skilled Nursing Facilities indicated that residents acknowledged receiving a copy of the Arbitration Agreement and being informed of its content. However, the Arbitration Agreement was not included in the admission packets for these residents. This discrepancy was identified during a review of the residents' Admission Agreement documentation, which showed that each resident had signed the documentation indicating receipt of the Arbitration Agreement, but the actual agreement was missing from the packet. Interviews with staff and residents revealed that the optional Arbitration Agreement documentation had only recently been provided to the facility by a regional administrator. Staff M, the Admissions Coordinator, confirmed that the Arbitration Agreement was not included in the initial admission packets and that the residents' admission documentation needed to be updated. Residents 81 and 87 did not recall signing or being informed about the Arbitration Agreement. Staff A, the Administrator, acknowledged that the required optional documentation related to the Arbitration Agreement had just been received and needed to be included in the residents' admission packets.
Infection Control and Isolation Precautions Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by incomplete collection and analysis of infection control data, failure to identify trends, and lack of follow-up activities for February and March 2024. Specifically, the infection control line listings for these months did not include all documented infections from residents' electronic health records. For instance, infections for residents prescribed antibiotics for various conditions such as conjunctivitis, septic joint infection, and urinary tract infections were not recorded. Additionally, there was no mapping of infections, no summary to identify trends, and multidrug-resistant organisms were not tracked. The facility also failed to implement proper isolation precautions on the Rose wing. Observations revealed that staff did not follow proper procedures for donning and doffing personal protective equipment (PPE) and did not perform hand hygiene as required. For example, a CNA was observed improperly removing an isolation gown and gloves, failing to perform hand hygiene, and contaminating surfaces by touching them with unsanitized hands. Other staff members were seen entering and exiting isolation rooms without wearing the required PPE or performing hand hygiene. Interviews with staff, including the Assistant Director of Nursing and the Director of Nursing Services, confirmed these deficiencies. Staff acknowledged that they should have tracked all new infections and completed monthly summaries, but this was not done. The Director of Nursing Services admitted that the facility had been struggling to keep up with infection control practices due to the recent loss of their infection preventionist.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program, which led to the inappropriate and unnecessary use of antibiotics for four residents. Resident 69 was administered eight different antibiotics for various infections, including a UTI, pneumonia, and osteomyelitis, despite laboratory results showing resistance to some of the prescribed antibiotics. Resident 304 received levofloxacin for a UTI without documented signs or symptoms of the infection, and the lab results showed no bacterial growth. Resident 56 was given ciprofloxacin for five days for osteomyelitis and sepsis, even though lab results indicated resistance to the antibiotic. Resident 305 was administered cephalexin for a UTI, but lab results showed no bacterial growth, and there were no documented signs or symptoms of the infection. Interviews with staff revealed a lack of awareness and oversight regarding the criteria for active infections and the review of lab results. Staff BB, an LPN, admitted to being unaware of the criteria for active infections and stated they would notify the provider upon receiving lab results. Staff B, the Director of Nursing Services, acknowledged that the infection preventionist should notify the provider when lab results show resistance and admitted that the lack of oversight for antibiotic stewardship did not meet their expectations. This deficiency placed residents at risk for potential adverse outcomes associated with inappropriate and unnecessary antibiotic use.
Failure to Adhere to Food Safety Protocols
Penalty
Summary
The facility failed to ensure food was prepared and served according to professional standards, placing residents at risk of foodborne illness and a diminished quality of life. Observations on 04/08/2024 revealed three packages of partially thawed ground beef, an uncovered and unlabeled container of cheese sauce, and an open can of a Named Brand Energy drink on the prep table. Staff G, the Dietary Manager, acknowledged that these practices did not meet expectations. Further observations on 04/11/2024 showed Staff H, a cook, adding hot water from the coffee maker to oatmeal and cream of wheat without taking temperatures, and placing a tray of ham on the steam table without checking its temperature. Both Staff H and Staff G admitted that they should have taken the temperatures but failed to do so due to being in a rush or considering the hot water temperature unpredictable. The Regional Director of Operations confirmed that the expectation was for staff to follow temperature measurement requirements according to professional standards. Additionally, on 04/11/2024, a large pot of uncovered, previously-cooked shredded chicken was observed on the prep table for at least 85 minutes without refrigeration. Staff H admitted that the chicken was not completely thawed and should have been placed in the refrigerator. Despite this, Staff H later placed the chicken in the refrigerator and then into a blender, stating they did not think it was unsafe to consume. Staff G and Staff A, the Administrator, both confirmed that the chicken was not safe for consumption and should have been discarded. These actions and inactions demonstrate a failure to adhere to proper food safety protocols, as outlined in WAC 388-97-1100 (3).
Failure to Provide Access to Personal Funds After Hours
Penalty
Summary
The facility failed to ensure residents had access to their personal funds during evenings and weekends, impacting one of the 37 sampled residents. Resident 36 reported not having a lock box and had to keep funds in their room due to the lack of access to personal funds after business hours. A review of Resident 36's financial statement showed a monthly deposit allowance and a significant available balance. Interviews with the Business Office Manager and the Administrator confirmed that residents did not have access to personal funds after hours, which was attributed to a recent petty cash audit. This failure did not meet the facility's expectations and violated residents' rights to manage their financial affairs as per WAC 388-97-0340.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
The facility failed to protect the residents' right to personal privacy for two residents during care activities. For Resident 52, an observation on 04/09/2024 at 9:34 AM revealed that the resident was seated in their wheelchair facing the doorway with the door not closed and the privacy curtain not pulled. Staff T, a CNA, was observed re-arranging Resident 52's shirt, exposing the resident's left breast, which was visible from the hallway. Staff T admitted that the door did not have a doorknob and would not stay closed, and the privacy curtain was not pulled far enough to provide adequate privacy. For Resident 69, during a wound care observation on 04/10/2024 at 11:40 AM, Staff K, an LPN, ensured the door was shut and the curtain was pulled to provide privacy. However, at 11:44 AM, Staff S, an LPN and Resident Care Manager, entered the room without knocking or asking to enter and stood at the opening of the curtain to speak to Staff K about another resident. When Staff S left the room, they did not close the door, leading to Resident 69 expressing frustration about the lack of privacy. Staff K confirmed that Resident 69 preferred the door closed and the curtain pulled during care, and staff should always knock before entering.
Failure to Conduct Timely Significant Change in Status Assessment
Penalty
Summary
The facility failed to timely identify and conduct a Significant Change in Status Assessment (SCSA) for a resident who experienced significant changes in their condition. The resident, who had a history of lower limb amputation, diabetes, and morbid obesity, reported a considerable weight gain, loss of mobility, and increased depression. Despite these changes, the facility did not complete an SCSA within the required 14 days, leading to unmet care needs and diminished quality of life for the resident. Observations and interviews revealed that the resident was confined to bed, experienced significant weight gain, and had poor dental health causing oral pain. The resident also reported feelings of unhappiness and social isolation. The facility's records showed discrepancies in the resident's weight assessments and a lack of timely updates to their care plan, including the failure to code significant weight gain and changes in mood and cognition. The MDS Coordinator acknowledged the oversight in coding the resident's significant weight gain and the dependency on the nursing team to notify them of changes in the resident's status. The resident's medical records indicated a 30% weight gain over the past year, a decline in mood and cognition, and the use of multiple anti-depressant and anti-psychotic medications without proper diagnoses coded to support their use. These failures contributed to the resident's overall decline and unmet care needs.
Failure to Conduct Timely Care Planning Conferences
Penalty
Summary
The facility failed to conduct timely and routine care planning conferences with the residents and/or their responsible parties for three of the four residents reviewed. Resident 63, who was readmitted with a brain injury and dysphasia, had not had a care plan conference since September 2022. Both the resident and their responsible party confirmed the lack of recent care conferences. Resident 72, admitted to the facility, had only one care conference documented four months after admission, despite a scheduled conference that was not documented as occurring. Resident 78, admitted to the facility, did not recall having any care conference, and the care conference evaluation form was found blank with no documentation of a conference being held. Interviews with staff confirmed the deficiencies in care conference documentation and scheduling. The Social Services Director acknowledged that the documentation did not meet expectations, and the Director of Nursing Services confirmed that the care conferences for Residents 63, 72, and 78 were not conducted as required. This failure placed the residents at risk for unmet needs and a diminished quality of life, as they were not involved or informed about their care plans.
Deficiencies in Providing ADLs and Hygiene Care
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living (ADLs) for several residents, leading to unmet care needs and poor hygiene. Resident 52, who was dependent on staff for eating, oral hygiene, toileting, personal hygiene, and transfers, was observed with unclean teeth, dry and peeling lips, and uncombed hair. Despite physician orders and Kardex instructions for regular oral care and repositioning, staff did not consistently perform these tasks. The resident's call light was also found on the floor, out of reach, preventing them from requesting assistance when needed. Interviews with staff and the resident's collateral contact confirmed these deficiencies in care, including inadequate toileting assistance and oral hygiene practices. Resident 69, who required diabetic nail care every seven days, was observed with long, curved nails, indicating that the prescribed nail care was not being performed as documented. The resident confirmed that they had not received regular nail care. Similarly, Resident 60, who was dependent on staff for personal hygiene and oral care, was observed with an unclean toothbrush and unclean teeth over multiple days. Staff interviews revealed that the toothbrush with dried toothpaste was indeed used for the resident, highlighting a lack of proper oral hygiene practices. Additional observations included Resident 9, who was seen with uncombed hair and white whiskers on their chin, and Resident 7, who had food particles in their teeth and uncombed hair. Both residents indicated that they did not receive adequate assistance with grooming and oral care. These findings collectively demonstrate a pattern of neglect in providing essential ADLs, leading to poor hygiene and unmet care needs for the residents involved.
Failure to Provide Resident-Centered Activity Programs
Penalty
Summary
The facility failed to provide resident-centered activity programs that incorporated the interests, hobbies, and cultural preferences of the residents. This deficiency was observed in four residents who were reviewed for activities. The lack of personalized activities placed these residents at risk for social isolation, boredom, decreased sense of security, and a diminished quality of life. Resident 52, who had moderate vision impairment and diagnoses including brain injury, dementia, and anxiety, was found to have an activity care plan that lacked individualized preferences. The resident's room was observed to be devoid of personal items, and the resident reported feeling bored and lonely. Despite the resident's preferences for music, pets, fresh air, and religious activities, there was no documentation of these activities being offered or attended. Similar deficiencies were observed in Residents 60, 57, and 7. Resident 60, who had severe neurological developmental disorder and was non-verbal, had no personalized items in their room and was observed with minimal interaction. Resident 57, who spoke a different language and had dementia, was observed self-propelling in the hallway with little engagement from staff. Resident 7, who had dementia and depression, was frequently observed sitting in their room with no activities or interactions. The activity care plans for these residents also lacked personalized preferences and documentation of activities being offered or attended.
Failure to Provide Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to provide an environment free of accidents and hazards for three residents and two smoking areas. Resident 13, who had a history of unsafe smoking behaviors, was observed smoking unsupervised in the parking lot, with a lit cigarette propped between their lips and ashes falling on their lap. Despite previous incidents of smoking in their bathroom and being re-educated on the smoking policy, Resident 13 continued to smoke unsafely. The care plan did not adequately address the resident's need for supervision or safety measures while smoking, and the facility did not reassess the resident after these incidents to update the care plan accordingly. Resident 66, who used an e-cigarette, was found to be vaping in their room, which was against the facility's non-smoking policy. This behavior was known to the staff, yet no actions were taken to enforce the policy or reassess the resident's smoking habits. Additionally, the facility grounds were observed to be littered with cigarette butts, and there were no proper receptacles for cigarette disposal. Staff and residents were seen smoking in non-designated areas, contributing to an unsanitary environment. Resident 27 experienced a fall, and although the incident report indicated that the care plan should be updated with new interventions to prevent future falls, this was not done. The failure to update the care plan left the resident at risk for further falls. Interviews with staff confirmed that the care plan was not revised as required, which did not meet the facility's expectations for resident safety and care planning.
Failure to Provide Routine Catheter Care and Proper Documentation
Penalty
Summary
The facility failed to ensure that two residents with urinary catheters received care and services consistent with professional standards of care. Resident 69, who had diagnoses including paraplegia, an amputation, urine retention, and a multi-drug resistant organism, did not receive routine catheter care every shift. Observations showed that the catheter tubing was not secured and was hanging in a dependent position with white sediment collected in the tubing. Interviews with staff revealed inconsistencies in catheter care practices and documentation, with the catheter drainage bag not being changed as ordered and the catheter not being properly secured, leading to discomfort and potential risk for infections and skin breakdown for Resident 69. Resident 70, who had quadriplegia and an indwelling supra pubic catheter, also did not receive routine catheter care. The resident reported issues with the catheter draining and leaking urine, and had recently experienced a bladder infection. Observations showed the catheter tubing hanging off the side of the bed with white sediment collected, and the catheter drainage bag was empty. Interviews with staff indicated that there were no physician orders, care plans, or Kardex directives for catheter care for Resident 70, and staff were unaware of the need for routine catheter care. The facility's failure to provide routine catheter care, secure catheter tubing properly, and ensure appropriate documentation and directives for catheter management placed both residents at risk for infections, skin breakdown, and diminished quality of care. Staff interviews highlighted a lack of adherence to facility protocols and professional standards of care, contributing to the deficiencies observed during the survey.
Failure to Administer and Document Pain Medication
Penalty
Summary
The facility failed to ensure staff provided pain medication as ordered for Resident 73, who was reviewed for pain management. Resident 73 had diagnoses including osteoarthritis of the knees and hip, and depression, and was dependent on staff for activities of daily living. The resident's pain management regime included a topical anti-inflammatory gel to be applied to both knees and the right shoulder three times a day, and acetaminophen extra strength every six hours as needed for pain. However, the April Medication Administration Record (MAR) showed no documentation that the acetaminophen was administered between April 1 and April 9, 2024. Additionally, during an observation, a nurse administered acetaminophen but did not apply the topical anti-inflammatory gel as scheduled, and the resident reported not receiving the gel for several weeks. Interviews with staff revealed inconsistencies in the documentation and administration of the medications. Staff FF, a registered nurse, failed to apply the topical gel during a medication round, and the April MAR inaccurately documented the administration of both the gel and acetaminophen. The Director of Nursing Services (DNS) and a Registered Nurse/Residential Care Manager (RN/RCM) confirmed that it was their expectation for nurses to document the administration of medications accurately and to provide all medications as ordered. The failure to administer the scheduled anti-inflammatory gel and accurately document the provision of acetaminophen placed Resident 73 at risk for delayed care and potential medical complications.
Failure to Provide Adequate Hemodialysis Services
Penalty
Summary
The facility failed to provide adequate hemodialysis (HD) services for a resident who required such care. The deficiency was identified through interviews and record reviews, which revealed that the facility did not consistently monitor the dialysis documentation or communicate pertinent clinical information to the dialysis unit. This lack of communication and incomplete documentation placed the resident at risk for unmet care needs, medical complications, and diminished quality of care. Specifically, the facility's Dialysis Transfer Forms, which are used to report laboratory values, pre and post HD weights, medication administration, and any changes in the resident's status, were found to be incomplete or missing for multiple HD treatment days in February and March 2024. The resident involved had diagnoses including lung and kidney disease and was dependent on HD. The care plan directed staff to ensure the resident was ready for transportation to the HD center and to collaborate with HD center staff as needed. However, the review of the resident's HD folder and Electronic Health Record (EHR) showed multiple instances where the Dialysis Transfer Forms were either incomplete or not initiated. Interviews with staff confirmed that it was the facility's expectation for licensed nurses to complete these forms and obtain necessary information from the HD center if the forms were not filled out. Despite this expectation, the documentation was found lacking, leading to the identified deficiency.
Failure to Administer Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to provide Influenza and Pneumococcal vaccines for two residents reviewed for vaccinations. Resident 55's electronic health record showed a signed consent form for the vaccines, but there was no indication if the resident consented or declined, and the vaccines had not been administered. Similarly, Resident 70's record showed a signed consent form for the influenza vaccine and an incomplete consent form for the pneumococcal vaccine, with no indication of administration. During an interview, the Director of Nursing Services stated that residents should be educated on and offered the vaccines upon admission, and the forms should be fully completed and the vaccines administered if consented to.
Failure to Administer COVID-19 Vaccines
Penalty
Summary
The facility failed to offer and follow-up on the completion of COVID-19 immunizations for two residents. Resident 55, admitted with heart disease, a pacemaker, and asthma, had no record of receiving the COVID-19 vaccine prior to admission. A signed consent form dated 03/14/2024 was found, but it did not indicate whether the resident consented or declined the vaccine, and there was no record of the vaccine being administered since admission. Resident 70, admitted with acute respiratory failure and a history of COVID-19 infection, had received their second dose of the COVID-19 vaccine on 04/01/2021 and was due for a booster. A signed consent form dated 08/04/2023 indicated the resident consented to the booster, but the vaccine had not been administered since admission. During an interview, the Director of Nursing Services stated that residents should be educated on and offered the COVID-19 vaccine upon admission, and if they consented, the vaccines should have been ordered and administered.
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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