Highland Health And Rehabilitation Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Bellingham, Washington.
- Location
- 2400 Samish Way, Bellingham, Washington 98229
- CMS Provider Number
- 505140
- Inspections on file
- 31
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Highland Health And Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
A resident with osteomyelitis, diabetes, and a left-arm PICC line for IV antibiotics experienced harm when an RN used unsterile wound care scissors during a weekly PICC dressing change, cutting the line instead of safely removing the dressing per facility policy. The resident reported bleeding and discomfort, and was emergently transferred to the ED where the PICC was removed and replaced after ultrasound and X-ray. Record review showed the facility’s policy required careful, non-sharp removal of dressings and use of alcohol to loosen adhesive, and the facility’s assessment identified IV and central line care as needed services. Multiple nurses’ competencies for central/PICC/CVAD care and central line dressing changes were past due, and interviews with staff, the resident, and family indicated limited training and frequent problems with IV antibiotic administration and pump management, leading to concerns about staff ability to safely manage the resident’s PICC line.
Surveyors found that the facility repeatedly failed to administer physician‑ordered medications over multiple days because drugs were not available, affecting numerous residents and a wide range of treatments including respiratory, cardiac, thyroid, diabetic, pain, GI, psychiatric, hormone, and supplement therapies. Review of the Medication Not Available report showed that some medications had been previously delivered in 7‑ to 30‑day supplies or were stocked OTC or in the pyxis, yet were still not given, and refill requests were often submitted after supplies should have run out. RNs, LPNs, and agency staff reported frequent shortages of OTC medications, barriers to pyxis access, confusion over who was responsible for ordering, and management discouraging documentation of unavailable meds. Staff described ongoing problems with pharmacy deliveries, late or missing orders, and high‑cost medications requiring administrative approval, while the consulting pharmacist reported a 5–7 day refill turnaround, noted late refill requests, and identified instances where medications should have been on hand or available in pyxis but were not used, resulting in missed doses, including at admission.
A resident’s PICC line was accidentally cut by an RN during a dressing change, leading to transfer to the ED, but the facility did not initiate an incident report or conduct a thorough investigation as required by its abuse prevention and reporting policy. Incident logs contained no entry for the event, and interviews with the interim CNO, a resident care manager, and the interim administrator showed that staff considered the occurrence a mistake, believed education of the nurse was sufficient, or incorrectly assumed an incident report and investigation had been completed. Leadership later stated they would have expected an investigation into what happened, but no formal incident report or documented investigation was found.
The facility did not update and post accurate daily nurse staffing information, including actual nursing hours worked and the current resident census, for an extended period. Surveyors repeatedly observed that the posted staffing sheet displayed an outdated date, and an interim CNO confirmed that the posting had not been updated as required. This failure prevented residents and visitors from readily viewing current nurse staffing levels.
A resident at risk for pressure injuries did not receive consistent preventive interventions, such as off-loading heels and use of heel protective devices, as outlined in the care plan. Documentation showed these measures were not regularly implemented, resulting in the development of a deep tissue injury on the resident's heel, significant discomfort, and improper wound care practices by staff.
Staff did not consistently perform hand hygiene during meal tray delivery, failed to use appropriate PPE when caring for a resident on enhanced precautions, and did not properly store or maintain oxygen and nebulizer equipment for a resident. These lapses were observed during direct care activities and confirmed through staff interviews and record review.
A resident with a history of hypersexuality and inappropriate touching was inadequately supervised, resulting in inappropriate contact with another resident who had dementia. Despite having a care plan to manage these behaviors, the facility failed to document and implement necessary interventions, leading to a lapse in supervision and protection.
The facility failed to provide adequate nursing staff, resulting in unmet needs for three residents. A resident with severe cognitive impairment was found undressed and unable to reach their call light or drinks. Another resident, at risk for falls, reported long delays in call light responses, leading to accidents. A third resident, also at risk for falls, had their call light turned off without assistance, prompting unsafe self-transfer attempts. Staff confirmed insufficient staffing levels.
The facility failed to meet professional standards in medication administration and physician consultations. During an internet outage, printed MARs were incomplete, leading to potential medication errors for residents. Staff relied on pharmacy labels instead of accurate physician orders. Additionally, a resident's GI specialist referral was not completed, despite a physician's order, leaving the resident's symptoms unaddressed.
The facility failed to ensure that NACs had the necessary competencies to provide nursing services, as five staff members lacked documented assessments of their skills. Despite policies requiring validation of competencies, interviews revealed that these assessments were not completed, placing residents at risk for unmet care needs.
A facility failed to comply with infection control guidelines during medication administration and laundry handling. An LPN did not use barriers or perform hand hygiene while administering medications, and the laundry room lacked procedures for handling contaminated linens. The infection control program had not been reviewed since 2022, and staff were not adequately trained.
The facility did not ensure residents had access to Saturday mail deliveries, impacting two residents. Despite the facility's policy on communication rights, mail delivered on Saturdays was not distributed until Mondays. This was confirmed by staff interviews, with one resident having moderate cognitive impairment and another with no cognitive impairment reporting the delay.
The facility failed to ensure comprehensive Resident Assessment Instrument (RAI) summaries for three residents, leading to incomplete care planning. A resident's significant change MDS assessment lacked input from their representative and comprehensive assessments in key areas. Another resident's annual MDS assessment was similarly deficient. Additionally, a resident's dental issue was not properly documented, preventing necessary care coordination. Staff interviews revealed remote MDS completion and inadequate CAA documentation.
A facility failed to provide appropriate care for a resident with an indwelling urinary catheter, increasing the risk of CAUTIs. The facility did not develop individualized plans for catheter care, instead following routine procedures for changing and flushing the catheter system, contrary to CDC guidelines and facility policy. The resident, with a chronic suprapubic catheter, was readmitted after a UTI, and observations showed potential issues with catheter care. Staff confirmed routine practices were not aligned with best practices, and the resident was not informed of the infection risk.
The facility failed to prevent unnecessary drug administration for two residents. One resident received PRN pain medication without documented non-pharmacological interventions, despite having a care plan requiring such attempts. Another resident with IBS and frequent diarrhea was given bowel medications that were supposed to be held for loose stools, resulting in unnecessary administration. Staff interviews confirmed these oversights.
A facility failed to maintain accurate clinical records for a resident with a chronic suprapubic catheter. Despite an order to measure and record urinary output every shift, documentation was missing for six shifts. An LPN was unable to provide information about the missing records.
A facility failed to implement its Antibiotic Stewardship Program effectively, as demonstrated by a resident who was prescribed antibiotics without documented clinical indication or validation of an active infection. Interviews with staff revealed a lack of communication and verification processes, highlighting deficiencies in the program's execution.
The facility did not ensure that NACs completed the required 12 hours of annual training. Two NACs, hired in 2022 and 2023, did not meet the training requirement, with one lacking documentation and the other completing only 6.10 hours. This was confirmed by the DNS during an interview.
A resident with diabetes mellitus type 2 experienced a hypoglycemic episode with a blood glucose level as low as 47 mg/dL. Despite having a continuous glucose monitoring system, the incident was not documented, and the physician was notified 26 days later. The resident sought help independently after the glucose monitor alarmed, and staff inconsistencies in reporting and documentation were noted. The facility lacked a policy for using the monitoring system, leading to a deficiency in diabetic management.
The facility failed to address the behavioral health needs of a resident with multiple diagnoses, including hip fracture and adjustment disorder. Despite ongoing confusion, restlessness, and refusal of care, the facility did not implement effective person-centered interventions. Observations and interviews revealed the resident's distress and unmet needs, with staff failing to respond to calls for help and adequately document behavioral health issues.
The facility failed to provide timely pharmacy services for three residents upon admission, resulting in delayed administration of critical medications for pain management, diabetes, leukemia, and Parkinson's disease. Staff inconsistencies and lack of proper documentation contributed to these deficiencies.
The facility failed to maintain a clean and sanitary shower room, leading a resident to avoid bathing due to the filthy conditions, including black grout and debris. Staff confirmed minimal cleaning practices and acknowledged built-up grime and a non-functional tub.
Improper PICC Line Dressing Change and Inadequate Nurse Competencies
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate administration of IV therapy by not following professional standards and aseptic technique during a PICC line dressing change for Resident 20. The facility’s own 2025 Facility Assessment identified that its resident population required nursing care for IV peripheral and central lines, and that competencies were to be monitored through leadership rounding, mentoring, skills checks, and annual staff competencies. The facility had a policy for central venous access device dressing changes that required careful removal of old dressings, stabilizing the catheter to minimize movement, and using alcohol to loosen adhesive. Resident 20 was admitted with osteomyelitis of the thoracic and lumbar vertebrae, type 2 diabetes, and vancomycin resistance, and had a PICC line in the left upper arm with care plan interventions for enhanced barrier precautions and dressing changes to maintain patency and keep the site infection-free. During a scheduled weekly PICC line dressing change, the nurse performing the procedure used general wound care scissors, which were unsterile, to cut tape on the dressing. The nurse reported attempting to cut the tape and believed they had cut the dressing, but the PICC line was in fact cut. The resident and collateral contact reported that the nurse took scissors from their scrub pocket and cut near the line while trying to remove “gummy stuff” from the dressing. After the dressing was mostly removed and a new dressing placed over the insertion site, the resident noticed bleeding and felt blood under the armpit. The nurse initially stated the line had “broke” or “snapped,” while the resident asserted that it had been cut. The facility’s progress note documented that the PICC line was accidentally cut during the dressing change and that a pressure dressing was applied before the resident was transferred emergently to the emergency department for PICC line replacement and additional diagnostic procedures, including ultrasound and X-ray. Interviews and record review showed that licensed nurse competencies related to central/PICC/CVAD care and central line/midline dressing changes for multiple nurses were past due as of the review date. One RN stated they were unaware of any in-service instructing staff not to use scissors during PICC line dressing changes, though they knew sharps should not be used. The RN who cut the line stated they had not received much training at the facility, were previously certified to insert IVs at another facility, and felt unsupported due to lack of education. The resident, their family member, and staff interviews indicated that few nurses were comfortable or experienced with PICC line care, that staff had difficulty managing IV antibiotics, IV pumps, and air bubbles, and that the resident’s PICC line care appeared problematic throughout the stay. The facility’s failure to ensure current nurse competencies and adherence to its own PICC dressing change policy resulted in the use of unsterile scissors during a PICC line dressing change, cutting the line and necessitating emergency transfer and replacement of the central line, and placed the resident at serious risk for central line–associated bloodstream infection as stated in the report. The report also documents that the resident and their family perceived that staff did not know how to care for the PICC line or administer IV antibiotics properly. The family member stated it appeared there was only one nurse who knew how to work with a PICC line and described wasted IV antibiotic while staff attempted to remove air bubbles, as well as a dropped and broken medication vial. The resident reported that staff repeatedly had problems with the IV pump jamming, excessive air bubbles, and understanding how the antibiotics were to be infused, and that staff told them they were the only resident with an IV like theirs. The resident described the nurse’s visible panic after cutting the line and uncertainty about what to do next, including the nurse asking about resuscitation preferences while the resident was bleeding and waiting for emergency services. These observations and statements, combined with the documented lapse in competencies and deviation from the facility’s dressing change procedure, form the factual basis for the cited deficiency.
Widespread Failure to Provide Ordered Medications Due to Stock, Ordering, and Coordination Breakdowns
Penalty
Summary
The deficiency involves the facility’s failure to provide all physician‑ordered medications to residents on 13 of 14 reviewed days for 20 residents, disrupting continuity of care and placing residents at risk of not having their medical needs met. Review of the facility’s Medication Not Available report for 01/30/2026 through 02/12/2026 showed numerous prescribed medications, including anticonvulsants, respiratory medications, gastrointestinal medications, antidepressants, antiplatelet agents, thyroid medications, diabetic medications, cardiac medications, hormone therapies, pain medications, supplements, and OTC products, were not administered because they were not available. The report also documented that some medications were available in the facility’s pyxis machine or should have been available as OTC facility stock, yet were still not given. The Medication Not Available report detailed repeated instances where residents’ medications were not administered despite prior deliveries or available stock. Examples included residents missing doses of gabapentin, albuterol inhalation, fluticasone‑salmeterol inhalers, metronidazole topical cream, ranitidine, duloxetine, levothyroxine, semaglutide, clopidogrel, diltiazem, oxybutynin, pantoprazole, estradiol, alendronate, and various vitamins, minerals, and protein supplements. In several cases, the pharmacy had delivered 7‑, 14‑, 28‑, or 30‑day supplies on earlier dates, but the medications were still documented as unavailable later, and refill requests were sometimes submitted after the expected depletion date. The consulting pharmacist later confirmed that many of the medications listed should have been on hand based on previous delivery dates and that some medications were available in pyxis at the time they were reported as not administered. Staff interviews described systemic problems with obtaining both pharmacy‑dispensed and OTC medications, as well as confusion and breakdowns in responsibility for ensuring medication availability. Nursing staff, including RNs and LPNs, reported that OTC medications were often not available, that management discouraged documenting unavailable medications, and that they were directed to speak with the Administrator or HR, who in turn reported not having a card to purchase needed OTC items. Agency nurses reported they could not access the pyxis and had to rely on regular staff to obtain medications, and that notifications to Resident Care Managers did not always result in orders being placed. Nursing staff and managers described ongoing issues with pharmacy deliveries, including medications not arriving despite being ordered, delays related to ordering cut‑off times, and high‑cost medications requiring administrative approval and signatures. The contracted pharmacist stated they were unaware of delivery difficulties, noted a 5–7 day refill turnaround time, and identified late refill requests and missed admission doses where orders were submitted late in the day and no rush requests were made, contributing to the pattern of unavailable medications. Additional interviews with leadership and clinical staff further illustrated the lack of clarity and follow‑through in the medication supply process. An interim CNO stated they did not know where the disconnect was in having medications available. A Resident Care Manager acknowledged continuous issues with the pharmacy and stated that medications listed on the Medication Not Available report were simply not available, whether pharmacy‑delivered or facility‑supplied OTCs, and that the problem had been ongoing. Nursing staff reported that when medications were not available for a day or two, they tried to notify providers, and that they often had to call the pharmacy multiple times, sometimes being told that medications had not been ordered even when staff believed they had been. The consulting pharmacist’s follow‑up email also noted that several medications on the report should have been available as OTC stock, that many should have been on hand based on prior deliveries, that refill requests were often delayed beyond the expected depletion date, and that for one admission, multiple ordered medications were available in pyxis but not used, and no rush request was submitted for the remaining medications, resulting in missing doses on the evening of arrival.
Failure to Investigate PICC Line Injury Incident
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete and thorough investigation of an incident in which a resident’s peripherally inserted central catheter (PICC) line was accidentally cut by an RN during a dressing change, resulting in the resident being sent to the emergency department. The facility’s abuse prevention and reporting policy required investigation of events suggesting possible abuse or neglect and documentation of such events, including appropriate corrective action if an allegation was verified. However, review of the facility’s incident logs for January and February 2026 showed no incident related to this PICC line event, despite a progress note documenting that the PICC line was accidentally cut and the resident was transferred to the hospital. Interviews with multiple staff revealed that no incident report or formal investigation was initiated at the time of the event. The interim CNO acknowledged that no incident report was completed because the resident was discharged home from the hospital and stated they were only going to complete an incident report on the day of the survey. The interim CNO also reported that, after reviewing internal guidance (“Purple Book”) with the intradisciplinary team, they had determined the event did not meet the definition requiring an incident report. A resident care manager stated that incident reports were usually started by the cart nurse or nursing managers, but in this case they were never directed to complete one and viewed the event as a mistake for which the nurse was educated. The interim administrator believed an incident report existed in the risk management system or had been reviewed in stand-up, but none was found, and stated they would have expected an investigation. The company lead CNO also stated they had been told an investigation was being conducted and would have expected one to be done.
Failure to Update and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate daily nurse staffing information, including the total number of actual nursing hours worked and the resident census, for a continuous period from 01/07/2026 through 02/13/2026, totaling 37 days. Surveyor observations on 02/11/2026 at 12:22 PM and on 02/12/2026 at 12:40 PM showed that the daily nurse staffing posting remained dated 01/07/2026. During an observation and interview on 02/13/2026 at 3:10 PM, the Interim Chief Nursing Officer confirmed that the nurse daily staffing posting was still dated 01/07/2026 and acknowledged that it should be updated daily to reflect the actual nurse staffing hours and the facility’s current census. This failure prevented residents and visitors from being able to readily view current nurse staffing information.
Failure to Implement Pressure Injury Prevention Leading to Deep Tissue Injury
Penalty
Summary
A resident with a history of fractured left hip, morbid obesity, and neuropathy was admitted to the facility without any existing pressure injuries but was identified as being at risk for developing them due to limited mobility and incontinence. The care plan specified the use of heel protective devices and off-loading of heels when in bed, and the initial skin inspection documented that green heel boots were placed on both feet. However, subsequent documentation and direct care staff records showed that these interventions were not consistently implemented or documented, and there was no evidence that the resident's heels were off-loaded or that heel protective devices were used as required. Over the course of the resident's stay, staff noted a boggy/soft spot on the left heel, which remained closed and painless initially. Despite this early sign, there was no documentation of preventive interventions being carried out. The resident eventually developed a large, closed blister on the left heel, which was later identified as a deep tissue injury (DTI). The root cause analysis indicated that the injury was due to the resident's heel rubbing on the bed, exacerbated by immobility and the use of a bed that was too small for proper positioning. Interviews and emails from a collateral contact and staff confirmed that heel boots were often not applied, and the resident's heels were observed rubbing against the bed, leading to further skin breakdown. The resident reported significant discomfort and pain from the heel wound, which interfered with rehabilitation efforts. Additional concerns were raised about improper wound care, including staff peeling back dead skin and applying socks over the open wound, which became stuck to the wound. Staff interviews confirmed lapses in documentation and implementation of ordered interventions, and the resident's care records did not reflect consistent use of off-loading boots or other preventive measures as outlined in the care plan.
Infection Control Failures in Hand Hygiene, PPE Use, and Respiratory Equipment Maintenance
Penalty
Summary
Staff failed to comply with infection prevention and control guidelines, as evidenced by multiple observations of a nursing assistant not performing hand hygiene during meal tray delivery. The staff member was seen handling meal trays, touching residents’ personal items and silverware, and assisting with resident care activities without performing hand hygiene before or after these tasks. The staff member also did not demonstrate knowledge of when hand hygiene should be performed during meal pass, and admitted to not performing hand hygiene while passing lunch trays. In another instance, a staff member did not use appropriate personal protective equipment (PPE) when providing care to a resident on enhanced based precautions (EBP) due to an indwelling device. The staff member only wore gloves, despite facility policy and signage indicating the need for additional PPE such as gowns, masks, and eye protection during high-contact care activities. The staff member was unable to explain the purpose of EBP or when it should be implemented, and reported only using gloves when assisting the resident with toileting. Additionally, the facility failed to ensure proper storage and maintenance of oxygen and nebulizer tubing for a resident. Observations revealed that oxygen tubing and a nasal cannula were left touching the floor or stored inappropriately, and nebulizer equipment appeared dirty, was not dated, and was not stored in a plastic bag. Staff interviews indicated inconsistent practices regarding labeling, dating, and storing respiratory equipment, and documentation of tubing changes was not found in the treatment administration record.
Inadequate Supervision Leads to Resident-to-Resident Contact
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with a history of hypersexuality and inappropriate touching, leading to a resident-to-resident sexual contact. Resident 1, who had diagnoses including Parkinson's disease, dementia, and other behavioral disturbances, was on medications known to have side effects that could exacerbate impulsive behaviors. Despite having a care plan in place to manage these behaviors, the facility did not effectively implement the necessary interventions to prevent inappropriate interactions. Resident 1's care plan included interventions such as diverting attention, removing them from situations, and offering activities to minimize disruptive behaviors. However, documentation showed multiple episodes of sexually inappropriate behavior by Resident 1 that were not recorded in the nursing progress notes. This lack of documentation and follow-through on the care plan interventions contributed to the failure to prevent the incident of inappropriate contact with Resident 2, who had dementia and was unable to consent. Interviews with staff revealed that there was a lack of consistent supervision and intervention when Resident 1 was around other residents, particularly female residents. Staff were aware of the need for enhanced supervision but did not consistently maintain line of sight or redirect Resident 1 as required. This oversight allowed Resident 1 to engage in inappropriate contact with Resident 2, highlighting a significant lapse in the facility's duty to protect residents from harm.
Insufficient Nursing Staff Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by the experiences of three residents. Resident 1, who has severe cognitive impairment and is dependent on staff for personal care, was found in a state of undress with their call light and drinks out of reach. Despite the resident's known behavior of rejecting care and language barriers, the situation was not addressed promptly, leaving the resident's needs unmet. Resident 2, who has no cognitive impairment but is at risk for falls due to impaired mobility, reported that their call light went unanswered for over an hour, resulting in an accident. The facility's investigation attributed this to staff miscommunication during breaks. The resident expressed that delays in responding to call lights were frequent, indicating a systemic issue with staffing levels. Resident 4, who has a history of falls and requires assistance for mobility, experienced a similar issue. Their call light was turned off without their needs being addressed, leading them to attempt self-transfer, which is against their care plan. Staff interviews confirmed that there was insufficient staffing to meet residents' needs, with some staff being pulled from their designated duties to cover shortages.
Medication Administration and Physician Consultation Deficiencies
Penalty
Summary
The facility failed to ensure professional standards were met in medication administration and physician consultations, leading to deficiencies in care. During an internet outage, the facility resorted to using printed medication administration records (MARs) instead of electronic records. However, the printed MARs were incomplete, with the first letters of each medication cut off, making it difficult for licensed staff to accurately administer medications. This issue was observed on both the North and South Halls, affecting multiple residents, including Resident 13 and Resident 10. Staff were observed administering medications based on incomplete MARs, relying on pharmacy labels to verify medication orders, which were not a reliable source for confirming physician orders. Resident 13 was administered medications with incomplete MARs, where the names of medications were partially missing, leading to potential medication errors. Staff involved in the medication pass were unaware of the printing issue until it was brought to their attention. Similarly, Resident 10's medication administration was compromised due to the incomplete MARs, with missing parts of physician orders such as medication names, routes, doses, and directions. Staff had to rely on medication labels to identify the correct medications, which posed a risk of errors. Additionally, the facility failed to follow through on a physician's order for a specialist referral for Resident 27, who was experiencing chronic diarrhea. Despite the physician's note indicating the need for a gastrointestinal (GI) specialist consultation, the order was not completed. Staff were unaware of the consultation order, and the resident continued to experience symptoms without appropriate specialist intervention. This oversight further highlights the facility's failure to adhere to professional standards and ensure residents' needs were met.
Failure to Ensure Competency of Nursing Assistants
Penalty
Summary
The facility failed to ensure that Nursing Assistants Certified (NACs) possessed the necessary competencies, skills, and proficiencies to provide nursing and related services to residents. This deficiency was identified during interviews and record reviews, where it was found that five sampled staff members (Staff H, I, Q, R, and S) did not have documented assessments of their competencies to provide nursing services. The facility's policy, dated November 28, 2017, required validation of nurse aides' competencies in skills and techniques, but this was not adhered to. The facility's assessment, dated July 26, 2023, to July 25, 2024, indicated that education was provided through orientation, monthly competencies, and annual skills fairs, with monitoring through senior leader rounding and mentorship programs. However, interviews with Staff B, a Registered Nurse/Clinical Resource Nurse, and Staff A, the Director of Nursing Services, revealed that competencies for the staff had not been completed, and no documentation could be located for the five staff members. This lack of competency assessment placed residents at risk for unmet care needs and a diminished quality of life.
Infection Control Deficiencies in Medication Administration and Laundry Handling
Penalty
Summary
The facility failed to ensure compliance with Infection Prevention and Control Guidelines during medication administration by a Licensed Practical Nurse (LPN). The LPN did not use a barrier when placing medication items on a resident's bed and over the bed table, and failed to perform hand hygiene before and after administering medications, including insulin and nasal spray. The LPN admitted to forgetting to use a barrier and only performed hand hygiene after leaving the resident's room. In the laundry room, the facility did not have a system in place for handling potentially contaminated linens to prevent cross-contamination. The housekeeping attendant was observed sorting and loading dirty linen without a clear procedure for cleaning the washing machines between loads. The laundry room was cluttered, with limited space for clean linen, and the machines were covered in dust and debris. The housekeeping manager, recently promoted, was unaware of any infection control procedures related to laundry. The facility's infection control program had not been reviewed or revised since October 2022, and no risk assessment had been conducted. The Infection Preventionist acknowledged the lack of a risk assessment and the failure to educate staff on proper infection control practices. The Director of Nursing Services was unaware of the deficiencies in the infection control program and the lack of training for the housekeeping manager.
Failure to Provide Saturday Mail Access
Penalty
Summary
The facility failed to ensure residents had access to Saturday mail deliveries, affecting two of the six sampled residents. According to the facility's policy on Resident Rights, residents are entitled to private and unrestricted communication, including the right to receive sealed, unopened correspondence. Resident 27, who has moderate cognitive impairment, reported receiving an email notification about mail delivery on Saturday but was unable to access the mail until later. Resident 2, with no cognitive impairment, confirmed that while the postal service delivers mail on Saturdays, it is not distributed to residents until Mondays. Staff interviews corroborated that mail is retrieved on weekends but not distributed until the following Monday, as confirmed by Staff M from the Business Office and Staff N, a Hospitality Aide.
Deficiencies in Resident Assessment and Care Planning
Penalty
Summary
The facility failed to ensure that the Resident Assessment Instrument (RAI) included comprehensive summaries of the Care Area Assessments (CAA) for three residents, which are essential for analyzing and planning individualized care. For Resident 4, the significant change Minimum Data Set (MDS) assessment did not include input from the resident's representative and lacked a comprehensive assessment of the resident's needs, strengths, goals, life history, or preferences in areas such as cognitive loss/dementia, behavioral symptoms, mood state, and psychotropic drug use. Similarly, for Resident 9, the annual MDS assessment was missing input from the resident's representative and did not provide a comprehensive assessment in the cognitive loss/dementia and psychotropic drug use CAAs. Resident 33 experienced issues with their upper denture not fitting, which was not addressed in the admission MDS dental section, leading to the Dental CAA not being triggered or completed. This oversight occurred despite the resident's care plan indicating the need for dental care coordination. Interviews with staff revealed that the MDS assessments were completed remotely, and there was a lack of comprehensive documentation in the CAAs, with some staff unaware of the issues until recently. The failure to properly assess and document the residents' needs placed them at risk of not receiving appropriate services based on their individualized needs.
Inadequate Catheter Care Increases Risk of CAUTIs
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to an increased risk of catheter-associated urinary tract infections (CAUTIs). The facility did not develop individualized plans for the prevention of CAUTIs, including specific clinical indications for changing catheters and catheter bags. Instead, the facility followed routine procedures for changing catheters and flushing the catheter system, which is contrary to the guidelines provided by the Centers for Disease Control (CDC) and the facility's own policy. These guidelines recommend changing catheters and drainage bags based on clinical indications such as infection or obstruction, rather than at routine, fixed intervals. Resident 3, who had a chronic suprapubic catheter due to a neuromuscular dysfunction of the bladder, was readmitted to the facility after hospitalization for a urinary tract infection. Observations revealed that the resident's urine was dark yellow with sediment, indicating potential issues with catheter care. The facility's records showed that the resident's catheter was changed monthly and flushed three times a week without documented clinical indications. Interviews with staff confirmed that these routine practices were not aligned with best practices for preventing CAUTIs, and the resident was not informed about the increased risk of infection due to these practices.
Failure to Prevent Unnecessary Drug Administration
Penalty
Summary
The facility failed to ensure that Resident 10's drug regimen was free from unnecessary medications by not documenting the use of non-pharmacological interventions before administering PRN pain medication. Resident 10, who was admitted with severe cognitive impairment and diagnoses including cancer of the pancreas and malignant neuroendocrine tumors, had a care plan that required non-pharmacological interventions to be attempted prior to administering Morphine Sulfate for pain. However, records from June and July 2024 showed multiple instances where the medication was administered without documentation of such interventions. Interviews with staff indicated that while non-pharmacological methods were reportedly attempted, they were not consistently documented as required. Additionally, the facility failed to follow hold orders for bowel medications for Resident 3, who had irritable bowel syndrome with diarrhea. Despite the resident experiencing frequent diarrhea, facility nurses continued to administer Senna and Docusate Sodium, which were ordered to be held in the presence of loose stools. This resulted in the resident receiving unnecessary bowel medications. Interviews with staff confirmed that the medications should have been held according to the orders, but this was not done, leading to the administration of 29 doses of Senna and 56 doses of Docusate Sodium unnecessarily.
Failure to Document Urinary Catheter Output
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who was reviewed for urinary catheter care and services. The resident, who had no cognitive impairment and was diagnosed with neuromuscular dysfunction of the bladder, was readmitted to the facility after hospitalization for a urinary tract infection secondary to a chronic suprapubic catheter. An order was placed on the resident's Treatment Administration Records (TARs) to measure and record the indwelling catheter urinary output every shift for hydration purposes. However, from July 14 to July 25, 2024, there was no documentation of urinary output for six shifts. During an interview, a Licensed Practical Nurse/Resident Care Manager was unable to provide information about the missing documentation for these six shifts and stated they would need to look into it, but no additional information was provided.
Failure in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) effectively, as evidenced by the case of Resident 3. Resident 3 was readmitted to the facility after a hospitalization for a urinary tract infection (UTI) related to a chronic suprapubic catheter. Upon discharge, the resident was prescribed amoxicillin-clavulanate, an antibiotic, to be taken twice daily for five days. However, the facility's medical records lacked any clinical indication, laboratory, or culture results to justify the use of this antibiotic. There was no analysis or validation to confirm the presence of an active infection, which is a critical step in the ASP to prevent unnecessary antibiotic use. Interviews with facility staff revealed gaps in the ASP's implementation. Staff G, the LPN/Infection Preventionist, acknowledged their responsibility to ensure proper antibiotic usage and indication but admitted to being unable to locate any documentation or analysis for Resident 3's antibiotic use. Furthermore, Staff A, the Director of Nursing Services, was unaware that the prescribed antibiotic for Resident 3 had not been reviewed for proper indication. This oversight indicates a failure in the communication and verification processes between the infection preventionist, resident care manager, and providers, which are essential components of the ASP.
Deficiency in NAC Annual Training Hours
Penalty
Summary
The facility failed to develop, implement, and maintain an in-service training program to ensure that Nursing Assistants Certified (NACs) received the required 12 hours of annual training. Specifically, two NACs, Staff H and Staff I, did not complete the mandated training hours. Staff H, hired in February 2022, lacked documentation of completing the required 12 hours of training for the period from February 2023 to February 2024. Similarly, Staff I, hired in August 2023, had only completed 6.10 hours of education by July 30, 2024, falling short of the required 12 hours. This deficiency was identified through a review of employee records and confirmed in an interview with the Director of Nursing Services (DNS), who acknowledged the expectation for NACs to complete the annual training requirement.
Deficiency in Diabetic Management for a Resident
Penalty
Summary
The facility failed to provide adequate care and services for a resident with diabetes mellitus type 2, resulting in a significant deficiency in managing the resident's blood glucose levels. The resident, who was cognitively intact, experienced a hypoglycemic episode with a blood glucose level as low as 47 mg/dL. Despite having a continuous glucose monitoring system, the resident's hypoglycemic episode was not documented in the progress notes, and the physician was not notified until 26 days later, leading to a delay in adjusting the resident's insulin order. The resident reported feeling fearful during the hypoglycemic episode, which occurred in the early morning hours. The resident's glucose monitor alarmed, but no staff responded to the call light, prompting the resident to seek help independently. The resident wheeled themselves to the nurse's station, where they were given juice and a peanut butter and jelly sandwich, but it took about an hour for their blood glucose to return to an acceptable range. The incident was not documented in the resident's clinical record, and the continuous glucose monitoring system's data was not cross-referenced with the medical record. Interviews with staff revealed inconsistencies in the reporting and documentation of the resident's low blood glucose levels. Staff members were unable to recall specific details of the incident, and there was no policy or procedure in place for using or gathering information from the continuous glucose monitoring system. The lack of documentation and timely notification to the physician placed the resident at risk for further complications and highlighted a deficiency in the facility's diabetic management practices.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to ensure the behavioral health needs of Resident 2 were identified and met. Resident 2, who was admitted with diagnoses including hip fracture, leukemia, chronic pain, anxiety disorder, and adjustment disorder with depressed mood, exhibited significant post-operative disorientation, agitation, and confusion. Despite these symptoms, the facility did not adequately address Resident 2's behavioral health needs. The resident's care plan included interventions for antidepressant and hypnotic medication use, but non-pharmacological interventions were not documented, and episodes of restless agitation were not reported to the provider. Additionally, Resident 2 experienced multiple episodes of depressive statements, refusal of care, withdrawal from activities, and disrobing, which were not effectively managed or documented by the staff. Resident 2's behavioral health concerns were not consistently addressed by the facility's medical staff. Progress notes from various medical professionals, including doctors and nurse practitioners, did not document or address Resident 2's behavioral health symptoms. Despite the resident's ongoing confusion, restlessness, and refusal of care, the facility's staff did not implement or document effective person-centered behavioral interventions. Interviews with staff members revealed a lack of consistent reporting and documentation of Resident 2's behavioral health issues, with some staff members stating that interventions were vague and not specific to the resident's needs. Observations and interviews with Resident 2 and staff members highlighted the resident's ongoing distress and unmet needs. Resident 2 was frequently found lying in bed uncovered and undressed, with their call light out of reach. The resident reported feeling neglected and in pain, with staff members failing to respond to their calls for help. Staff interviews indicated that behavioral interventions were not effectively communicated or implemented, and the resident's refusal of care and other behavioral symptoms were not adequately addressed. The facility's failure to identify and meet Resident 2's behavioral health needs resulted in a diminished quality of life for the resident.
Failure to Ensure Timely Medication Administration for New Admissions
Penalty
Summary
The facility failed to ensure pharmacy services were provided to meet the needs of three residents upon their admission. Resident 1, who was admitted with diagnoses including aftercare for heart bypass surgery, anxiety, and depression, did not receive their prescribed tramadol for pain management on the day of admission. The medication was only administered the following day, causing the resident to experience significant pain. The facility's process for acquiring and administering the medication was not followed, leading to a delay in pain relief for the resident. Resident 2, admitted with diagnoses including diabetes and leukemia, did not receive their prescribed medications, Steglatro and Imatinib Mesylate, on the scheduled dates. The MAR showed that the medications were not administered due to a need for prior authorization and high cost, which was only approved later in the day. This delay in medication administration was not properly documented or communicated, resulting in missed doses for the resident. Resident 3, admitted with a diagnosis of Parkinson's disease, did not receive their prescribed carbidopa-levodopa medication until the day after admission. The facility's staff failed to ensure the timely administration of this critical medication, which is essential for managing the resident's condition. Interviews with staff revealed inconsistencies in the medication administration process and a lack of proper documentation, contributing to the deficiencies observed in the care of these residents.
Unsanitary Shower Room Conditions
Penalty
Summary
The facility failed to provide a clean and sanitary environment in the residents' shower room, which negatively impacted Resident 4's desire to bathe. During an interview, Resident 4 described the shower room as filthy, with black grout and a dirty tub, leading them to prefer bed baths over showers. Observations confirmed the presence of black debris on the threshold and north wall of the shower room. Staff C, a Nursing Assistant Certified, mentioned that they only wiped down the shower stall with sanitizer wipes after each use and noted that housekeeping cleaned the shower room weekly. Staff D from housekeeping acknowledged the presence of built-up grime and attributed it to the building's age. The tub was also noted to be non-functional, contributing to the unsanitary conditions.
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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