Judson Park Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Des Moines, Washington.
- Location
- 23620 Marine View Drive South, Des Moines, Washington 98198
- CMS Provider Number
- 505455
- Inspections on file
- 20
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 50
Citation history
Health deficiencies cited at Judson Park Health Center during CMS and state inspections, most recent first.
The facility did not obtain or maintain required advance directive and guardianship documentation for several residents with cognitive impairment or complex medical needs. Despite verbal reports and admission paperwork indicating the existence of such documents, staff failed to ensure these were present in the medical records, and care plans lacked specific information about advance directives or decision-makers. Staff interviews confirmed that there was no consistent follow-up to secure or file these critical documents.
The facility did not consistently provide or document required written transfer/discharge notices, bed hold policies, or notification of appeal rights and LTCO contact information to residents being transferred to hospitals. In several cases, forms were unsigned or missing, and staff were unaware of the requirements. Additionally, discharge planning was inadequately documented for some residents who wished to return to the community, with gaps in communication and progress notes.
The facility did not ensure accurate PASRR screenings or timely Level II referrals for several residents with serious mental illness indicators, including those admitted under hospital exemptions who remained beyond 30 days. Residents with diagnoses such as depression and anxiety, and who were receiving psychotropic medications, were not properly identified or referred for further evaluation as required.
Several residents did not receive timely care conferences or have their care plans updated as required, with documentation missing for quarterly or admission care conferences and incomplete care plan revisions following changes in condition. Residents with complex medical needs were not given opportunities to participate in care planning, and staff did not consistently document or conduct these processes according to facility policy.
The facility did not follow physician orders or professional standards for wound care, skin assessments, and documentation for several residents, including those with abrasions, surgical wounds, and on anticoagulant therapy. Staff also failed to monitor and notify providers about low blood pressure readings for a resident with a pacemaker, with unclear care plan parameters and lack of documentation of interventions or notifications.
A resident with neurological and memory impairments reported that their roommate's belongings blocked access to shared spaces, but staff did not initiate or document a grievance as required by policy. Multiple staff members were either unaware of the complaint or did not act on it, resulting in the resident's concerns remaining unresolved and unaddressed.
Three residents received psychotropic medications without required monitoring for target behaviors, nonpharmacological interventions, or documented consent. Staff did not document behavior monitoring or obtain consent for antianxiety medication, and care plans lacked nonpharmacological approaches, as confirmed by nurse supervisors.
The facility did not ensure accurate MDS assessments for several residents, resulting in discrepancies between documented clinical events—such as falls, depression diagnoses, behavioral issues, and cognitive changes—and what was recorded in the MDS. Staff interviews confirmed that updates were not made to reflect residents' actual conditions, despite supporting documentation in medical records and care plans.
The facility did not complete required PASRR Level II evaluations for three residents who exhibited or developed signs of serious mental illness or behavioral issues. Despite documented cognitive impairment, behavioral changes, and new psychiatric symptoms, staff did not initiate updated screenings or referrals as required by policy. Staff interviews revealed a lack of understanding of when to repeat the PASRR process after changes in condition.
Surveyors found that staff did not clarify or follow physician orders for several residents, including missing medication parameters, incomplete dosage instructions, and failure to document required assessments before medication administration. Staff also signed off on tasks that were not performed, such as removing a brace from a resident who was no longer using it and documenting infection control precautions that were not in place. These deficiencies were confirmed through interviews and record reviews.
The facility did not ensure that activity programs met the individualized needs of several residents, resulting in minimal participation, lack of invitations or assistance to attend activities, and insufficient documentation of engagement or refusals. Residents who valued music, reading, socializing, and pet visits were often left without meaningful activities, leading to boredom and reduced quality of life.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, resulting in the occurrence and worsening of pressure ulcers.
Surveyors found that the facility did not keep an area free from accident hazards and failed to provide adequate supervision to prevent accidents, resulting in a deficiency.
Three residents with complex medical conditions and pain from fractures or catheter issues did not receive comprehensive pain management. Staff administered pain medications but failed to assess pain thoroughly, investigate underlying causes, or offer non-pharmacological interventions as required by facility policy. Care plans and medication records lacked documentation of alternative pain relief methods, and staff interviews confirmed these omissions.
A resident with a history of trauma, depression, and moderate memory impairment did not have a trauma-informed care plan developed, despite documented assessments and recommendations. The care plan failed to address the resident's trauma history, identify triggers, or include prevention strategies, and staff confirmed that trauma-informed interventions were not initiated as expected.
Surveyors found that medications were not properly labeled, stored, or secured in the facility. Expired and undated medications were observed in medication rooms and carts, and a resident had unsecured prescription eye drops at their bedside. Staff confirmed these practices did not follow facility policy for medication labeling, expiration, and security.
A resident with significant dental issues, including broken and decayed teeth and mouth pain, did not receive timely dental services despite a care plan and physician order for a dental consult. Although a referral for dental evaluation and extractions was made, there was no documentation that the referral was sent or that an appointment was scheduled, resulting in a prolonged lack of follow-up.
Surveyors found that food items in both the skilled nursing and main kitchens were not properly labeled with expiration or open dates, and some were past their expiration date. Several staff members with facial hair were observed preparing food without required beard nets. Staff interviews confirmed these practices were not in line with facility policy, which mandates proper labeling and use of hair restraints to prevent contamination.
Nurses failed to sign the MAR for a resident's scheduled thyroid medication on two occasions, resulting in incomplete documentation. Additionally, hospice provider notes were not added in a timely manner for two residents receiving hospice care, with the last available notes being over three weeks old despite ongoing visits. Staff confirmed the expectation for timely and complete recordkeeping.
Staff did not consistently use required PPE or perform proper hand hygiene for residents on Enhanced Barrier Precautions and Transmission Based Precautions, including those with feeding tubes, indwelling catheters, and C. difficile infection. Staff entered rooms without donning gowns and gloves, failed to wash hands with soap and water as directed, and did not change gloves between care tasks. Additionally, a resident used a wheelchair with uncleanable, damaged surfaces, further compromising infection control.
The facility did not ensure that contact information for State regulatory and advocacy groups was accessible to residents, as observed during a Resident Council meeting. Despite being included in the admission packet, residents were unaware of where to find this information. Observations on two nursing units confirmed the absence of posted contact details, which staff attributed to oversight during a remodel. The DON acknowledged the requirement for visible posting of this information.
The facility failed to document and communicate necessary resident information to receiving healthcare institutions during transfers for three residents. This deficiency was identified through interviews and record reviews, revealing that required information was not provided during hospital transfers. Staff members, including the DON and Assistant DON, acknowledged the lack of communication and documentation in the residents' medical records.
The facility failed to provide required written transfer/discharge notifications to residents and their representatives, and did not notify the LTCO for five residents who were hospitalized. This deficiency was confirmed through interviews and record reviews, revealing a lack of documentation for these notifications.
The facility failed to provide written notice of its bed hold policy to residents or their representatives during hospital transfers, as required by their policy. This deficiency affected five residents who were hospitalized, with no documentation of bed hold discussions or offers. Staff interviews confirmed the lack of documentation and the importance of offering a bed hold as a resident right.
The facility failed to update care plans for three residents, leading to outdated or missing care instructions. A resident with a removed indwelling catheter still had outdated care instructions, another resident lacked a care plan for bowel and bladder needs despite observations of independent toileting attempts, and a third resident's care plan lacked specific instructions for catheter care. Additionally, a resident was not involved in a care conference, leaving them uninformed about their care interventions.
The facility failed to administer medications as ordered for two residents undergoing dialysis, missing doses due to the residents being out for treatment. There was no communication with the provider to adjust medication timing, as expected by staff.
The facility failed to ensure sanitary conditions in food storage and preparation. A resident's refrigerator contained spoiled food past the use-by date, and the main kitchen had unlabeled and improperly stored food items. Additionally, a Food Service Worker did not perform hand hygiene or change gloves between tasks, increasing the risk of food contamination.
The facility failed to timely investigate incidents involving two residents, one with stage three pressure ulcers and another with falls, contrary to policy requirements. Investigations were delayed beyond the five-day requirement, leaving potential risks of repeated incidents and unidentified abuse or neglect. Staff interviews confirmed the lack of timely and thorough investigations.
The facility failed to accurately complete MDS assessments for two residents, missing bilateral hand contractures in one and the use of a wander guard device in another. The MDS Coordinator confirmed these inaccuracies, which affected the residents' care plans and device use documentation.
The facility failed to provide necessary ADL assistance for two residents, leading to unmet care needs. A resident with heart failure and brain injury was left with food remnants on their face and bedding after a meal, while another resident with right-sided weakness had long fingernails growing into their palm, risking skin impairment. Staff acknowledged these oversights, highlighting the need for proper hygiene and grooming care.
A resident at risk for pressure ulcers did not receive physician-ordered off-loading boots, leading to the development and worsening of stage three pressure ulcers. Despite recommendations from the wound care team, the facility failed to implement the necessary interventions, and documentation was lacking to support any trial or failure of the boots. Staff interviews confirmed the oversight, and weekly skin assessments were delayed.
A resident with memory impairment and a history of hip fracture was inaccurately assessed for bowel and bladder needs, leading to unmet care requirements. Despite being assessed as occasionally incontinent and unable to reach the bathroom independently, the resident was observed attempting to crawl to the bathroom multiple times. Staff interviews confirmed the resident's confusion and failure to use the call light, but the assessment was not updated to reflect these needs.
The facility failed to attempt alternatives before using bed rails and did not conduct necessary assessments or obtain informed consent for three residents. One resident with a brain injury and contracted hands had side rails that were not appropriate for their condition. Another resident, capable of independent mobility, had side rails without updated evaluations. A third resident, also independent, had side rails despite a fall incident, with no recent assessment to justify their use.
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. A resident received blood pressure medication despite a heart rate below the prescribed parameter, and another resident was given incorrect eye drops. Staff acknowledged the errors, highlighting a need for better verification against physician orders.
The facility failed to provide correct meal portion sizes for therapeutic diets to two residents. One resident with unstable blood sugar levels received a full dessert portion instead of a half portion, and another resident was served mechanically soft ground meats without following portion size guidelines. Staff approximated serving sizes without proper guidance, leading to incorrect portions.
The facility failed to maintain complete and accurate records for two residents with memory impairments. Both residents had expired legal guardianship documents, yet the guardians were still listed as active in the records. This oversight was confirmed by the Social Service Director.
The facility failed to maintain proper infection control as staff did not adhere to hand hygiene protocols. A CNA provided care to a resident without changing contaminated gloves, and CNAs assisted residents with meals without washing hands after touching surfaces. The Infection Preventionist confirmed these lapses, highlighting the need for hand hygiene to prevent infection.
Failure to Obtain and Maintain Advance Directives and Guardianship Documentation
Penalty
Summary
The facility failed to obtain, maintain, or renew guardianship papers and advance directive (AD) documentation for six residents reviewed for these requirements. According to facility policy, the social services director or designee is responsible for inquiring about and obtaining ADs prior to admission, maintaining these documents in the medical record, and ensuring the care plan reflects the resident's preferences. However, for multiple residents with cognitive impairments, complex medical conditions, or on hospice care, there was no evidence in their records of the required AD or durable power of attorney (DPOA) paperwork, despite documentation or verbal reports indicating such documents existed or were in process. For example, one resident with non-Alzheimer’s dementia stated their daughter was their DPOA, but the facility did not have the paperwork on file, even though a physician's note referenced consulting the DPOA. Another resident on hospice care had a consent form indicating a POA, but no POA paperwork was found in the record. In several cases, admission or social service assessments noted that a family member was the POA or that AD documents were being provided, but there was no follow-up or documentation that these documents were ever received or maintained in the resident's file. Care plans often referenced following resident preferences, but lacked specific documentation of ADs or who to contact for health decisions. Interviews with staff revealed that while the admissions nurse or social worker was expected to obtain ADs, there was no consistent follow-up to ensure the documents were actually received and filed. Staff acknowledged that ADs were important for honoring resident preferences and for knowing who to contact in emergencies, but confirmed that the necessary paperwork was missing from the records of the affected residents. This lack of documentation was observed across multiple residents with varying degrees of cognitive impairment and medical complexity.
Failure to Provide Required Transfer Notices, Bed Hold Policies, and Discharge Planning Documentation
Penalty
Summary
The facility failed to provide required written notices and documentation to residents at the time of transfer or discharge, as well as to offer bed hold policies and notify the Long Term Care Ombudsman (LTCO) as required. In several instances, residents were transferred to hospitals without receiving signed transfer or discharge notices. For example, one resident was discharged to the hospital, but the transfer notice was not signed by either the administrator or the resident/representative, and staff could not locate a signed form. In other cases, transfer/discharge forms were signed only by facility staff, with no evidence that the resident or their representative received or acknowledged the notice. Staff interviews confirmed that the expected process was not consistently followed, and some staff were unaware of the requirements for providing these notices. The facility also failed to provide or document the offering of bed hold notices to residents or their representatives when residents were transferred to hospitals. In multiple cases, there was no evidence in the medical records that bed hold policies were discussed or offered, and staff interviews confirmed that these forms were not completed or could not be located. Additionally, one resident was transferred to an acute care hospital without being provided a notice of transfer that included appeal rights and LTCO contact information. Staff acknowledged that it was not their practice to provide such notices, indicating a lack of awareness of regulatory requirements. Discharge planning was also insufficiently documented for some residents who expressed a desire to return to the community. In these cases, initial assessments indicated discharge goals and potential barriers, but there was no ongoing documentation of pre-discharge planning or progress notes by social services. Residents reported not being informed about their discharge plans, and staff confirmed that expected documentation and communication regarding discharge planning were missing from the records.
Failure to Complete Accurate PASRR Assessments and Timely Level II Referrals
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) assessments were accurate, revised, or submitted for Level II evaluation as required for several residents with indicators of Serious Mental Illness (SMI) or related conditions. In multiple cases, residents were admitted with documented diagnoses such as depression, anxiety, and mood disorders, and were receiving psychotropic medications, yet their Level I PASRR screenings either did not identify these SMI indicators or, when identified, did not result in the required Level II referral. For example, one resident with a mood disorder and on antidepressant medication was not referred for a Level II PASRR despite the SMI indicator being present on the Level I screening. Staff interviews confirmed that these referrals should have been made but were not completed as required. Additionally, the facility did not submit new or revised PASRR Level I screenings for residents who were admitted under a 30-day hospital exemption but remained in the facility beyond the exemption period. In these cases, residents with SMI indicators, such as mood or anxiety disorders and use of psychotropic medications, were not referred for Level II PASRR evaluations after their stays extended past 30 days. Staff acknowledged that the process required a new Level I PASRR and referral for Level II evaluation in such situations, but this was not done for the affected residents. Record reviews and staff interviews consistently showed that the facility's PASRR process failed to accurately identify residents with SMI indicators and did not ensure timely referrals for Level II evaluations as required by regulation. This resulted in residents with mental health needs not being properly assessed for appropriate placement and services during their stay.
Failure to Conduct Timely Care Conferences and Update Care Plans
Penalty
Summary
The facility failed to conduct timely and comprehensive care conferences and to update care plans as required, resulting in deficiencies in person-centered care for several residents. For three residents, there was no evidence that care conferences were held quarterly or upon admission, as required by facility policy. One resident reported not having a care conference for nearly nine months, and another did not recall any care plan meeting since admission. Documentation for these residents lacked input from all relevant departments, such as therapy, dietary, and nursing, and did not address all aspects of their care needs and preferences. Additionally, the facility did not ensure that care plans were updated and revised as needed for two residents. In one case, a care plan revision following a fall did not specify the frequency of range of motion checks or neurological assessments, leaving staff without clear guidance on the resident's care requirements. Staff interviews confirmed that care conferences and care plan updates were not consistently documented or conducted according to policy, and that these processes are essential for ensuring all departments and the resident are informed and able to address concerns. The residents involved had complex medical histories, including recent admissions with conditions such as hip fractures, malnutrition, major infections, and wounds. Despite being cognitively intact and able to participate in care planning, these residents were not provided with the opportunity to engage in care conferences or have their care plans updated to reflect their current needs. Facility policy required resident and representative participation in care planning, with advanced notice and documentation, but these procedures were not followed.
Failure to Provide Person-Centered Care and Monitoring for Skin Conditions and Low Blood Pressure
Penalty
Summary
The facility failed to provide care and services in accordance with residents' goals and professional standards of practice in several areas, including the management of non-pressure skin conditions and monitoring of low blood pressure. For multiple residents, staff did not follow physician orders or facility policy regarding wound care, skin assessments, and documentation. One resident was found with a bandage on their elbow that had not been changed for nine days after the treatment order was discontinued, and staff failed to document weekly skin assessments as required. Another resident on anticoagulant therapy exhibited multiple bruises, but staff did not document or report these as adverse reactions, nor did they clarify or follow orders for skin checks and provider notification. A resident with a surgical wound did not have weekly skin assessments or wound measurements documented for nearly four weeks, despite orders and care plan directives. Another resident, who was on hospice and at risk for pressure ulcers, had a bandage on their forehead, but staff did not include this resident in weekly wound rounds or document required skin assessments, wound measurements, or refusals. The documentation in the treatment administration record was unclear, and staff could not provide evidence that assessments were completed as expected. Additionally, the facility failed to monitor and notify the provider regarding low blood pressure readings for a resident with a history of low BP and a pacemaker. The care plan lacked clear parameters for when to notify the provider, and staff did not document interventions or notifications for multiple low BP readings. Interviews with staff revealed a lack of understanding about when to notify the provider and an absence of instructions in the care plan or medication administration record. No documentation was provided to show that the provider was informed or that interventions were implemented in response to low BP readings.
Failure to Initiate and Resolve Resident Grievance Regarding Roommate Encroachment
Penalty
Summary
The facility failed to initiate, investigate, and resolve a grievance for a resident who reported ongoing issues with their roommate encroaching on their personal space and cluttering shared areas. The resident, who had neurological conditions, memory impairment, and required assistance with personal hygiene, stated that their access to the closet, sink, and bathroom was obstructed by their roommate's belongings. Despite informing nursing staff on several occasions, the resident received no follow-up or resolution, and no grievance report was completed as required by facility policy. Observations confirmed the clutter and obstruction in the room, and interviews with staff revealed a lack of awareness or action regarding the resident's complaints. Staff members, including a CNA, social services, nurse supervisor, and DON, acknowledged either being unaware of the specific grievance or failing to complete the necessary grievance documentation. The facility's policy required staff to complete a grievance form for any resident concern or complaint, forward it to appropriate departments, and provide feedback to the resident. However, in this case, the process was not followed, and the resident's concerns were not formally addressed or tracked, resulting in unresolved issues and lack of communication with the resident.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, as evidenced by the lack of monitoring for target behaviors, absence of nonpharmacological interventions, and missing consent for medication use in three out of five residents reviewed. For one resident with depression, records showed daily administration of an antidepressant without documentation of target behaviors or nonpharmacological interventions, and the care plan did not address these areas. A nurse supervisor confirmed that staff were not monitoring or implementing nonpharmacological approaches for this resident. Another resident with depression received an antidepressant daily, but staff did not document behavior monitoring as required, despite the care plan directing such monitoring. The resident expressed emotional distress during an interview, and a nurse supervisor acknowledged the absence of behavior monitoring documentation. A third resident with anxiety and depression was administered both antidepressant and antianxiety medications without behavior monitoring or documented consent for the antianxiety medication. Staff interviews confirmed the lack of required documentation and consent for these psychotropic medications.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the clinical status and care needs of five residents. For one resident, the MDS incorrectly documented multiple falls, including injury and major injury falls, when the incident reports only supported one fall and one non-fall injury. Additionally, the MDS did not accurately reflect the resident's active diagnosis of depression, despite physician documentation and ongoing antidepressant therapy. Another resident's MDS failed to include an active diagnosis of depression, even though the care plan and medication administration records indicated daily antidepressant use for depression. For a third resident, the MDS did not capture behavioral issues or cognitive changes, despite progress notes and assessments indicating confusion, hallucinations, and serious mental illness indicators. Staff interviews confirmed a lack of awareness and failure to update the MDS in response to these documented changes. Two additional residents had MDS assessments that did not reflect significant behavioral incidents or cognitive changes. One resident had documented episodes of attempted elopement, verbal and physical aggression, and medication non-compliance, none of which were captured in the MDS. Another resident with intermittent confusion, delusional thought content, and a diagnosis of moderate dementia with psychotic disturbance was not accurately represented in the MDS regarding behaviors and cognition. Staff interviews revealed that updates to the MDS were not made despite clear documentation of these issues in the residents' records.
Failure to Complete Required PASRR Level II Evaluations for Residents with Mental Health Indicators
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) Level II comprehensive evaluations were obtained for three residents who exhibited or developed indicators of serious mental illness or behavioral issues. According to facility policy, all new admissions and readmissions should be screened for mental, intellectual, or related disorders, and if a Level I PASRR indicates possible mental health needs, a referral for a Level II evaluation must be made. However, for three residents, this process was not followed as required. One resident with cognitive impairment and depression had documented behavioral issues, confusion, and hallucinations, but no Level II PASRR referral was made despite these indicators. Another resident with chronic medical conditions and a history of behavioral problems, including elopement attempts, aggression, and medication refusal, was not rescreened or referred for a Level II PASRR after significant changes in behavior. Staff interviews revealed a lack of awareness regarding the need to repeat the PASRR process following changes in condition. A third resident with impaired cognitive function and delusional thoughts, including recent psychotic disturbances, was also not rescreened or referred for a Level II PASRR after new symptoms emerged. Staff acknowledged uncertainty about the requirements for rescreening and the Level II PASRR process, and confirmed that screenings and referrals should have been completed for these residents but were not. This failure was identified through observation, interview, and record review, and was found to be inconsistent with both facility policy and regulatory requirements.
Failure to Clarify and Follow Physician Orders and Accurate Documentation
Penalty
Summary
The facility failed to ensure that physician orders were properly clarified and followed, and that staff only signed for tasks that were actually completed, as evidenced by multiple observations, interviews, and record reviews. For several residents, medication orders lacked necessary parameters or dosage information, such as pain medication orders without pain level parameters, a suppository order referencing a laxative that was not ordered, and supplement orders missing dosage amounts. Additionally, there was a failure to document required assessments, such as not recording heart rates before administering blood pressure medication, and staff confirmed that these orders required clarification. Further deficiencies included staff administering medication outside of prescribed parameters, such as giving blood pressure medication when a resident's heart rate was below the specified threshold. Staff also documented completion of tasks that were not performed, including recording the removal of a chest brace for a resident who was no longer using it and documenting contact precautions for a resident who was not on such precautions. These actions were confirmed through staff interviews and record reviews, indicating a lack of adherence to professional standards and facility policy.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to ensure that activity programs met the individualized needs and preferences of five out of seven residents reviewed for activities. According to facility policy, each resident should have an activity evaluation incorporated into their care plan, facilitating participation in preferred activities. However, multiple residents expressed that they were not invited to activities, were unaware of scheduled events, or did not receive materials or assistance to participate in their chosen activities. Documentation showed minimal or no activity participation for these residents over a 30-day period, with no refusals recorded. Specific observations and interviews revealed that residents who valued activities such as listening to music, being around animals, reading, socializing, and attending religious services were often left in their rooms without engagement. For example, one resident was observed lying in bed and stated that lying in bed all day was not fulfilling, while another resident expressed boredom and a desire for more reading materials and pet visits. Several residents were not present at group activities, and staff interviews confirmed that there was a lack of consistent invitation and assistance for residents to attend scheduled activities, especially for those dependent on staff support. Activity documentation was inconsistent, with some residents only receiving one-to-one activities on rare occasions and others having no documented participation or refusals. Staff interviews indicated that the process for inviting and assisting residents to activities relied heavily on nursing assistants, and there was a lack of clear communication and follow-through. Additionally, scheduled activities sometimes started earlier than posted, causing residents to miss out. The failure to provide meaningful and individualized activities as outlined in care plans resulted in residents experiencing boredom and a diminished quality of life.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Effective Pain Management and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to provide effective pain management consistent with professional standards of practice for three residents reviewed for pain management. Staff did not offer non-pharmacological interventions or investigate the underlying causes of pain, as required by facility policy. The policy specified that staff should conduct comprehensive pain assessments, address underlying causes, and implement both pharmacological and non-pharmacological interventions, but these steps were not followed. One resident with a neurological condition, feeding tube, and indwelling catheter experienced pain related to kidney stones and catheter issues. The care plan did not address the resident's history of kidney stones or include interventions for this pain. Despite receiving narcotic pain medication, the resident reported ongoing pain, and staff did not offer alternative interventions or promptly assess the cause, which was later found to be a kinked catheter. Staff interviews confirmed that non-pharmacological interventions were missing from the care plan and medication record, and that pain assessment was inadequate. Another resident with a right arm fracture and a third resident with a leg fracture both received pain medications, but their care plans and medication records lacked documentation of non-pharmacological interventions. Staff provided medications without specifying the type or location of pain and did not document or offer alternative pain relief methods. Staff interviews confirmed that non-pharmacological interventions were not included or documented, and that pain assessments and care plans were incomplete.
Failure to Develop Trauma-Informed Care Plan for Resident with Trauma History
Penalty
Summary
The facility failed to identify triggers and develop a care plan with goals and interventions for a resident with a history of trauma. Despite documentation in a trauma-informed screening form that the resident had experienced abuse in the past and could experience mood swings, confusion, disorientation, and depression, the resident's comprehensive care plan did not include trauma-informed care planning, did not address the resident's trauma history, and did not identify any triggers or prevention strategies. Recommendations for trauma-informed care planning and specific interventions were documented in a spiritual care progress note, but these were not incorporated into the resident's care plan. Interviews with staff confirmed that the expectation was to develop individualized care plans with triggers and interventions for residents with a history of trauma, but this was not done for the resident in question. The resident had a diagnosis of depression and moderate memory impairment, and had reported an incident of being punched by staff, which was documented and discussed with the family. However, the lack of a trauma-informed care plan persisted despite these assessments and recommendations.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and labeling of medications in multiple areas, including the Cascade Hall medication storage room, two medication carts, and at a resident's bedside. In the Cascade Hall medication room, an open bottle of tuberculosis testing solution was found with an open date exceeding the 28-day discard policy, and another vial lacked an open date entirely. On the Cascade Hall medication cart, an injectable medication and a blood sugar control solution were both found to be expired based on their open dates and manufacturer instructions. Similarly, on the Shoreline Hall medication cart, an injectable medication was found to be kept beyond the 28-day discard period. Staff interviews confirmed that these medications should have been discarded according to facility policy and manufacturer guidelines. Additionally, a resident was found to have two prescription eye drop medications unsecured at their bedside on two separate observations. Staff confirmed that these medications should not have been left unsecured in the resident's room. The facility's policy requires all medications to be labeled with expiration dates and stored securely, with multi-dose vials dated and discarded within 28 days of opening. These observations and staff confirmations demonstrate that the facility did not adhere to its own medication labeling and storage policies.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure prompt dental services were provided for one resident who was assessed with obvious or likely tooth decay, broken teeth, and mouth or facial pain and discomfort or difficulty with chewing. Upon admission, the resident was noted to have clear speech and the ability to communicate needs. The resident reported ongoing dental discomfort, including cracked teeth down to the gum, a tooth with a hole, and the need to pick food out of the tooth after eating. Observations confirmed the presence of broken upper and lower teeth. The resident's care plan directed staff to coordinate dental care and transportation as needed. A physician order was in place for a dental consult, and the facility's visiting dentist evaluated the resident, recommending x-rays, evaluation, and extraction of all upper teeth due to several broken and decayed teeth, including an abscess. A referral request form was completed for these services, but there was no documentation indicating where the referral was sent. The staff member responsible for scheduling appointments could not find a fax confirmation or a scheduled dental appointment for the resident. Review of records confirmed that, for nearly seven months after the referral request, there was no evidence that the dental appointment was scheduled or that follow-up occurred.
Failure to Properly Store, Label, and Handle Food in Facility Kitchens
Penalty
Summary
Surveyors observed that the facility failed to properly store and label food items in both the skilled nursing and main kitchens. Opened boxes of snacks such as nacho chips, cheese crackers, and popcorn packages were found without expiration dates, and unopened frozen orange juice cartons in the walk-in freezer were also missing expiration labels. In the main kitchen, several items including tubs of bacon jam, cream cheese, uncooked eggs, corn tortillas, and an opened package of ham lunch meat were either not labeled with open or expiration dates or were past their labeled expiration date. Additional items in the walk-in freezer and small refrigerator, such as frozen french fries, bagels, chicken quarters, chopped lemons, and butter packets, were also not properly labeled or covered. Mayonnaise packets in dry storage lacked expiration dates as well. Interviews with staff confirmed that facility policy required all food to be labeled with either the manufacturer's expiration date or the date of receipt, and that this was not being consistently followed. Additionally, three kitchen staff members with facial beards were observed preparing food without wearing beard nets, contrary to facility policy requiring facial hair to be restrained to prevent contamination. The Director of Nutrition Systems acknowledged these lapses, stating that all food should be labeled and staff with facial hair should wear appropriate coverings when in the kitchen.
Incomplete Documentation of Care and Delayed Hospice Notes
Penalty
Summary
The facility failed to ensure timely and complete documentation of care and provider notes for multiple residents. For one resident with multiple complex medical conditions, nurses did not sign the Medication Administration Record (MAR) to indicate administration of a scheduled thyroid medication on two separate days, leaving the documentation incomplete. Staff confirmed that MARs should not be left blank and emphasized the importance of maintaining accurate and complete records. Additionally, for two residents receiving hospice care, the facility did not ensure that hospice provider notes were added to the residents' records in a timely manner. In both cases, the last hospice note available was from over three weeks prior, with no documentation of subsequent hospice visits. Staff interviews confirmed that hospice visits occurred more frequently and that it was expected for these notes to be promptly available in the residents' records to ensure accessibility for care staff and providers.
Failure to Follow Infection Control Protocols and PPE Use
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols for multiple residents requiring Enhanced Barrier Precautions (EBP), Transmission Based Precautions (TBP), and standard hand hygiene practices. For two residents with feeding tubes and immune deficiencies, staff did not consistently use required personal protective equipment (PPE) such as gowns, gloves, and masks during personal care. Staff were observed not changing gloves or performing hand hygiene between care tasks, and in some cases, did not wear masks or sanitize hands after removing PPE and before leaving the resident’s room. For a resident on contact enteric precautions due to a C. difficile infection, staff from various departments, including housekeeping and therapy, entered the room without donning gowns and gloves as required. Staff also failed to wash hands with soap and water upon exiting the room, instead using only hand sanitizer, contrary to posted instructions. Staff were observed moving between rooms and handling items for other residents without performing appropriate hand hygiene after contact with the resident on TBP. During wound care for another resident, a nurse supervisor did not change gloves or perform hand hygiene between removing soiled dressings and applying clean ones, and touched multiple surfaces and other residents’ rooms before sanitizing hands. Additionally, a resident was observed using a wheelchair with cracked and peeling armrests, which staff acknowledged could not be properly cleaned, increasing the risk of infection transmission.
Failure to Post Contact Information for Advocacy Groups
Penalty
Summary
The facility failed to ensure that contact information for all pertinent State regulatory and informational agencies and advocacy groups was provided and/or posted in areas accessible to residents in a format and language they understood. This deficiency was identified for eight residents during a Resident Council meeting. The facility's admission packet did include a Supplement to Health Facility Admission Agreement outlining resident rights and contact information for State and local advocacy organizations, including the State Survey Agency and the State Long-Term Care Ombudsman (LTCO) program. However, during the Resident Council meeting, attendees stated they did not know the State and/or LTCO contact number or where to find the contact information. Observations and interviews conducted on the 2nd and 3rd floor nursing units revealed that the State and/or LTCO contact information was not posted or accessible to residents. Staff members responsible for oversight and administrative assistance on these units confirmed the absence of the contact information. Staff V mentioned that the sign might have been removed during a remodel and was not reposted. The Director of Nursing acknowledged that the contact information should be posted and visible to residents as it is a resident right, but it was not.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to document and communicate necessary resident information to the receiving healthcare institution during transfers or discharges for three of the five sampled residents. This deficiency was identified through interviews and record reviews. For Resident 56, there was no documentation of necessary information being provided to the hospital during a transfer on January 18, 2024. The Director of Nursing admitted to not knowing the requirement to report resident information to the receiving hospital. Similarly, Resident 2 was transferred to the hospital on two occasions, September 7, 2023, and November 24, 2023, without the necessary documentation being provided to the hospital. The Resident Care Manager confirmed the absence of documentation for these transfers. Additionally, Resident 51 was sent to the hospital due to low blood pressure on August 10, 2023, but there was no documentation of communication to the hospital regarding the resident's health status and information. The Assistant Director of Nursing acknowledged the lack of communication in the resident's medical records.
Failure to Provide Required Transfer/Discharge Notifications
Penalty
Summary
The facility failed to ensure that residents received the required written notices at the time of transfer or discharge, and also failed to notify the Office of the State Long Term Care Ombudsman (LTCO) of these events. This deficiency was identified for five residents who were hospitalized. The facility's policy required that residents or their representatives be given a notice of transfer as soon as practicable, and that all resident transfers be reported to the LTCO monthly. However, the facility did not adhere to this policy, as evidenced by the lack of documentation for the required notifications. Resident 54 was transferred to the hospital from a dialysis center due to a change in condition, but neither the resident nor their representative received a written notification of the transfer. Similarly, Resident 28, who had end-stage kidney failure, was hospitalized due to increased confusion, yet there was no documentation of a written transfer notice or LTCO notification. Resident 51, with heart and kidney failure, was sent to the hospital for low blood pressure, but again, no written notice or LTCO notification was documented. The same issue was observed with Resident 56, who was transferred to the hospital emergently, and Resident 2, who was transferred twice without the required notifications. Interviews with facility staff, including the Resident Care Manager, Social Services, and Medical Records, confirmed the absence of documentation for these notifications. Staff acknowledged the need for education on providing written transfer/discharge notices and notifying the LTCO, but no corrective actions were mentioned in the report.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to residents or their representatives at the time of transfer to a hospital or within 24 hours, as required by their policy. This deficiency was identified for five residents who were reviewed for hospitalization. The facility's policy, revised in October 2022, mandates that residents receive a copy of the bed hold paperwork, including reserve bed payment information and agreement, during emergent transfers or within 24 hours. However, the facility did not adhere to this policy for any of the five residents reviewed. For Resident 54, there was no documentation of a bed hold discussion or offer during their transfer to the hospital for further evaluation after a dialysis session. Similarly, Resident 28, who was hospitalized after returning from dialysis confused and disoriented, did not have documentation of a bed hold offer. Resident 51, hospitalized due to low blood pressure, also lacked such documentation. Resident 56 and Resident 2, both discharged to the hospital on separate occasions, did not receive the required bed hold policy or agreement documentation within the stipulated time frame. Interviews with staff confirmed the absence of documentation and acknowledged the importance of offering a bed hold as a resident right.
Care Plan Deficiencies and Lack of Resident Involvement
Penalty
Summary
The facility failed to update and revise care plans for three residents, leading to deficiencies in care. Resident 20, who was admitted with a breathing problem and had an indwelling catheter (IC), had their IC removed in April 2024, but the care plan was not updated to reflect this change. Observations and interviews confirmed the absence of the IC, yet the care plan still directed staff to use protective gear for IC care, indicating a lack of timely updates. Resident 54, with impaired memory and chronic kidney failure requiring dialysis, was observed attempting to manage their toileting needs independently, including crawling on the floor. Despite these observations, there was no care plan addressing their bowel and bladder needs. Additionally, the dialysis care plan was outdated, lacking necessary communication sheets, which staff confirmed were not available, highlighting inaccuracies in the care plan. Resident 18, who had an IC due to urinary issues, had a care plan that acknowledged the presence of the IC but lacked specific care instructions for staff. This omission was confirmed by the Assistant Director of Nursing, who acknowledged the need for detailed interventions. Furthermore, Resident 40 was not provided an opportunity for a care conference, as there was no documentation of such an event, leaving them uninformed about their care plan interventions.
Failure to Administer Dialysis Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered and did not communicate with the provider to adjust medication timing for residents undergoing dialysis. Resident 28, who has end-stage kidney failure, was hospitalized due to increased confusion related to kidney disease. The resident had physician orders for a bowel medication and a phosphate binder, both to be taken three times daily. However, on two occasions, the 12:00 PM doses were missed because the resident was out of the facility for dialysis. There was no documentation indicating that staff communicated with the provider to adjust the medication schedule on dialysis days. Similarly, Resident 54, who has chronic kidney failure and receives dialysis treatment, had a physician order for a phosphate binder to be administered with meals three times daily. The 5:00 PM doses were missed on multiple occasions when the resident was out for dialysis. Again, there was no documentation of communication with the provider to adjust the medication timing. Staff interviews revealed an expectation for staff to notify the provider of missed medications, which was not done.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and preparation, as observed in the kitchen and resident areas. In the Cascadia Neighborhood, a resident's refrigerator contained food brought from outside that was not consumed within the facility's policy of three days, leading to spoiled items like wilted carrots and mushed berries. The Dietary Manager confirmed that the food was past the use-by date and should have been discarded. Additionally, in the main kitchen, several food items were found unlabeled, undated, and improperly stored, including uncovered biscuits, open bags of peas, tater tots, burger patties, pie crusts, and sausages with freezer burn. The Dietary Manager acknowledged that these items should have been labeled and dated according to the facility's policy. Unsanitary food preparation practices were also noted, with a Food Service Worker failing to perform hand hygiene or change gloves between handling different food items and surfaces. The worker used the same gloves to handle baked chicken, frozen hotdogs, and various kitchen equipment, and even checked their cellphone without changing gloves. The Dietary Manager stated that staff are expected to wash hands and change gloves between clean and dirty areas to prevent food contamination. These lapses in hygiene and food safety practices contributed to an unsanitary environment, increasing the risk of food-borne illness among residents.
Failure to Timely Investigate Pressure Ulcers and Falls
Penalty
Summary
The facility failed to initiate and thoroughly investigate incidents in a timely manner for two residents, leading to potential risks of repeated incidents and unidentified abuse or neglect. Resident 40, who had a brain injury, heart failure, and malnutrition, developed two stage three pressure ulcers (PUs) while in the facility. Despite the facility's policy requiring investigations to be completed within five days, the investigation into Resident 40's PUs was not completed until a month later, and the root cause was not identified. Interviews with staff confirmed that the investigation was neither thorough nor timely. Resident 54, admitted for a fall with a hip fracture and assessed to have memory impairment, experienced two falls in their room while attempting to go to the bathroom unassisted. The facility's investigation into these falls was completed 12 days after the incidents, contrary to the policy of completing investigations within five days. Staff interviews revealed that the investigations were not completed on time, and the importance of timely investigations to rule out abuse and neglect was acknowledged but not adhered to.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments for two residents were completed accurately, reflecting their true health status and conditions. Resident 40's MDS did not identify bilateral hand contractures, which limited their functional range of motion. This oversight was confirmed by the MDS Coordinator, who acknowledged the inaccuracy and the importance of accurate MDS assessments for updating care plans. Observations showed Resident 40 had contracted hands, requiring assistance with personal care and the use of a soft splint to prevent further contractures. Resident 7's MDS failed to capture the use of a wander guard device, despite the resident wearing it daily. Interviews with staff revealed a lack of awareness about the device's presence and its necessity, as the resident did not exhibit wandering behaviors for months. The Charge Nurse and Social Services staff confirmed the resident's improved behavior, and the Assistant Director of Nursing stated the appropriateness of the device was evaluated quarterly. However, there was no documentation to support the continued need for the wander guard, and the MDS Coordinator later confirmed the device should have been coded under Alarms in the MDS.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for two residents, leading to unmet care needs. Resident 18, who had medical conditions including heart failure, brain injury, and malnutrition, required substantial assistance with personal hygiene. Despite being assisted with lunch, Resident 18 was observed with food remnants on their face, chest, and bedding, indicating a lack of clean-up care post-meal. Staff D, a Resident Care Manager, acknowledged the oversight and stated that the condition was unacceptable, emphasizing the importance of maintaining the resident's dignity. Resident 40, with a history of brain injury and right-sided weakness, also required substantial assistance with personal hygiene. Observations revealed that Resident 40's fingernails were long and growing into their palm, posing a risk for skin impairment. Staff O, a Charge Nurse, confirmed the need for nail trimming to prevent potential skin breakdown and infection. The facility's failure to adhere to care plans and provide adequate grooming assistance for these residents was noted as a deficiency.
Failure to Implement Pressure Relief Interventions
Penalty
Summary
The facility failed to provide physician-ordered pressure relief interventions for a resident, identified as Resident 40, who was at risk for developing pressure ulcers (PUs) due to immobility and other medical conditions, including a brain injury resulting in right-sided weakness. Despite the wound care team's recommendation to use off-loading boots to prevent further deterioration of the resident's condition, the facility did not implement this intervention. Observations over several days confirmed that the resident's feet were not in off-loading boots, and the resident reported never having them applied. The facility's documentation did not support any trial use of the boots or reasons for their ineffectiveness. The resident developed new stage three PUs on both heels, which were not present upon admission, and the wounds increased in size over time. The facility's skin management assessments were delayed, with weekly assessments not initiated until more than two months after the PUs were discovered. Interviews with staff, including the Assistant Director of Nursing and the Director of Nursing, revealed that the nursing staff did not follow the wound care team's recommendations, and the resident's PUs were not addressed properly. The facility was unable to provide documentation to justify the lack of implementation of the recommended interventions.
Inaccurate Bowel and Bladder Assessment for a Resident
Penalty
Summary
The facility failed to accurately assess and provide appropriate care for a resident's bowel and bladder (B/B) needs, leading to a deficiency. Resident 54, who was admitted for a fall with a hip fracture and had memory impairment, was assessed as incontinent of B/B and required total assistance for toileting. However, a subsequent B/B assessment indicated the resident was occasionally incontinent and unable to get to the bathroom independently. Despite this, observations showed the resident attempting to get out of bed and crawl on the floor multiple times to reach the bathroom, indicating a discrepancy between the assessment and the resident's actual needs. Interviews with facility staff revealed that the resident was confused and did not use the call light for help, instead crawling on the floor to reach the bathroom. Staff members acknowledged that they took the resident to the bathroom when asked but failed to update the B/B assessment to reflect the resident's needs accurately. The Resident Care Manager confirmed that the assessment should have been updated once staff became aware of the resident's behavior, but this was not done, resulting in unmet care needs and a diminished quality of life for the resident.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that appropriate alternatives were attempted before installing bed side rails for residents, and did not conduct necessary assessments, evaluations, or obtain informed consent for their use. This deficiency was identified for three residents who were reviewed for accident hazards. The facility's policy required that bed side rails should only be used if specific criteria were met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. However, these steps were not followed, placing residents at risk for harm and significant injury. Resident 40, who had a brain injury resulting in right-sided weakness and contracted hands, was observed with bilateral side rails in the up position. The resident stated they could barely use their hands to grab the side rails. The medical records did not show an assistive device assessment or informed consent for the use of side rails. Staff confirmed that the quarterly side rails evaluation was not completed, and the side rails were not appropriate for the resident's condition. Resident 28, who had a brain disorder and was capable of independent bed mobility, was also observed with side rails in the up position, despite stating they did not use them. The side rail evaluation section of their quarterly nursing assessment was not updated. Similarly, Resident 51, who was independent with bed mobility, had side rails in use without a recent assessment to justify their necessity. A fall incident report indicated that Resident 51 had rolled out of bed, highlighting the potential risk posed by the side rails. Staff confirmed that the quarterly assessment regarding side rails use was not completed for Resident 51.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an observed error rate of 8% during a medication pass. This deficiency involved two residents, Resident 70 and Resident 9, and was identified through observation, interview, and record review. For Resident 70, a registered nurse, Staff BB, under the training of Staff S, administered a blood pressure medication despite the resident's heart rate being below the prescribed parameter of 60 beats per minute. The resident's heart rate was recorded at 56 beats per minute prior to administration, and Staff S acknowledged the error, stating that the medication should have been held according to the physician's order. For Resident 9, Staff CC, an LPN, prepared and administered the wrong eye drops, using a redness reliever instead of the prescribed artificial tears. Staff CC admitted to not verifying the medication against the physician's order, which was a repeated error. The Director of Nursing, Staff B, confirmed that staff are expected to verify all aspects of medication administration, including the resident's name, medication name, form, dosage, route, and timing, against the physician's orders to ensure accuracy.
Failure to Provide Correct Meal Portions for Therapeutic Diets
Penalty
Summary
The facility failed to ensure that residents were provided with the correct meal portion sizes as part of their prescribed therapeutic diets. This deficiency was observed in the cases of two residents. Resident 7, who had unstable blood sugar levels and was on a low concentration sweets, small portions diet, was served a full portion of dessert pie instead of the prescribed half portion. This occurred despite clear instructions on the meal ticket for dietary staff to provide half portions of desserts or fresh fruits. Staff W, responsible for preparing the meal, incorrectly provided a full slice of pie, believing it to be a smaller cut piece. Staff L, a corporate dietary personnel, confirmed that the portion served was incorrect. Similarly, Resident 1, who had a diet order for small portions of mechanically soft ground meats, was served without adherence to portion size guidelines. Staff W prepared the resident's lunch tray by approximating the amount of ground meat without measuring or following any guide for small portion sizes. The Menu/Diet Spread Sheet Report available to Staff W did not include portion size guidelines for mechanically altered meats, leading to the incorrect serving size. Staff L emphasized the importance of serving residents their therapeutic diets in the correct portion sizes to meet their nutritional and dietary needs.
Incomplete and Inaccurate Resident Records
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible resident records for two residents, which is a violation of accepted professional standards. For Resident 1, the records indicated that Abacus Guardianship Incorporated was listed as the financial power of attorney, but the legal guardianship documents had expired. Despite this expiration, Abacus was still listed as an active legal guardian, which was incorrect. Resident 1 had memory impairment, as noted in their Annual Minimum Data Set (MDS) assessment. Similarly, Resident 21's records showed an agent/attorney listed as responsible for healthcare and financial power of attorney, but the legal guardianship documents had also expired. Despite the expiration, the agent/attorney was still listed as the resident's legal guardian. Resident 21 had severe memory impairment, as indicated in their MDS assessment. The Social Service Director confirmed that the guardianship documents for both residents were expired and should not have been listed as active.
Inadequate Hand Hygiene Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to proper hand hygiene protocols. During an observation, a CNA provided peri care to a resident and assisted with wound dressing without changing contaminated gloves, subsequently touching clean areas and items in the resident's environment. The CNA admitted to forgetting to change gloves, and the LPN present confirmed the lapse in protocol. The Infection Preventionist also acknowledged that the CNA should have changed gloves after providing peri care. In another instance, CNAs were observed assisting residents with meals without performing hand hygiene after passing meal trays and touching various surfaces. One CNA assisted a resident with their meal without washing hands, while another CNA assisted two residents simultaneously, touching one resident's hands and then feeding the other without hand hygiene. The Infection Preventionist emphasized the importance of hand hygiene before dining assistance to prevent infection and expected CNAs to assist residents one at a time to avoid cross-contamination.
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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