Kin On Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Seattle, Washington.
- Location
- 4416 South Brandon Street, Seattle, Washington 98118
- CMS Provider Number
- 505453
- Inspections on file
- 23
- Latest survey
- August 11, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Kin On Health Care Center during CMS and state inspections, most recent first.
A resident with dementia, mobility issues, and osteoporosis was transferred by staff without the use of a gait belt, contrary to the care plan and facility policy. During the transfer, the resident experienced pain and was later diagnosed with a fractured clavicle. Staff interviews confirmed the gait belt was not used due to the urgency of the situation, and leadership acknowledged the expectation to follow care plans.
Two residents with cognitive impairment were exposed to dangerously hot water due to staff providing water from an auxiliary spout in the nurse's lounge, with temperatures far exceeding the safe limit. One resident suffered second-degree burns after spilling the hot water, while another was observed accessing the hot water unsupervised. Staff were unaware of the required safety protocols and did not monitor water temperatures, leading to serious injury and risk.
The facility did not thoroughly investigate or document several incidents involving injuries of unknown source and abuse allegations. In multiple cases, residents were found with unexplained injuries such as fractures and bruising, but investigations lacked required interviews and did not include conclusions ruling out abuse. Staff confirmed that investigative procedures and documentation were incomplete or missing.
The facility did not ensure that the attending physician reviewed residents' care and completed timely progress notes for all residents seen. The Medical Director failed to document or upload progress notes in the electronic health record for several weeks, despite expectations from staff that such documentation should be completed promptly after each visit. This resulted in a lack of timely and complete physician oversight for all residents reviewed.
A resident was found with large bruises on the chest and torso, and was unable to explain the cause of the injuries. The incident was documented by nursing staff and logged internally, but was not reported to the state agency as required by policy and regulation. Both the DON and Administrator confirmed the event should have been reported.
Facility staff failed to maintain resident dignity by not knocking or introducing themselves before entering rooms. An LPN was observed entering multiple rooms without following protocol, contrary to the facility's policy on resident rights. Interviews with staff confirmed the expectation to knock and introduce themselves, highlighting a lapse in maintaining residents' personal space and dignity.
The facility did not include recertification and complaint survey results in the survey result binder for two of the three years reviewed, and failed to post notices of survey report availability in prominent areas. The Administrator acknowledged the missing documents and lack of postings.
The facility failed to develop and implement comprehensive care plans for the use of bed rails for seven residents, despite physician orders and observations of their use. Staff interviews confirmed the absence of care plans, placing residents at risk for unmet care needs.
The facility failed to update care plans for four residents, including one with dementia and another with dental issues. Two residents had discharge goals not reflected in their care plans. Staff interviews confirmed the need for revisions.
The facility failed to assess the risks and benefits of bed rail use for several residents, contrary to its policy. Observations showed residents with bed rails in use without documented assessments, placing them at risk. Staff interviews confirmed the absence of assessments and a lack of adherence to policy requirements.
The facility did not accurately complete the daily nurse staffing form with actual hours worked after the start of each shift for several days. Despite policy requirements, the forms were not updated until the end of shifts, leaving residents uninformed about current staffing levels. Interviews revealed that the Personnel Coordinator and DON were responsible for updates, but the process was not followed as required.
The facility failed to ensure proper medication management for four residents, leading to potential medication errors. A resident received methotrexate without clarifying a physician's order, another's medication was not documented, and two residents were not properly identified before medication administration. Staff acknowledged these oversights, which were against the facility's policies.
The facility failed to monitor and document refrigerator temperatures for vaccine storage in the Station 2 Medication Room, with multiple missing checks over several months. Additionally, expired medical supplies were found in the Station 2 Clean Utility Room, which should have been discarded. Staff acknowledged these oversights, which were against facility policy and CDC guidelines.
The facility failed to maintain the correct concentration of sanitizing solution for food preparation surfaces, as observed during a survey. The solution was found below the required 50 ppm, and there was no log to track changes or tests. Staff confirmed the deficiency, acknowledging the absence of a log and the need to follow policy, placing residents at risk for foodborne illnesses.
The facility failed to report an influenza outbreak and did not adhere to proper infection control practices. Multiple residents tested positive for Influenza A, but the outbreak was not reported as required. Staff failed to perform hand hygiene during resident care and did not use barriers during medication administration. Additionally, staff did not follow proper PPE protocols for residents on droplet/contact isolation, increasing the risk of infection spread.
A resident reported a missing lower denture, but the facility failed to log or investigate the grievance, contrary to its policy. The resident, who was cognitively intact, did not receive a resolution, and the Social Services Director acknowledged the oversight. The Administrator confirmed that grievances should be resolved within five days, highlighting a lapse in the grievance process.
The facility failed to investigate injuries of unknown source and falls for two residents, leading to a deficiency in incident management. A resident with cognitive impairment had a bruise on their forehead that was not logged or investigated, while another resident experienced a fall outside the facility that was not documented or investigated. The facility's policy required all incidents to be logged and investigated, but this was not followed in these cases.
A facility failed to accurately assess two residents' conditions in their MDS assessments. One resident's broken denture was not documented, despite observations and a dental consult note indicating the issue. Another resident's GDR attempt for antipsychotic medication was not recorded, and the date of clinically contraindicated GDR was inaccurately documented. Staff acknowledged these errors, highlighting a gap in the facility's assessment process.
A resident with depression was admitted to the facility without a correct PASARR form, which failed to indicate the need for a Level II evaluation. The social worker and Social Services Director acknowledged the oversight, and the facility administrator expected accurate PASARR completion.
A LTC facility failed to provide adequate supervision for a resident with a history of stroke during meals, despite care plans and physician orders requiring 1 to 1 supervision for aspiration precautions. Additionally, the facility did not ensure bed rails were properly secured for another resident, as the enabler was found to be loose and not initially reported to maintenance. These deficiencies posed risks for accidents and injuries.
A facility failed to ensure monthly pharmacy recommendations were followed for a resident, leading to a lapse in addressing a psychotropic dose reduction. The DON acknowledged the oversight, noting that the process of reviewing and signing recommendations did not always occur as expected, resulting in the deficiency.
A resident with intact cognition reported financial exploitation by a family member, with over three thousand dollars missing from their account and an ATM card unaccounted for. Despite reports to Adult Protective Services, the police, and the facility, no investigation was conducted, violating facility policy and guidelines.
A resident with severe cognitive impairment exhibited increased urinary frequency and had multiple positive urine analyses indicating a UTI. Despite these findings, the UTI was not treated promptly, and the physician did not document the rationale for this decision. The facility's policy on antibiotic stewardship was not followed, and staff interviews revealed that the resident's symptoms met the criteria for a UTI, which should have been treated.
The facility failed to investigate bruises of unknown origin for four residents, contrary to its policy requiring immediate investigation of such incidents. Despite observations and staff acknowledgment of the bruises, no incident reports or investigations were initiated, leaving the residents at risk for unidentified abuse.
Failure to Use Gait Belt During Transfer Results in Resident Injury
Penalty
Summary
Staff failed to follow the established plan of care and facility policy requiring the use of a gait belt during transfers for a resident with dementia, difficulty walking, and osteoporosis. The resident's care plan specifically indicated the use of a gait belt when additional assistance was needed due to weakness. On the night of the incident, staff attempted to assist the resident, who was found attempting to transfer themselves, and subsequently became too weak to bear weight. Staff members transferred the resident from the floor to a wheelchair and then to bed without using a gait belt, despite facility policy and care plan directives. During the transfer, the resident experienced pain and later was found to have sustained a left clavicle fracture, as confirmed by hospital records. Staff interviews revealed that the gait belt was not used because they felt the situation required immediate action, and they did not retrieve the device. The Director of Nursing and Administrator both stated that staff were expected to follow the care plan and use the gait belt as required. The failure to use the gait belt during the transfer directly resulted in harm to the resident.
Unsafe Hot Water Access and Inadequate Supervision Result in Resident Injury
Penalty
Summary
The facility failed to ensure safe water temperatures and adequate supervision to prevent accidents, resulting in serious harm to two residents. One resident, who had hemiplegia and cognitive impairment, was provided with hot water directly from a nurse's lounge auxiliary spout, which was measured at temperatures significantly above the safe limit of 120°F. The resident attempted to drink the water, spilled it on themselves, and sustained second-degree burns to the neck, chest, and abdomen. Staff interviews revealed that the hot water was routinely provided to this resident without checking or mixing the temperature, and staff were unaware of the actual temperature or the policy requirements. Another resident, with Alzheimer's disease and cognitive impairment, was observed entering the nurse's lounge unsupervised and accessing the same hot water auxiliary spout. This resident filled a metal container with hot water and resisted staff attempts to intervene, leaving the lounge with the hot water. Staff acknowledged that this resident had a history of entering nourishment areas to obtain hot water or use the microwave, often without supervision, and that residents were not permitted in the nurse's lounge. However, staff did not consistently prevent access or monitor the water temperature. Record reviews and staff interviews confirmed that the facility's policy required hot liquids to be served at safe temperatures, with water provided by dietary staff and not exceeding 120°F. Despite this, staff frequently used the nurse's lounge hot water spout, did not log or check temperatures, and were unaware of the risks. The lack of supervision and failure to adhere to safety protocols directly led to one resident's injury and placed another at risk of harm.
Removal Plan
- Remove the hot water auxiliary spout in the nurse's lounge
- Lock door to the nurse's lounge and require key access to nourishment rooms
- Provide training to staff
- Complete hot liquids evaluations for all residents
- Revise hot liquids safety policy
Failure to Thoroughly Investigate Injuries of Unknown Source and Abuse Allegations
Penalty
Summary
The facility failed to ensure that injuries of unknown source and abuse allegations were thoroughly investigated for four out of five residents reviewed. According to the facility's own policy and state guidelines, all substantial injuries of unknown source, as well as all alleged incidents of abuse, neglect, or mistreatment, must be thoroughly investigated and documented. However, the records showed that investigations were either incomplete, lacked documentation, or did not include required interviews and conclusions to rule out abuse. For one resident, an allegation of rough treatment by staff was reported, but there was no initial written documentation of an investigation, and the investigation report was only completed after surveyor inquiry. Another resident was found with a fractured ankle of unknown origin, but the investigation did not include interviews with other residents or a documented conclusion ruling out abuse. A third resident was discovered with significant bruising on the torso, but the investigation lacked staff and resident interviews and did not document a conclusion. The fourth resident, who had cognitive deficits, was found with a dislocated shoulder and fractured arm, but again, the investigation did not include interviews or a documented conclusion regarding abuse. Staff interviews confirmed that the required investigative steps, such as interviewing witnesses or other residents and documenting conclusions, were not consistently followed. In several cases, staff acknowledged that investigations were incomplete or that documentation was missing. The lack of thorough investigations and documentation for injuries of unknown source and abuse allegations was observed across multiple incidents and residents.
Failure to Ensure Timely Physician Progress Notes and Care Review
Penalty
Summary
The facility failed to ensure that the attending physician reviewed the total program of care, including treatments and medications, and completed timely progress notes for all 38 residents reviewed. The Medical Director, who was responsible for seeing approximately 40 residents, did not document or upload progress notes in the electronic health record for any of the residents he visited over a period of several weeks. Staff interviews confirmed that while other providers uploaded their notes within 24 to 48 hours, the Medical Director did not follow this practice, and no progress notes from him were available in the system for the specified timeframe. Staff members, including the CEO, DON, and medical records personnel, all stated that they expected timely documentation of resident visits and care, but acknowledged that this was not occurring for the Medical Director’s visits. The Medical Director stated that his process was to provide handwritten documentation after seeing residents and to upload progress notes every four to six weeks, but also indicated that it was not possible to include a full review of the care program, medications, and treatments in his handwritten notes. The lack of timely and complete documentation was confirmed by multiple staff members and through joint record reviews, which showed no progress notes had been uploaded by the Medical Director during the review period. This deficiency was reported to the state agency due to concerns about the Medical Director’s fulfillment of his medical duties.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report a significant injury of unknown origin for one resident, as required by both state regulations and the facility's own policies. A Certified Nursing Assistant notified a Registered Nurse that the resident had bruising on the upper torso. The RN documented a large green-yellow bruise on the chest between the breasts and another purple bruise on the left side of the torso next to the left breast. The resident was unable to explain how the injuries occurred and exhibited discomfort and pain during movement and touch. According to the facility's policy and state guidelines, such injuries—especially those in areas not generally vulnerable to trauma—must be reported to the state agency. Despite logging the incident in the facility's March incident log, the event was not reported to the state agency. Both the Interim Director of Nursing and the Interim Administrator acknowledged during interviews that the incident met the criteria for mandatory reporting and should have been reported according to the guidelines outlined in the Purple Book and facility policy. The failure to report the injury constituted a deficiency in the facility's abuse, neglect, and injury reporting procedures.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility staff failed to uphold the residents' rights to dignity and respect by not knocking or introducing themselves before entering resident rooms. This deficiency was observed in four out of eleven rooms reviewed for dignity. Specifically, Staff R, an LPN, was seen entering rooms multiple times without knocking or identifying themselves to the residents. These actions were contrary to the facility's policy on resident rights, which emphasizes treating residents with respect and dignity. Interviews with facility staff, including Staff R, the Resident Care Manager, the Director of Nursing, and the Administrator, confirmed the expectation that staff should knock and introduce themselves before entering a resident's room. Staff R acknowledged the failure to do so, citing that some residents were sleeping, but admitted that they should have followed the proper protocol. The Resident Care Manager and other senior staff reiterated that a resident's room is considered their personal private space, and staff are expected to respect this by knocking and introducing themselves.
Failure to Maintain and Display Survey Results
Penalty
Summary
The facility failed to ensure that the survey result binder included the recertification and complaint survey results that resulted in citations for two of the three years reviewed (2022 and 2024). This omission was identified during a review of the State Survey/Inspection Report binder, which did not contain the necessary recertification and complaint surveys and associated plans of corrections dated 09/28/2022, 08/01/2024, and 12/23/2024. Staff A, the Administrator responsible for maintaining the binder, acknowledged the absence of these documents and confirmed that they should have been included. Additionally, the facility did not post notices of the availability of survey reports in prominent and accessible areas, such as the facility entrance, lobby, hallway by the main dining room, and bulletin board by the Social Services office. During an observation, it was noted that there was no posting of the availability of state survey results in these areas. Staff A initially claimed that such postings were present but later admitted that they were not, acknowledging that they should have been displayed.
Failure to Implement Care Plans for Bed Rail Use
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for the use of bed rails for seven residents. These residents included those with cognitive impairments and those who relied on bed rails for repositioning and transfers. Despite having physician orders for bed rails, the care plans for these residents did not reflect the use of these devices, which is a requirement according to the facility's policy. Observations and interviews revealed that residents were using bed rails for assistance, yet their care plans did not document this usage. For instance, Resident 43 and Resident 78 were observed using side rails for repositioning and transfers, but their care plans lacked documentation of this need. Staff interviews confirmed the absence of care plans for bed rail use, despite audits being conducted to address this issue. The Director of Nursing and other staff members acknowledged the expectation that care plans should include the use of bed rails. However, the care plans for residents such as Resident 1, Resident 9, Resident 80, Resident 3, and Resident 85 did not include this information, even though these residents had orders for bed rails and were observed using them. This oversight placed residents at risk for unmet care needs and diminished quality of life.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise comprehensive care plans for four residents, which placed them at risk for unmet care needs and diminished quality of life. Resident 76, who was diagnosed with dementia, did not have their care plan updated to reflect this diagnosis. Instead, the care plan addressed an altered thought process related to encephalopathy, which was classified as a historical diagnosis. Staff interviews confirmed that the care plan should have been revised to address the resident's dementia. Resident 1 had a broken upper denture and a missing lower denture, yet their dental care plan had not been updated since 2021 to reflect these changes. Observations showed the resident wearing the broken denture, and staff interviews confirmed that the care plan should have been revised to address the resident's current dental status. Residents 492 and 58 had discharge goals that were not reflected in their care plans. Resident 492's care plan did not include their goal to return home after rehabilitation, despite this being determined in IDT meetings. Similarly, Resident 58's care plan did not reflect their or their representative's goal for discharge to the community. Staff interviews confirmed that these discharge goals should have been included in the residents' care plans.
Failure to Assess Bed Rail Use Risks
Penalty
Summary
The facility failed to comprehensively assess residents for the use of bed rails, which is a critical safety measure. The report highlights that for 7 out of 8 residents reviewed, there was no documented assessment of the risks and benefits associated with bed rail use. This lack of assessment is contrary to the facility's policy, which mandates a person-centered approach and a thorough evaluation of alternatives before bed rails are used. The absence of these assessments placed residents at risk for potential injury and unmet care needs. For Resident 1, who was cognitively intact, observations showed bed rails attached to both sides of the bed, yet no assessment was documented in the Electronic Health Record (EHR). Similarly, Resident 9, who was moderately impaired cognitively, had half bed rails in the raised position without any documented assessment. Staff interviews confirmed the absence of assessments and highlighted a misunderstanding or neglect of the facility's policy requirements. Other residents, including those with varying levels of cognitive impairment, such as Residents 80, 3, 43, 78, and 85, also had bed rails or enabler bars in use without documented assessments. Staff interviews revealed a lack of awareness or adherence to the policy requiring risk and benefit assessments and education for residents or their representatives. This systemic failure to conduct and document necessary assessments and education underscores a significant deficiency in the facility's compliance with safety protocols.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the daily nurse staffing form was accurately completed with actual hours worked after the start of each shift for five out of seven days reviewed. The facility's policy required that the nurse staffing form be posted daily, reflecting the total number and actual hours worked by licensed and unlicensed nursing staff per shift, including any staff absences due to call-outs and illness. However, observations on multiple dates showed that the posted staffing forms did not include the actual hours worked for each shift that had started. Interviews with facility staff revealed that the Personnel Coordinator was responsible for updating the daily nurse staffing form, but was off work on certain days, during which the Director of Nursing was supposed to update the postings. Despite this, the actual working hours were not updated until the end of the shift, contrary to the facility's policy. Both the Director of Nursing and the Administrator acknowledged that the staffing forms should have been updated with actual hours worked at the beginning of each shift, but this was not done, leading to a deficiency in accurately informing residents and their representatives of current staffing levels.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper medication management for four residents, leading to potential medication errors and negative outcomes. For Resident 39, the facility did not clarify a physician's order regarding the administration of methotrexate while the resident was on antibiotics, resulting in the administration of both medications without proper verification. Staff U, a registered nurse, acknowledged the oversight and admitted to not clarifying the order with the physician before administering methotrexate. Resident 14's medication administration was not properly documented. Staff T, a registered nurse, administered a fluticasone inhaler but failed to record it in the electronic medication administration record (e-MAR). This lack of documentation was acknowledged by Staff T, who admitted to forgetting to mark the medication as given, despite having administered it during a blood glucose check. For Residents 49 and 6, the facility did not adhere to proper resident identification protocols before medication administration. Staff I, a registered nurse, failed to use available identification methods, such as photos or identification bands, to confirm the residents' identities. This was particularly concerning for Resident 6, who did not have an identification band and could not verbally confirm their identity. Staff I admitted to not using the pictures available in the medication cart for identification, which was against the facility's policy.
Deficiencies in Vaccine Storage and Expired Medical Supplies Management
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of refrigerator temperatures for the safe storage of vaccines in the Station 2 Medication Room. The temperature log for the refrigerator showed multiple missing checks during both day and night shifts across several months, contrary to the facility's policy and CDC guidelines which require daily monitoring and documentation. Staff E, the Resident Care Manager, acknowledged the missing entries and stated that the expectation was for staff to monitor and document the temperatures as directed. Additionally, the facility did not remove or discard expired medical supplies in the Station 2 Clean Utility Room. During an observation, expired items such as Central Line Trays, BD Culture Swabs, and Intermittent Urinary Catheters were found. Staff E confirmed that these items should have been discarded and stated that the utility room was checked monthly to ensure expired items were removed. The Director of Nursing, Staff B, reiterated the expectation for staff to check refrigerator temperatures twice daily and to discard expired medical supplies.
Improper Sanitizing Solution Concentration in Kitchen
Penalty
Summary
The facility failed to maintain the correct concentration of sanitizing solution used for cleaning food preparation surfaces in the kitchen, as observed during a survey. Staff N, a Dietary Aid, tested the sanitizing solution in two red buckets and found the concentration to be below the required 50 parts per million (ppm). The facility's policy, as well as the Washington State Food Worker Manual, requires that sanitizing solutions be maintained within a range of 50 ppm to 100 ppm and be changed every two hours or when they become dirty or cloudy. However, there was no record or log maintained to track when the sanitizing solution was last changed or tested, leading to the deficiency. Interviews with Staff N and Staff O, the Dietary Manager, confirmed that the sanitizing solution was used for cleaning work surfaces and should be changed every two hours. Both staff members acknowledged the absence of a log to document the timing of changes and tests of the sanitizing solution. Staff A, the Administrator, also stated that the facility was expected to follow its policy and maintain a log for the sanitizing solution. This oversight placed residents at risk for foodborne illnesses due to potential contamination of food preparation surfaces.
Failure in Infection Control and Outbreak Reporting
Penalty
Summary
The facility failed to report a communicable disease outbreak, specifically an influenza outbreak, as required by their policy and the guidelines outlined in the Nursing Home Guidelines The Purple Book. The outbreak involved multiple residents testing positive for Influenza A and respiratory syncytial virus over the course of January and February 2025. Despite the facility's policy mandating timely reporting of such outbreaks, the Infection Preventionist, Staff C, acknowledged that the outbreak had not been reported to the appropriate authorities, which was a clear deviation from the established guidelines. In addition to the reporting failure, the facility did not adhere to proper infection control practices during resident care and medication administration. For instance, during the care of Resident 65, a CNA failed to perform hand hygiene between changing gloves, which is a critical step in preventing the spread of infections. Similarly, during medication administration for Resident 6, a nurse did not use a barrier between the medication and the bedside table, potentially leading to contamination. These lapses in infection control practices were acknowledged by the staff involved, indicating a lack of adherence to the facility's policies. Furthermore, the facility did not ensure proper use of Transmission-Based Precautions (TBP) for residents on droplet/contact isolation. Staff members were observed entering and exiting rooms of residents with Influenza A without wearing the required PPE, such as face shields or goggles, and without changing masks after exiting the rooms. These actions were contrary to the facility's infection control policies and the signage posted outside the residents' rooms, which clearly outlined the necessary precautions. The staff involved admitted to not following the proper procedures, highlighting a significant gap in the facility's infection prevention and control program.
Failure to Address Resident Grievance for Missing Denture
Penalty
Summary
The facility failed to initiate and resolve a grievance for a resident who reported a missing personal item, specifically a lower denture. The resident, who was cognitively intact, reported the missing denture to the facility, but no grievance was logged, and no investigation was completed. The facility's policy requires the Grievance Official to oversee the grievance process, including receiving, tracking, and investigating grievances, and issuing written decisions. However, in this case, the grievance was not documented or investigated, despite the resident's report and the Social Worker's awareness of the issue. Interviews with the Social Services Director/Grievance Official and the Administrator revealed that the grievance process was not followed. The Social Services Director acknowledged awareness of the missing denture but could not find a completed grievance form. The Administrator stated that grievances should be tracked, logged, and resolved within five days, indicating that the facility's procedures were not adhered to in this instance. This oversight placed the resident at risk for feelings of frustration and unmet care needs.
Failure to Investigate Injuries and Falls
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown source and falls for two residents, which placed them at risk for repeated incidents and unidentified abuse. Resident 81, who had cognitive impairment and was diagnosed with Non-Alzheimer's Dementia, was found with a bruise on their forehead. Despite the bruise being in an area not generally vulnerable to trauma and the resident's inability to explain its cause, the incident was not logged or investigated as required by the facility's policy. Staff members acknowledged the bruise but did not consider it a substantial injury, and no incident report was filed. Resident 65 experienced a fall while at a nephrology appointment outside the facility. The fall was reported by the resident's representative, but the facility did not log or investigate the incident. Staff members recognized that the facility was responsible for the resident's safety, even when outside the facility, and acknowledged that an investigation should have been conducted to determine the factors contributing to the fall and to prevent future occurrences. The facility's policy on incidents and accidents required that all incidents, whether occurring inside or outside the facility, be logged and investigated. However, in both cases, the facility failed to adhere to its policy, resulting in a lack of documentation and investigation for the incidents involving Residents 81 and 65. This oversight highlights a deficiency in the facility's incident management and reporting processes.
Inaccurate MDS Assessments for Oral/Dental Status and Medication Management
Penalty
Summary
The facility failed to accurately assess the oral/dental status of Resident 1, as evidenced by the discrepancies in the Minimum Data Set (MDS) assessments. Despite observations showing Resident 1 wearing a broken upper denture with missing teeth, the MDS assessments did not reflect this condition. The dental consult note from June 2024 indicated a loose or ill-fitting upper denture, yet the MDS assessments from October 2024 and January 2025 did not mark the oral/dental status as broken or loosely fitting. Staff F, the MDS Coordinator, admitted to completing the assessments based on the resident's response rather than the dental consult note, leading to inaccurate documentation. For Resident 57, the facility failed to accurately document the Gradual Dose Reduction (GDR) attempts for antipsychotic medication in the MDS. The resident was on olanzapine, and the MDS indicated no GDR attempt, despite a documented dose reduction in April 2024. Furthermore, the MDS inaccurately recorded the date of clinically contraindicated GDR. Staff F acknowledged the errors, stating that the GDR attempt should have been marked as attempted, and the date of contraindication should have been recorded as May 6, 2024, based on the progress notes. These inaccuracies in the MDS assessments for both residents highlight a failure in the facility's assessment process, potentially leading to unidentified and unmet care needs. The Director of Nursing expressed an expectation for accurate assessments, indicating a gap between expected and actual practices in the facility's assessment procedures.
Inaccurate PASARR Form Leads to Missing Level II Referral
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASARR) form for a resident with a diagnosis of depression. The PASARR form, dated 12/30/2024, incorrectly indicated that no Level II evaluation was required, despite the presence of a mood disorder. This oversight was identified during a joint record review and interview with the facility's social worker, who acknowledged that the PASARR was not accurate and that a Level II referral should have been in place. The facility's policy requires the Social Services Director or designee to track each resident's PASARR screening status and make necessary referrals. However, the social worker and the Social Services Director both confirmed that the PASARR for the resident in question was not reviewed or corrected, resulting in the absence of a necessary Level II referral. The facility administrator also stated that they expected staff to ensure PASARRs were filled out accurately and corrected upon admission if needed.
Inadequate Supervision and Equipment Maintenance in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision and assistance during meals for Resident 65, who had a history of a stroke and required 1 to 1 supervision assist for aspiration precautions. Despite having a care plan and physician orders indicating the need for strict supervision during meals, observations showed that Resident 65 was left unsupervised on multiple occasions while eating. Staff members, including a Licensed Practical Nurse and the Director of Nursing, acknowledged that the resident should have been supervised according to the care plan, but the supervision was not consistently provided. Additionally, the facility did not ensure that bed rails were properly secured for Resident 3, who used an enabler to assist with transfers. Observations revealed that the enabler was loose and moved when pushed, which was confirmed by the resident and staff. Although a Certified Nursing Assistant tightened the screw of the enabler, it was not initially reported to maintenance for further inspection, as expected by the facility's policy. These deficiencies in supervision and equipment maintenance placed the residents at risk for accidents and injuries. The facility's policies and care plans were not adequately followed, leading to potential hazards for the residents involved.
Failure to Follow Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that monthly pharmacy recommendations were followed up for a resident reviewed for unnecessary medications. The facility's policy required staff to act upon all recommendations according to procedures for addressing medication regimen review irregularities. However, for one resident, there was no documentation of a pharmacy recommendation being addressed, specifically regarding a psychotropic gradual dose reduction for Trazadone and Olanzapine. The physician or prescriber response was not completed, indicating a lapse in the follow-up process. During an interview, the Director of Nursing (Staff B) acknowledged that they and the medical records department were responsible for overseeing the pharmacy drug regimen review documents. Staff B stated that the pharmacy recommendations were printed and placed in a binder for the provider to review and sign. However, it was noted that this process did not always occur as expected, and the recommendation for the resident in question was missing. Staff B mentioned that if the provider did not come to the facility, the recommendations would be faxed, but this did not happen in this case, leading to the deficiency.
Failure to Investigate Financial Exploitation Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of financial exploitation involving a resident. The resident, who had intact cognition, was informed by their Collateral Contact (CC1) that a family member had been taking money from their account without their knowledge. This was discovered through a review of the resident's bank statement, which showed over three thousand dollars missing, and the resident's ATM card was also reported missing. The incident was reported to Adult Protective Services and the facility administrator by the social worker, and CC1 also reported it to the police and the facility. Despite these reports, a review of the facility's incident reporting log for November and December 2024 showed no investigation was conducted regarding the allegation. The facility's administrator acknowledged awareness of the allegation but cited a miscommunication as the reason for the lack of investigation. This oversight was in violation of the facility's policy and the Nursing Home Guidelines, which require immediate and thorough investigation of all alleged incidents of abuse, neglect, or exploitation.
Failure to Treat UTI in Resident with Positive Lab Results
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice in managing signs and symptoms of a urinary tract infection (UTI) for a resident. The resident, who had severe cognitive impairment, exhibited increased urinary frequency and had multiple positive urine analyses indicating the presence of Escherichia coli, a common causative agent of UTIs. Despite these findings, the resident's UTI was not treated promptly, and there was a lack of documentation explaining the rationale for not treating the infection. The facility's policy on antibiotic stewardship, which follows the CDC's NHSN Surveillance Definitions and McGeer criteria, was not adhered to by the physician responsible for the resident's care. The physician expressed distrust in the laboratory results and stated that they only treat UTIs if the resident has a fever, dysuria, and acidic urine pH. However, the physician did not document their rationale for not treating the UTI, despite the resident's symptoms and positive laboratory results. Interviews with facility staff, including the Infection Preventionist and Director of Nursing, revealed that the resident's symptoms and positive laboratory results met the criteria for a UTI and should have been treated. The Director of Nursing and Administrator both expected the physician to document the rationale for not treating the infection within 24 hours, which was not done. This lack of documentation and treatment placed the resident at risk of unmet care needs and medical complications.
Failure to Investigate Bruises of Unknown Origin
Penalty
Summary
The facility failed to investigate possible allegations of abuse for four residents, each of whom had bruises of unknown origin. The facility's policy on abuse, neglect, and exploitation, dated September 7, 2023, mandates that any physical marks such as bruises or injuries of unknown source should trigger an immediate investigation. However, the facility did not log or investigate the bruises found on Residents 1, 2, 3, and 4, as evidenced by the absence of these incidents in the July 2024 Incident Log. Observations and interviews confirmed the presence of bruises on these residents, and staff members acknowledged that no investigations were initiated to determine the root cause of these injuries. Resident 1 had bruises on the left upper and lower arm, Resident 2 had a bruise on the left upper arm, Resident 3 had multiple bruises on the left wrist and arm, and Resident 4 had a discoloration on the arm. Despite these findings, the facility did not follow its policy to start an incident report, conduct assessments, notify family and providers, or interview residents and staff to determine the cause of the bruises. The Director of Nursing and the Administrator both stated that investigations should have been conducted immediately, but this was not done, leaving the residents at risk for unidentified abuse and a diminished quality of life.
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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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