Lacamas Creek Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Camas, Washington.
- Location
- 740 Ne Dallas Street, Camas, Washington 98607
- CMS Provider Number
- 505273
- Inspections on file
- 30
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Lacamas Creek Post Acute during CMS and state inspections, most recent first.
A resident, assessed as cognitively intact, reported repeated sexual assaults and called 911, also expressing suicidal ideation. Despite this, key staff including the DON, Social Services Director, and Administrator were unaware of the allegation, and the DON confirmed it was not reported due to doubts about its credibility and the resident's history of hallucinations. This resulted in a failure to follow policy and regulatory requirements for timely reporting of abuse allegations.
A resident with a history of trauma and a mood disorder did not have trauma informed care integrated into their care plan. Staff interviews revealed a lack of awareness and unclear communication processes between mental health providers and facility staff, resulting in the omission of trauma informed interventions in the resident's care planning.
A resident with severe cognitive impairment and a legal guardian experienced ongoing right knee pain and emotional distress due to chronic osteoarthritis. Despite repeated documentation of pain and limited participation in physical therapy, the facility did not notify the guardian about treatment options or seek consent for pain management interventions, such as a cortisone injection, until nearly seven weeks after admission.
The facility did not obtain daily weights as ordered by physicians for two residents with heart failure, resulting in multiple missed weight checks without proper documentation or explanation in the nursing notes. The DON confirmed that daily weights should be taken as ordered.
A resident who was alert and oriented and had a Living Will and DNR order did not have documentation in their record showing that their advance directive was reviewed quarterly as required. The Social Services Director confirmed that such reviews should occur but could not find additional information regarding the resident's advance directive.
A resident who was alert and oriented experienced a gap of over 105 hours between bowel movements, but the facility did not initiate the required bowel protocol interventions after 72 hours as per policy. Review of records and staff interviews confirmed that the protocol was not followed, and no medication intervention was documented during the period of constipation.
A resident with severe cognitive impairment and an unstageable sacrococcyx pressure ulcer did not receive proper infection control during wound care. An LPN compromised the clean field by placing wound dressing packages on the bed and failed to cleanse the wound after a bowel movement before applying topical treatment, contrary to physician orders and facility protocol. The infection control nurse confirmed that wounds should be recleaned after incontinence care.
The facility failed to ensure accurate MDS assessments for three residents. One resident was on hospice care, but this was not reflected in the MDS. Another resident was incorrectly documented as receiving insulin, despite no diagnosis or orders for it. A third resident's use of bed rails was wrongly coded as a restraint, although they were used for mobility aid. Staff confirmed these discrepancies, indicating errors in the MDS assessments.
The facility failed to initiate bowel interventions for two residents as per their Bowel Management Policy, leading to significant delays in bowel movements. Despite the policy requiring action after three days without a BM, the protocol was not followed, and documentation was lacking. Staff interviews confirmed the absence of necessary documentation and adherence to the protocol, placing residents at risk for discomfort and health complications.
The facility did not complete an annual performance review for a Nursing Assistant, Staff G, who was hired in 2014. The Administrator confirmed the absence of the evaluation, which is required annually, potentially risking resident care quality.
The facility failed to ensure informed consent for arbitration agreements with two residents. One resident did not recall signing the agreement, and her daughter usually handled such matters. Another resident's POA stated she should not sign legal documents due to a lack of understanding. The Marketing Director admitted to not fully explaining the agreement, including the revocation clause.
A facility failed to ensure bed rails were securely fastened for a resident who was moderately cognitively impaired. The resident's care plan included the use of side rails for bed mobility. Observations revealed the left side bed rail was loose on two occasions, with significant movement. Staff indicated that nursing assistants and floor nurses were responsible for monitoring bed rails, and the Maintenance Director noted that a clip had popped out, causing the issue.
The facility failed to provide dementia training to a Nursing Assistant, Staff G, who had been employed since 2014. Training records showed that Staff G did not complete dementia training in the past year, which was confirmed by the Staff Training Coordinator. The Administrator acknowledged the oversight, stating that Staff G should have received the training.
The facility failed to administer prescribed medications to two residents, including critical medications for heart conditions, hypertension, and pain management. There were no progress notes explaining the omissions, and the Director of Nursing Services confirmed the lack of documentation.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of sexual abuse for one resident. According to the facility's policy, all reports of resident abuse, neglect, exploitation, or theft are to be reported to appropriate authorities and thoroughly investigated. Documentation in the electronic health record showed that a resident, who was cognitively intact according to the most recent MDS, reported to a nurse that someone had been entering her room at night and alleged repeated sexual assaults over a nine-month period. The resident also called 911 to report these allegations and expressed suicidal ideation. Despite this, key staff members, including the Social Services Director, Resident Care Manager, and Administrator, were unaware of the allegation, and the Director of Nursing confirmed that the facility did not report the allegation because they did not believe it was real, citing the resident's history of hallucinations and the lack of a staff member matching the description provided. The failure to report the allegation was confirmed through interviews with multiple staff members, who indicated that such concerns would typically be communicated during meetings or directly by staff. The Administrator acknowledged not being aware of the allegation and attributed the lack of reporting to the resident's history of hallucinations. The Director of Nursing stated that the allegation was not reported because it was not considered credible. This lack of timely reporting was in direct violation of the facility's policy and regulatory requirements.
Failure to Integrate Trauma Informed Care into Resident Care Plan
Penalty
Summary
The facility failed to integrate trauma informed care into the care plan for one resident who was admitted for rehabilitation following hospitalization. Documentation showed that the resident was cognitively intact and had a history of trauma from adolescence into adulthood, as well as a mood disorder that warranted evaluation for mental health services. Despite this, a review of the electronic health record revealed there was no care plan addressing trauma informed care for this resident. Interviews with facility staff, including the Social Services Director, Resident Care Manager, and Director of Nursing, indicated a lack of awareness regarding the resident's trauma history and mental health needs. Staff were uncertain about how mental health providers communicated relevant information to the facility and how such information should be incorporated into the resident's care plan. As a result, the resident's trauma history and mental health concerns were not addressed in their care planning process.
Failure to Notify Guardian of Significant Change in Treatment for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to notify the legal guardian of a resident with severe cognitive impairment and a legal guardian regarding significant changes in treatment options for ongoing right knee pain due to chronic osteoarthritis. The resident, who had a BIMS score of 00/15 indicating severe cognitive impairment, repeatedly expressed pain and emotional distress related to her right knee. Despite multiple medical evaluations and documentation of her ongoing pain and inability to participate fully in physical therapy, the facility did not contact the guardian to discuss or obtain consent for potential pain management interventions, such as a cortisone injection, for nearly seven weeks after admission. Throughout this period, medical records show that the resident was offered a cortisone injection several times but declined due to fear of needles and limited understanding of the procedure, as noted by her providers. The lack of timely notification to the guardian meant that alternative consent for pain management was not pursued, and the resident continued to experience pain and emotional distress. Documentation of guardian notification and consent for the injection was not present until a progress note dated almost seven weeks after admission.
Failure to Obtain Daily Weights per Physician Orders for Residents with Heart Failure
Penalty
Summary
The facility failed to follow physician orders for obtaining daily weights for two residents diagnosed with heart failure. For one resident with severe cognitive impairment and congestive heart failure, the physician's order required daily weights to be taken in the morning before breakfast and after the first void, with instructions to notify the physician if certain weight gains occurred. However, there were three documented occasions when the resident was not weighed as ordered, and the Treatment Administration Record (TAR) indicated omissions with a chart code referencing nurses' notes. Upon review, there were no corresponding nurses' notes explaining the omissions on those dates. Similarly, another resident with heart failure and intact cognition had a physician's order for daily weights under the same protocol. There were six occasions when this resident was not weighed as ordered, with the TAR documenting chart codes for sleeping or referencing nurses' notes. Except for one note indicating the wheelchair scale was broken, there were no nurses' notes explaining the missed weights on the other dates. The Director of Nursing Services confirmed that daily weights should be taken as ordered, as the resident allows.
Failure to Review and Maintain Advance Directive Documentation
Penalty
Summary
The facility failed to provide assistance with completing advance directives and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for one resident. The resident was admitted to the facility, was alert and oriented, and had a Living Will and Do Not Resuscitate (DNR) order documented in their social history assessment. However, a review of the resident's electronic record revealed there was no documentation that the advance directive had been reviewed on a quarterly basis as required. During an interview, the Social Services Director confirmed that advance directives are supposed to be reviewed quarterly and annually during care conferences, but could not locate any additional information regarding the resident's advance directive.
Failure to Initiate Bowel Protocol for Constipated Resident
Penalty
Summary
The facility failed to initiate bowel interventions as required by its own bowel protocol policy for a resident who experienced constipation. According to the facility's policy, licensed nurses are to monitor residents' bowel movements and initiate interventions if a resident has not had a bowel movement for three days. The policy specifies that after 72 hours without a bowel movement, the nurse should administer Milk of Magnesia, followed by a Dulcolax suppository if there is still no bowel movement by the next shift, and notify the physician if the period exceeds four days. For one resident, who was alert and oriented, documentation showed a gap of approximately 105.5 hours between bowel movements. Review of the Medication Administration Record did not show any medication intervention after 72 hours without a bowel movement. Interviews with nursing staff confirmed that the bowel protocol should have been initiated at the 72-hour mark, but it was not. This lapse was identified through record review and staff interviews, confirming that the facility did not follow its established protocol for bowel management.
Failure to Follow Infection Control Protocol During Wound Care
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to implement proper infection control practices during wound care for a resident with an unstageable bilateral sacrococcyx pressure ulcer. The resident, who was severely cognitively impaired and dependent for activities of daily living, had physician orders specifying wound cleansing with normal saline or wound cleanser, treatment of the periwound area, application of anasept gel and collagen, and covering with a bordered dressing. During an observed wound care procedure, the LPN set up a clean field but moved wound dressing packages onto the resident's bed, which compromised the clean field. The LPN then opened the dressing packages and began wound care. While providing care, the resident had a bowel movement. The LPN provided incontinence care but proceeded to apply anasept gel to the wound bed without first cleansing the wound as required by protocol. When questioned, the LPN acknowledged the need to clean the wound after a bowel movement and subsequently did so. The infection control nurse confirmed that the expectation was for licensed nurses to maintain a clean field and reclean sacral wounds with normal saline or wound cleanser if a resident had a bowel movement.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the health status and care needs of three residents. Resident 39 was admitted for hospice care due to a terminal prognosis related to acute kidney failure, as documented in physician orders and the care plan. However, the Significant Change MDS assessment did not indicate that Resident 39 was receiving hospice care, despite confirmation from both the resident and staff that hospice services were being provided. This discrepancy was acknowledged by the Resident Care Manager, who admitted that hospice should have been marked on the MDS. Resident 41's Quarterly MDS assessment inaccurately documented that the resident received insulin injections, although there was no diagnosis of diabetes, physician orders for insulin, or a care plan for diabetes in the resident's Electronic Health Record. Both the resident and staff confirmed that Resident 41 was not on insulin, indicating an error in the MDS. Additionally, Resident 59's MDS assessment incorrectly coded the use of bed rails as a restraint, despite documentation and staff statements indicating that the rails were used to aid with bed mobility and were not considered restraints. The Director of Nursing Services confirmed that the MDS needed modification to accurately reflect the use of bed rails.
Failure to Initiate Bowel Interventions for Residents
Penalty
Summary
The facility failed to initiate bowel interventions for two residents, which was identified during a survey. According to the facility's Bowel Management Policy, a Licensed Nurse is required to review the Bowel Management Report at the beginning of each shift to identify residents who have not had a bowel movement (BM) for three days. The policy outlines a step-by-step protocol involving the administration of Milk of Magnesia, followed by a Dulcolax suppository, and then a Fleets enema if necessary. However, for Resident 5, there was a significant gap of over 15 days between documented BMs, and the bowel protocol was not initiated as per the Medication Administration Record (MAR). Similarly, Resident 32 experienced a gap of over 90 hours between BMs without the bowel protocol being initiated. Interviews with staff revealed a lack of documentation and adherence to the bowel management protocol. Staff K, a Registered Nurse, acknowledged the absence of documentation for the initiation of the bowel protocol for both residents and mentioned that such documentation should be present on the MAR. Staff B, the Director of Nursing Services, confirmed that the bowel management protocol should have been triggered according to the policy but was unable to provide evidence of its initiation for the affected residents. This oversight placed the residents at risk for discomfort and health complications, as noted in the report.
Failure to Conduct Annual Performance Review for Nursing Assistant
Penalty
Summary
The facility failed to complete performance reviews for one of the two sampled Nursing Assistants (NA), specifically Staff G. Staff G was hired on March 29, 2014, and their personnel records lacked a performance evaluation for the previous year. During an interview on September 26, 2024, the Administrator, Staff A, confirmed the absence of a performance evaluation for Staff G and acknowledged that such evaluations should be conducted annually. This oversight placed residents at risk of receiving care from unskilled staff.
Failure to Ensure Informed Consent for Arbitration Agreements
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to two residents, leading to a deficiency in ensuring informed consent. Resident 28 signed the Alternative Dispute Resolution Agreement but later stated she did not recall signing it, indicating her daughter handled such matters. Similarly, Resident 46 signed the agreement but did not remember doing so, and her Power of Attorney (POA) confirmed that Resident 46 should not be signing legal documents due to a lack of understanding. The Marketing Director, Staff F, admitted to covering the arbitration agreement last during the admission process and was unaware of the revocation clause, suggesting a lack of comprehensive explanation to the residents or their representatives.
Failure to Securely Fasten Bed Rails
Penalty
Summary
The facility failed to ensure that bed rails were securely fastened to the bed and without gaps between the mattress and bed rails for one of the three sampled residents. Resident 22, who was moderately cognitively impaired, was admitted to the facility and had a care plan indicating the use of bilateral 1/4 side rails to aid in bed mobility and increase independence. On two separate occasions, the left side bed rail of Resident 22 was observed to be loose, with approximately 9 to 10 inches of movement. Staff I, a Resident Care Manager and Registered Nurse, stated that nursing assistants and floor nurses were responsible for monitoring bed rails and reporting issues to maintenance. Staff J, the Maintenance Director, mentioned that he attempted to audit bed rails every other week and identified that a clip had popped out, causing the bed rail to be loose.
Failure to Provide Dementia Training to Nursing Assistant
Penalty
Summary
The facility failed to ensure that staff received necessary dementia training, as evidenced by the case of Staff G, a Nursing Assistant hired on March 29, 2014. A review of training records revealed that Staff G had not completed dementia training in the past year. This oversight was confirmed during an interview with Staff H, the Staff Training Coordinator, who stated that dementia training is typically covered during new employee orientation and then annually. An email from Staff A, the Administrator, acknowledged the error, noting that Staff G, being a long-standing employee, should have received the training.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when medications were not administered in accordance with provider orders for two residents. Resident 1, who was admitted with diagnoses including atrial fibrillation and hypertension, did not receive their prescribed doses of Apixaban and Metoprolol on a specified date. There were no progress notes explaining the omission of these medications, which are critical for managing the resident's heart condition and blood pressure. Similarly, Resident 2, who had multiple diagnoses including prostate cancer, hypertension, and gastro-esophageal reflux, did not receive several prescribed medications on a specified date. These medications included Amlodipine, Methadone, Omeprazole, Tamsulosin, Tizanidine, and MiraLAX. Again, there were no progress notes explaining why these medications were not administered. The Director of Nursing Services confirmed the lack of documentation for both residents' medication omissions, and the Administrator acknowledged the need to correct this practice.
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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