Lacey Post Acute & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Lacey, Washington.
- Location
- 4524 Intelco Loop Se, Lacey, Washington 98503
- CMS Provider Number
- 505525
- Inspections on file
- 37
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Lacey Post Acute & Rehabilitation during CMS and state inspections, most recent first.
A resident with moderately impaired cognition, poor judgment, and significant ADL dependence was discharged home against medical advice after insurance coverage ended, despite the provider not recommending discharge home alone and the resident’s son expressing concerns about unsafe home conditions, medication nonadherence, and lack of informal supports. Documentation showed the resident required maximum assist with dressing, was dependent with toileting, refused to participate in mobility and transfer training, and had poor safety awareness. Social services proceeded with planning discharge home and requested facility transportation when the resident’s ride did not arrive, and transportation staff took the resident home, while the administrator later reported being unaware that transportation had been provided.
Two residents experienced significant delays in receiving pain medication due to staff not following established procedures for accessing emergency medication and failing to promptly notify providers. One resident endured severe pain for several hours after admission, requiring family intervention and a 911 call, while another waited nearly 10 hours for pain relief due to a lapse in communication between nursing staff and the provider. Both residents suffered ongoing pain and psychological distress as a result.
A resident with an open wound and a catheter did not have Enhanced Barrier Precautions (EBP) implemented as required by facility policy. Staff failed to place EBP signage on the door, and direct care was provided without PPE. Interviews indicated confusion among staff regarding responsibility for EBP signage and understanding of EBP indications.
Three residents did not have comprehensive care plans addressing their specific needs, including safe smoking practices, mobility and ADL support for hemiplegia, and management of anticoagulant therapy for pulmonary embolism. Staff confirmed these omissions, noting that care plans lacked required focus areas and interventions for these conditions.
The facility did not provide wound care as ordered for a resident with multiple wounds, as dressing changes were not completed despite being documented as done. Additionally, three residents did not receive timely bowel assessments or PRN medications after several days without a bowel movement, and staff confirmed that bowel protocols were not initiated as required.
A resident with severe cognitive impairment and mental health diagnoses was administered quetiapine and duloxetine without documented consent from the resident or their representative. Staff confirmed that consent should have been obtained and documented, but no such records were found in the electronic health record.
A resident's trust funds were not conveyed to their representative or the state within the required 30-day period after discharge. The trust account remained open and continued to receive credits for over two months, and the funds were not issued to the Office of Financial Recovery until 78 days after discharge. The administrator confirmed that timely disbursement was not documented or completed as required.
A resident who was alert and oriented did not have documentation of an Advance Directive (AD) or evidence that information or assistance was provided to develop one. Despite indications that the resident had a Health Care DPOA, the paperwork was not present in the record, and the care plan did not address ADs. Staff confirmed that the facility's protocol for obtaining and documenting ADs was not followed during admission, re-admission, or quarterly care conferences.
Two residents were observed using bed rails without documented evaluation, consent, or physician order as required by facility policy. Staff confirmed that assessments and orders were missing for both residents, one of whom was severely cognitively impaired and the other alert and oriented.
The facility did not ensure that PASRR assessments accurately documented mental health diagnoses for two residents with conditions such as depression, anxiety, and bipolar disorder. Required sections of the PASRR forms were left incomplete, and serious mental illness indicators were not recorded as per facility policy.
A resident who was alert and oriented did not have nutrition or hydration issues addressed in their care plan, and staff failed to document both the completion and refusal of weights in the EHR as required. Although the resident often refused to be weighed, there was no record of these refusals in the progress notes, despite staff stating this was the expected process.
Surveyors found expired and undated medications and medical equipment in both a medication storage room and a treatment cart. An LPN and a unit manager confirmed that items such as an opened vial of PPD, Bisacodyl suppositories, blood collection sets, and Hibiclens solution were not properly dated or discarded after expiration, and the administrator was aware of these storage issues.
A resident who required moderate assistance with transfers was discharged without documented transfer training or assessment of the spouse's ability to provide necessary care at home. Staff could not provide evidence that the family was prepared for the resident's care needs, and the spouse later reported not receiving training and feeling unprepared for the discharge.
A resident was admitted with conflicting code status information: transfer orders indicated full code, while the EHR showed no CPR per advance directives. The admission LPN did not validate the transfer order with the resident, and the required POLST form was not completed. The DON and nurse practitioner were unaware of the discrepancy, and there was no documentation clarifying the resident's wishes, resulting in the failure to honor the resident's advance directives.
A resident admitted with a Stage II pressure ulcer did not have a wound care plan documented in their comprehensive care plan. Although wound care orders were in place, the care plan was missing due to a recent update in the electronic medical record system that affected automatic care plan generation. Staff acknowledged the oversight and were addressing the issue.
The facility failed to obtain and document Advance Directives (AD) for a resident, compromising their right to have healthcare preferences honored. Despite being alert and oriented, the resident's AD paperwork was not requested or documented in the Electronic Health Record (EHR). Interviews with staff revealed inconsistencies in requesting and documenting ADs, with the Director of Nursing Services and the facility administrator emphasizing the importance of documentation.
A facility failed to provide the SNF ABN to a resident's representative, leaving them uninformed about potential financial liability for non-covered services. The Business Office Manager and Social Services Director confirmed the oversight and uncertainty about who was responsible for issuing the notice.
A facility failed to provide a written Bed-Hold notice to a resident or their representative during a hospital transfer. The resident, who was moderately cognitively impaired, had no documentation in their EHR regarding the Bed-Hold offer. The Admissions Liaison admitted to not having a form or documentation for this process, and the administrator confirmed the expectation for such documentation.
A facility failed to accurately complete the MDS assessment for a resident with a history of strokes, omitting their visual impairment. Despite staff awareness of the resident's vision loss and need for assistance with ADLs, the MDS did not reflect this condition, indicating a lapse in the assessment process.
A facility failed to implement PASARR Level II recommendations for a resident with Parkinson's Disease and Depression, who was experiencing hallucinations and delusions. The care plan did not include necessary behavioral health interventions, and staff were unable to locate specific interventions in the records. The Social Service Director and Administrator acknowledged the oversight, but the recommendations were not integrated into the care plan or the Kardex.
The facility failed to complete accurate PASARR assessments for two residents, risking inadequate mental health services. One resident's PASARR indicated a mood disorder with an exemption requiring a doctor's signature, which was misunderstood by the administrator. Another resident's PASARR lacked documentation of serious mental illness indicators, despite being on multiple psychiatric medications. The Social Services Director recognized the need for improved accuracy in PASARR reviews.
A resident with multiple health issues, including falls and cognitive impairment, did not have an updated care plan reflecting their needs for assistance with toileting, eating, and grooming. Despite multiple falls and an incident involving a urinary catheter, the care plan and Kardex lacked specific directives, leading to unmet care needs.
A resident with falls and aphasia experienced inconsistent toilet assistance, leading to a deficiency in care. The care plan and Kardex lacked specific directives for toileting, and staff were unaware of a toileting schedule. The resident, who was continent before admission, experienced multiple falls and often attempted to use the bathroom independently. Staff provided inconsistent accounts of the resident's needs, contributing to the deficiency.
The facility failed to provide necessary restorative care services to maintain or improve ROM and daily living activities for four residents, leading to an avoidable decline in their physical abilities. Residents with conditions such as hemiplegia, hemiparesis, and post-fall fractures did not receive appropriate therapy, and there was a lack of documentation and oversight of the restorative program.
A significant medication error occurred when a resident with a documented allergy to Tuberculin was administered the TB solution. Despite the allergy being noted in the resident's hospital records, the resident received both steps of the Tuberculin test. The error was confirmed by the Infection Preventionist and the Administrator, highlighting a failure in the facility's medication administration process.
A medication security lapse occurred when an LPN left a medication cup with lactulose unattended on a medication cart. The LPN was observed attending to a resident, leaving the medication accessible. The DON expected medications to be locked when not in use, highlighting a failure to secure medications properly.
The facility failed to ensure the suction machine on the 2nd Floor crash cart was in safe operating condition, as it had no suction when checked. Despite nightly checks by the night shift nurse, the staff did not verify the suction capability, only that the motor was running. The suction machine is crucial for clearing a resident's airway in emergencies, and a non-functional machine would necessitate obtaining another from the supply room.
The facility failed to obtain informed consents for wanderguards for two residents, one cognitively intact and one severely impaired, leading to the use of the device without proper authorization. Staff confirmed the absence of required consent documentation in both cases.
The facility failed to conduct proper assessments before placing wanderguards on three residents, leading to potential risks related to improper use of the device. One resident was cognitively intact and did not exhibit wandering behavior, another was severely cognitively impaired and had a delayed assessment, and the third had an outdated safety evaluation.
Failure to Ensure Safe Discharge Planning and Transportation for a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe discharge plan for a resident whose needs and preferences required more support than was arranged. The resident was admitted after hospitalization and was initially documented as alert and oriented on the 5-day MDS. Subsequent EHR entries showed that the provider did not recommend discharge home alone due to safety concerns. Therapy and nursing documentation indicated the resident required maximum assistance with dressing, was dependent with toileting, refused to work on bed mobility, transfers, and ambulation, and demonstrated poor safety awareness. The resident’s cognition was documented as impaired: she was unable to sign the NOMNC due to decreased cognition, had a BIMS score of 9 indicating moderately impaired cognition, and scored 9/20 on a verbal test of practical judgment, suggesting severe impairment in judgment skills. Despite these findings, the facility planned to discharge the resident home and proceeded with discharge. The resident’s son expressed concerns to social services about the cleanliness of the home, the likelihood that the resident would not take medications as prescribed, and reported that informal supports would no longer assist due to safety concerns about her being home alone. The EHR documented that the resident was discharged against medical advice, with the discharge described as being facilitated to promote a safe environment at home. When the resident’s arranged ride did not arrive, transportation support staff provided transport to the home at the request of social services. The social services assistant later stated she did not feel the resident should have been discharged home but was unsure of what options were available, and the administrator reported being unaware that facility transportation had been provided for this discharge.
Failure to Provide Timely Pain Medication
Penalty
Summary
The facility failed to ensure that residents received timely pain medication, resulting in ongoing pain and diminished quality of life for two residents. One resident, admitted for rehabilitation and cognitively intact, reported not receiving pain medication for several hours after admission despite repeated requests. The nurse informed her that the pharmacy did not have her prescription and that there could be a two-hour wait, but the delay extended for several hours. The resident experienced severe pain, rated 10/10, and ultimately called her son for help, who then called 911 to intervene. The pharmacy narcotic log showed that pain medication was retrieved from the emergency medication stock supply several hours after admission. Another resident, admitted for rehabilitation and moderately cognitively impaired, was observed crying and requesting pain medication for leg pain. She reported asking for pain medication since early morning and was told she had run out of medication and that the nurse was waiting for a new prescription to be signed by the provider. The medication administration record indicated a significant gap between doses, with the resident waiting nearly 10 hours for pain relief. The nurse stated she was waiting for the provider to sign the order but did not attempt to contact the provider directly, assuming the provider was busy. The provider later confirmed she was available and had not been notified of the need for additional pain medication. Interviews with facility staff revealed that there was a system in place to access emergency medication stock, which should have allowed for timely administration of pain medication within 15 minutes. However, this process was not followed, resulting in prolonged pain for both residents. Both residents described experiencing severe physical and psychological distress due to the delays in receiving pain medication.
Failure to Implement Enhanced Barrier Precautions for Resident with Open Wound and Catheter
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident who required them due to an open wound and the presence of a catheter. The resident, who was moderately cognitively impaired and admitted for rehabilitation after hospitalization, had a care plan indicating the need for EBP. However, during multiple observations, there was no EBP signage on the resident's door, and staff were seen entering the room and providing direct care without donning personal protective equipment (PPE) as required by the facility's EBP policy. Interviews with staff revealed a lack of clarity regarding responsibility for placing EBP signage and understanding of when EBP should be implemented. The admit nurse did not place the required signage during the admission process, and the infection control nurse did not identify the omission during routine checks. Additionally, a nursing assistant was unsure about the specific indications for EBP, and the administrator confirmed that the signage had not been placed as required.
Failure to Develop Comprehensive Care Plans for Smoking, Mobility, and Anticoagulant Use
Penalty
Summary
The facility failed to develop comprehensive care plans addressing all identified needs for three of four sampled residents. For one resident with COPD who was alert and oriented, the care plan did not include a focus, goal, or interventions related to safe smoking practices, despite the resident being observed smoking independently off facility property. Facility policy required evaluation and care planning for residents who smoke, but the care plan was not updated to reflect this until after the observation. Staff confirmed that the omission was due to a computer system change that resulted in the care plan entry being canceled and not reinstated until later. Another resident, who was alert, oriented, and dependent for personal hygiene and transfers due to hemiplegia, did not have a care plan addressing positioning, mobility, or ADL needs, despite requiring a hoyer lift for transfers and being unable to move one side of her body. Additionally, a third resident with a history of pulmonary embolism and prescribed apixaban, an anticoagulant, did not have a care plan addressing the diagnosis or the use of high-risk medication. Staff interviews confirmed that these care needs should have been included in the care plans but were not present at the time of review.
Failure to Provide Ordered Wound Care and Bowel Management
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents' needs in several instances. For one resident with multiple wounds, including a left hip abrasion and diabetic foot ulcers, the treatment administration record indicated that wound care was to be performed every other day. However, documentation and staff interviews revealed that the dressing change for the left hip/buttock was not completed as ordered, despite being signed off in the treatment record. A nurse was unaware of the wound and only discovered it upon direct observation, confirming that the treatment had not been performed as documented. Additionally, the facility did not initiate bowel interventions for three residents who had not had a bowel movement for several days. Review of medication administration records and bowel movement task sheets showed that PRN bowel medications and assessments were not administered or documented as required after 72 hours without a bowel movement. Staff interviews confirmed that bowel protocols and assessments were not initiated in a timely manner, contrary to facility expectations and residents' care needs.
Failure to Obtain Consent for Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed and provided consent prior to the administration of psychotropic medications. Specifically, a resident with severe cognitive impairment and multiple mental health diagnoses, including bipolar disorder and depression, was prescribed and administered quetiapine and duloxetine. Documentation in the Electronic Health Record did not show any evidence of consent from the resident or their representative for either medication. Staff interviews confirmed that a consent form should have been completed when the psychotropic medications were prescribed or if the dosage was changed. Both the Administrator and the DON acknowledged that they could not locate the required consent documentation for the medications in question, indicating that the necessary process for obtaining and recording consent was not followed.
Delayed Disbursement of Resident Trust Funds After Discharge
Penalty
Summary
The facility failed to ensure that a discharged resident's trust funds were conveyed to the resident's representative or to the state Office of Financial Recovery (OFR) within 30 days of discharge, as required. Record review showed that the resident was discharged with return anticipated, but the trust account continued to show credits and a balance for over two months after discharge. The account was not closed and the funds were not issued to the OFR until 78 days after discharge, with the issue date for the payment to OFR occurring even later. The administrator confirmed that dispersing funds within 30 days of discharge was not documented in the resident's electronic health record and acknowledged that this step should have been addressed.
Failure to Obtain and Maintain Advance Directives Documentation
Penalty
Summary
The facility failed to obtain and/or maintain Advance Directives (AD) documentation for one resident who was alert and oriented. Upon admission and re-admission, there was no documentation in the resident's electronic health record (EHR) regarding the presence of an AD or that information or assistance was provided to develop one. The Social Service Initial Evaluation indicated the resident had a Health Care Durable Power of Attorney (DPOA), and a progress note stated that DPOA paperwork was supposed to be brought to the facility, but it was not present in the record. The care plan did not address ADs, and quarterly notes did not reflect any change or follow-up regarding the AD status. Staff interviews confirmed that the facility's protocol was not followed, as the AD was not readdressed upon the resident's re-admission, nor was a copy requested or obtained during the quarterly care conference. The Social Services Director acknowledged the lack of documentation and stated that reminders to provide the AD were given periodically, but no documentation or follow-up was completed. The Administrator also confirmed that the protocol for obtaining and documenting ADs was not followed for this resident.
Failure to Obtain Assessment, Consent, and Physician Order for Bed Rail Use
Penalty
Summary
The facility failed to obtain required evaluation assessments, consents, and physician's orders for the use of bed rails for two residents. According to the facility's policy, any resident considered for bed rail use must be evaluated by the interdisciplinary team to determine appropriateness, and if deemed suitable, the facility must educate the resident or representative on risks, obtain documented consent, notify the representative as appropriate, and secure a specific physician's order detailing the type and use of bed rails. For both residents sampled, there was no evidence in the electronic health records of an evaluation assessment, consent, or physician's order related to the use of bed rails. One resident, who was severely cognitively impaired, was repeatedly observed with quarter length bed rails in use on various days, with no documentation of the required assessment, consent, or order. Another resident, who was alert and oriented, was also observed with a one-third length bed rail in use on multiple occasions, again without the necessary documentation. Staff interviews confirmed that the expected procedures were not followed for these residents, and the required documentation was missing.
Inaccurate PASRR Assessments for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected the mental health diagnoses for two residents. For one resident admitted with depression and anxiety, the Level 1 PASRR did not document a serious mental illness indicator, nor was Section IV Service Needs and Assessor Data completed to indicate if a Level II evaluation was necessary. Similarly, another resident admitted with depression, bipolar disorder, and anxiety had a Level 1 PASRR that did not document these serious mental illness indicators, and Section IV was also left incomplete. According to facility policy, the Social Worker, Admissions Coordinator, or designee is responsible for reviewing completed screening forms prior to admission and ensuring they are placed in the electronic medical record. However, interviews and record reviews revealed that these steps were not properly followed, resulting in inaccurate PASRR documentation for both residents. Staff acknowledged the inaccuracies upon review.
Failure to Document Resident Weight Refusals and Monitoring
Penalty
Summary
The facility failed to document the completion and/or refusal of weights for one resident reviewed for nutrition. The resident was admitted alert and oriented, but their care plan did not include any identified problems or goals related to nutrition or hydration. The electronic health record (EHR) showed several recorded weights over a two-month period, but staff interviews revealed that the resident often refused to be weighed. Despite this, there was no documentation in the EHR progress notes regarding the resident's refusals. Certified Nursing Assistants (CNAs) were responsible for obtaining weights and reporting them to nursing staff, who then entered the data into the EHR. Both nursing and dietary staff confirmed that refusals should be documented in the EHR progress notes, and that the process included educating the resident on the risks and benefits of refusing weights. However, a review of the EHR found no documentation of weight refusals for this resident, indicating a failure to follow established procedures for documenting refusals and monitoring nutritional status.
Expired and Undated Medications and Equipment Found in Storage Areas
Penalty
Summary
Surveyors observed that drugs, biologicals, and medical equipment in the facility were not consistently dated upon opening or discarded once expired. In the medication storage room refrigerator on the 2nd floor, a vial of Tuberculin Purified Protein Derivative (PPD) was found opened without a date indicating when it was opened or when it should be disposed of. Additionally, two boxes of Bisacodyl Suppositories and a box containing 35 BD Vacutainer Safety Lock Blood Collection Sets were found with expiration dates that had passed. On the 1st floor treatment cart, a bottle of Hibiclens Solution was observed with an expiration date of 04/2024, and staff confirmed it should have been discarded after expiration. Staff interviews confirmed that medications and equipment in the medication storage room and refrigerator are expected to be destroyed at the time of expiration, and the administrator was aware of the medication storage issues.
Failure to Provide Transfer Training to Family Prior to Discharge
Penalty
Summary
The facility failed to ensure that transfer training was provided to the family of a resident who was being discharged, resulting in an unsafe discharge. The resident, who was cognitively intact but required moderate assistance with transfers, was admitted for rehabilitative services after previously being independent with mobility prior to hospitalization. Documentation showed that the resident's spouse was not trained or assessed for the ability to provide necessary transfer assistance at home. Staff interviews confirmed that there was no record of transfer training being provided to the spouse, and discharge planning did not include a formal conference close to the discharge date. Further, the resident's progress towards discharge was not documented after weekly skilled rounds, and there was no evidence that the spouse was prepared to safely care for the resident post-discharge. The spouse later reported not receiving any training and expressed concerns about the resident's safety at home following discharge. The lack of documented training and preparation for the family member responsible for care led to an unsafe discharge process for the resident.
Failure to Implement and Document Advance Directives on Admission
Penalty
Summary
The facility failed to ensure that advance directives were properly implemented upon admission for one resident. Upon admission, the resident was provided with conflicting information regarding their code status: acute care transfer orders indicated full code status (to perform CPR), while the advance directives in the electronic health record (EHR) indicated no CPR. The admission nurse did not validate the transfer order with the resident for accuracy, and the process for confirming and documenting the resident's wishes was not followed. The required Physician Order for Life Sustaining Treatment (POLST) form was not completed, and there was no documentation in the EHR clarifying the resident's CPR status. Interviews with staff revealed that the process for discussing and documenting advance directives was not streamlined. The nurse practitioner responsible for discussing advance directives with new admissions was unaware of the resident's existing directives and could not recall why the POLST form was not completed. The director of nursing confirmed that the order for CPR should have been entered into the EHR and that conflicting information should have been clarified with the physician, but there was no evidence this occurred. This failure resulted in the resident's advance directives not being honored as required by policy and state regulations.
Failure to Establish Wound Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to establish a wound care plan for a resident who was admitted with a Stage II pressure ulcer. Upon admission, the resident was documented as having a pressure injury to the sacrum, but the comprehensive care plan did not include a wound care plan for this condition. Interviews with staff revealed that although wound care orders were in place, the expected care plan was missing from the resident's documentation. The Director of Nursing Services acknowledged the absence of a wound care plan and noted that a recent update to the electronic medical record system had altered the automatic generation of care plans for residents admitted with skin issues. This change occurred shortly before the resident's admission, leading to the oversight. The facility recognized the deficiency and was in the process of correcting the issue to ensure care plans would be automatically generated in the future.
Failure to Obtain and Document Advance Directives
Penalty
Summary
The facility failed to obtain and maintain Advance Directives (AD) for one of the sampled residents, which compromised the resident's right to have their healthcare preferences honored. Resident 157, who was alert and oriented, was admitted to the facility, and the initial evaluations documented that the resident's son was the Power of Attorney (POA). However, there was no documentation in the Electronic Health Record (EHR) indicating that AD paperwork was requested or obtained. Interviews with facility staff revealed a lack of consistent procedures in requesting and documenting ADs. The Director of Social Services and a Social Worker both indicated that they would ask for AD copies during the care conference, but there was no documentation of such a request for Resident 157. The Director of Nursing Services confirmed that it was the social worker's responsibility to request and document ADs in the EHR. The facility administrator also stated that it was expected for staff to request and document ADs, emphasizing that if it wasn't documented, it wasn't done.
Failure to Provide SNF ABN to Resident's Representative
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) to a resident's representative, which is required to inform them of potential financial liability for services not covered by Medicare. Specifically, for one of the three sampled residents, the Notice of Medicare Non-Coverage indicated that the resident's representative was informed of the termination of services, but the SNF ABN was not provided. This oversight was confirmed during interviews with the Business Office Manager and the Social Services Director, who acknowledged the lack of clarity regarding responsibility for issuing the SNF ABN. The resident remained in the facility without being informed of potential financial obligations.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide a written Bed-Hold notice to a resident or the resident's representative at the time of transfer to the hospital. This deficiency was identified for a resident who was moderately cognitively impaired and had been admitted to the facility prior to hospitalization. The Electronic Health Record (EHR) lacked documentation of a written Bed-Hold notice or any contact made to the resident or their representative regarding the Bed-Hold. During an interview, the Admissions Liaison stated that while they typically contacted the resident or representative to offer a Bed-Hold, there was no form filled out or documentation available for this particular resident. The facility administrator confirmed the expectation that a Bed-Hold should be offered and documented when a resident is transferred to the hospital.
Inaccurate MDS Assessment for Visually Impaired Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a resident's condition, specifically regarding visual impairment, for one of the sampled residents. The resident, who had a history of strokes, was documented in the MDS as alert and oriented, able to make care needs known, but the assessment did not account for the resident's visual deficit. This oversight was identified through observations, interviews, and record reviews, revealing that the resident had significant vision loss due to strokes, impacting their ability to perform Activities of Daily Living (ADLs) independently. Interviews with staff, including the Activity Director and Certified Nursing Assistant, confirmed the resident's visual impairment and the need for assistance with daily activities such as reading the activity calendar and identifying food items during meals. Despite the staff's awareness of the resident's condition, the MDS assessment did not reflect this critical aspect of the resident's health status, indicating a lapse in the facility's assessment process. Staff involved in the MDS assessments stated they followed CMS guidance, yet the deficiency suggests a failure in accurately gathering and documenting comprehensive information about the resident's needs.
Failure to Implement PASARR Level II Recommendations for Resident
Penalty
Summary
The facility failed to follow the recommendations of the Preadmission Screen and Resident Review (PASARR) Level II for a resident diagnosed with Parkinson's Disease and Depression, who was also experiencing hallucinations and delusions. The PASARR, dated 06/25/2024, indicated that Level II services were appropriate for new behaviors of a psychotic disorder. The Notice of Determination and the Initial Psychiatric Evaluation Summary recommended specialized behavioral health services, which could be provided in a skilled nursing facility by a licensed mental health professional. These recommendations included providing a low-stimulation environment, routine, and predictability, as well as specific behavioral interventions such as reorientation, redirection, empathic listening, and simple communication. Despite these recommendations, the resident's care plan, dated 07/28/2024, did not include the PASARR Level II recommendations for behavioral health interventions. Observations revealed that the resident was calling out, tearful, and making disorganized statements, indicating distress and confusion. Staff members, including a Certified Nursing Assistant and a Licensed Practical Nurse, were unable to locate specific interventions for behavior management in the electronic medical records or the Medication Administration Record. The Social Service Director and the Administrator acknowledged that PASARR Level II recommendations should be integrated into the care plan, but they were not found in the resident's care plan or the Kardex, which directs care for nursing assistants.
Inaccurate PASARR Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Pre-Admission and Resident Review (PASARR) assessments were completed correctly for two residents, which placed them at risk of not receiving necessary mental health services. Resident 38 was admitted with a diagnosis of depression, and the PASARR indicated a mood disorder with an exemption for a Level II evaluation due to an exempted hospital discharge. However, the exemption required a doctor's signature and was valid for only 30 days, which was not initially understood by the facility's administrator. Resident 100, admitted with depression and anxiety disorders, was noted to be severely cognitively impaired. The PASARR from the local hospital did not document any serious mental illness indicators, despite the discharge summary listing medications for anxiety and antipsychotic treatment. The Social Services Director acknowledged the need for a better system to review PASARRs for accuracy, indicating a lapse in the current review process.
Failure to Update Care Plan for Resident's Changing Needs
Penalty
Summary
The facility failed to update the care plan for a resident, identified as Resident 67, to reflect their changing needs, which placed the resident at risk for unmet care needs and diminished quality of care. Resident 67 was admitted with multiple diagnoses, including falls with fractures, dysphagia, aphasia, and dementia. The Minimum Data Set (MDS) assessment indicated that the resident was moderately cognitively impaired and required moderate assistance with toileting. Despite these needs, the care plan initiated on 07/31/2024 did not document the specific assistance required for toileting, eating, and grooming. The resident experienced multiple falls and had an incident where they pulled out their urinary catheter, which was not replaced. Observations showed that the resident had difficulty eating independently and was not offered assistance with toileting before meals. The Kardex, which is used to communicate care instructions to caregivers, also lacked specific directives for the resident's assistance needs. Staff J, the Unit Manager, acknowledged that the care plan was not updated to include these directives, indicating a lapse in communication and documentation of the resident's care needs.
Inconsistent Toilet Assistance for Resident with Falls and Aphasia
Penalty
Summary
The facility failed to provide consistent toilet assistance in accordance with Resident 67's preferences and abilities, leading to a deficiency in care. Resident 67, who was admitted with diagnoses including falls and aphasia, had moderate cognitive impairment and required moderate assistance with toileting. Despite this, the care plan did not specify the assistance needed for toileting, and the Kardex lacked directives for such care. Observations revealed that Resident 67 was not offered assistance to use the bathroom before meals, and staff interviews indicated a lack of awareness of a toileting schedule or specific assistance requirements. Resident 67 experienced multiple falls shortly after admission, and staff reported that the resident often attempted to use the bathroom independently, which led to falls. The resident's representative noted that Resident 67 was continent before hospitalization and questioned the use of incontinence briefs at the facility. Staff members provided inconsistent accounts of the resident's toileting needs, with some stating the resident required total care for incontinence, while others acknowledged the resident's requests for bathroom assistance. The lack of a clear toileting program and communication among staff contributed to the deficiency in care.
Failure to Provide Restorative Care Services
Penalty
Summary
The facility failed to provide necessary care and services to maintain or improve the range of motion (ROM) and activities of daily living for four residents, leading to an avoidable decline in their physical abilities. Resident 64, who was admitted with hemiplegia affecting the left side, was observed with limited mobility in her left arm and hand, yet no restorative therapy services were included in her care plan. Similarly, Resident 82, who suffered from hemiparesis following a stroke, reported that staff did not address his left-hand function, and he resorted to using online videos for exercises. Resident 15, who had a history of falls resulting in fractures, was observed using her non-dominant hand for eating due to weakness in her dominant arm. Despite her need for therapy to prevent stiffness in her right shoulder, no restorative services were documented in her care plan or electronic health record. Additionally, Resident 67, who was at risk of falls due to cognitive impairment and deconditioning, had multiple falls and was supposed to participate in a restorative program. However, there was no documentation of a plan, interventions, or goals for his participation. The facility's staff, including the Unit Manager, Activities Assistant, and Director of Rehab, indicated a lack of awareness and oversight regarding the restorative program. The program was reportedly overseen by the activities department, but there was no schedule or task assignment for restorative services, and participation was not adequately documented. The facility administrator acknowledged the absence of restorative documentation in resident records and the need to re-establish a restorative program.
Significant Medication Error: Tuberculin Administered to Allergic Resident
Penalty
Summary
The facility administered Tuberculin (TB) Solution to a resident who was allergic to it, resulting in a significant medication error. The resident, who was severely cognitively impaired, had a documented allergy to Tuberculin in their hospital history and physical note. Despite this, the resident was given the first step of the Tuberculin test on August 8, 2024, and the second step on August 16, 2024, as recorded in the Medication Administration Record. The error was confirmed by the Infection Preventionist and the Administrator after reviewing the resident's electronic health record, which indicated the resident should not have received the Tuberculin due to the allergy. This oversight placed the resident at risk for medical complications and diminished quality of life.
Medication Security Lapse in Medication Cart
Penalty
Summary
The facility failed to ensure the security of medications in one of the four medication carts reviewed, specifically the 100 hall medication cart. During an observation, a Licensed Practical Nurse (LPN), identified as Staff K, was seen leaving a medication cup with a clear yellow liquid on the cart unattended while attending to a resident in a room. The LPN later identified the liquid as lactulose, a medication used to prevent constipation, which the resident had refused. This incident occurred despite the expectation set by the Director of Nursing Services that all medications should be locked in the medication cart when not being administered, thereby placing residents at risk of unauthorized access to medications.
Failure to Maintain Suction Machine on Crash Cart
Penalty
Summary
The facility failed to maintain patient care equipment in safe operating condition, specifically the suction machine on the 2nd Floor crash cart. During an inspection, it was discovered that the suction machine had no suction when turned on. Staff L, an LPN, was unaware of what the sign-off forms on the cart were for, despite the crash cart being checked every night shift. Staff B, the Director of Nursing Services, confirmed that the night shift staff were responsible for checking the crash cart, including ensuring the suction machine was functional. However, it was acknowledged that the staff did not verify the suction capability of the machine, only that the motor was running. Staff M, an RN, explained the importance of the suction machine for clearing a resident's airway in emergencies, indicating that a non-functional machine would require obtaining another from the supply room.
Failure to Obtain Informed Consent for Wanderguards
Penalty
Summary
The facility failed to ensure consents for wanderguards were in place for two residents reviewed for informed consents regarding wanderguards. Resident 1, who was cognitively intact and did not exhibit wandering behavior, was asked to wear a wanderguard after a hospital stay without signing a consent. The resident expressed discomfort with the device and did not recall giving consent. Staff confirmed that an informed consent should have been obtained but could not locate the consent in the resident's electronic medical record (EMR). Resident 2, who was severely cognitively impaired and exhibited wandering behavior, also had a wanderguard placed without documented informed consent. The resident's care plan included monitoring for skin breakdown under the wanderguard, but there was no consent found in the EMR. Staff acknowledged the absence of the required consent documentation for both residents.
Failure to Conduct Proper Wanderguard Assessments
Penalty
Summary
The facility failed to ensure proper assessments and placement of wanderguards for three residents, leading to potential risks related to improper use of the device. Resident 1, who was cognitively intact and did not exhibit wandering behavior, was asked to wear a wanderguard without a prior safety evaluation. The Director of Nursing Services confirmed that no safety evaluation was completed before the wanderguard was placed on Resident 1. Resident 2, who was severely cognitively impaired and exhibited wandering behavior, had a wanderguard applied 47 days after an elopement care plan intervention was documented, but no prior elopement risk evaluations were found in the resident's electronic medical record (EMR). The Director of Nursing Services could not find a prior safety evaluation for Resident 2 either. Resident 3, who exhibited wandering behavior, had a safety evaluation indicating no elopement risk, but a wanderguard was ordered and placed without a subsequent safety assessment. The Director of Nursing Services acknowledged that the safety evaluation for Resident 3 was not updated before the wanderguard placement. These lapses in conducting timely and appropriate safety evaluations before placing wanderguards on residents led to deficiencies in the facility's accident hazard prevention measures.
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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