Lake Ridge Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Moses Lake, Washington.
- Location
- 817 East Plum Street, Moses Lake, Washington 98837
- CMS Provider Number
- 505261
- Inspections on file
- 31
- Latest survey
- October 16, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Lake Ridge Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities experienced a change in urinary condition and had orders for urinalysis with culture and sensitivity, but the facility failed to ensure timely review and follow-up of the lab results. The results, which showed multi-drug resistant bacteria, were not reviewed for 14 days, during which the resident's condition deteriorated, leading to hospitalization for septic shock due to urosepsis. Communication lapses among LNs, the medical provider, and the DON contributed to the delay and harm.
A resident with dementia, heart failure, and diabetes repeatedly refused prescribed diabetes medications, including insulin, over an extended period. Facility staff did not notify the resident's representative or physician of these refusals, as required, and there was no documentation of such notifications. The resident was later hospitalized for hyperglycemia and altered mental status, and the representative was unaware of the medication refusals.
The facility failed to properly monitor and respond to significant changes in a resident's respiratory status, resulting in an opioid overdose and aspiration pneumonia, and did not promptly assess or notify providers about a worsening pressure injury in another resident, causing severe pain. Additionally, two residents did not receive required specialized services due to missed referrals and lack of care plan communication, placing them at risk for health decline.
A resident with multiple health conditions, including malnutrition and skin breakdown, experienced significant unplanned weight loss due to the facility's failure to conduct ongoing nutritional assessments, monitor intake, and communicate changes to the interdisciplinary team. Staff did not consistently offer alternative food options or document refusals, and key team members were unaware of the resident's decline until hospitalization for complications related to poor nutrition.
A resident with severe cognitive impairment and a history of falls did not receive the required supervision and proper use of a fall prevention device when a nursing assistant failed to engage the drop seat in the resident's wheelchair. This omission led to the resident falling forward in the dining room and sustaining a forehead laceration that required hospital treatment.
Three residents were admitted with mental health diagnoses and received psychotropic medications, but their PASARR documentation did not accurately reflect these conditions or the need for Level II evaluation. Staff interviews revealed inconsistent verification of PASARRs against actual diagnoses and confusion about updated processes, leading to incomplete or incorrect PASARR records at admission.
The facility did not complete required OBRA registry verifications for several nurse aides before they began providing direct care, with some verifications delayed by months and others missing entirely. This failure meant the aides' eligibility and background were not confirmed as required by policy.
Multiple resident rooms and shower rooms were found with significant environmental deficiencies, including water on bathroom floors, cracked and stained flooring, exposed cement, mildew odors, damaged walls and trim, missing tiles, and unsanitary conditions such as soap scum and black substances. Maintenance staff were not consistently notified of these issues due to lapses in regular facility rounds and reporting procedures.
A resident with a urinary retention catheter experienced multiple UTIs and repeated antibiotic treatments after admission. Despite ongoing catheter use and recurrent infections, the facility did not refer the resident to a urologist to assess the need for continued catheterization or to address the cause of the UTIs.
Two residents requiring continuous oxygen therapy did not receive care according to physician orders, including failure to monitor oxygen saturation, replace and label oxygen tubing, maintain equipment cleanliness, and ensure humidification. One resident experienced skin irritation and used unlabeled, unchanged tubing without humidification, while another was left with an empty oxygen tank and low oxygen saturation, with staff unaware of the issue.
Two residents receiving high-risk medications, including a cytotoxic drug and an immunosuppressant, did not have appropriate care plans, monitoring, or administration protocols in place. Staff failed to use required precautions during medication administration, did not consistently administer medications at prescribed times, and did not monitor therapeutic drug levels as needed. Staff interviews revealed a lack of awareness regarding special handling and monitoring requirements for these medications.
Three residents received meals that were not appetizing or at safe temperatures due to delays in meal service. Although food was initially at the correct temperature, it became cold or lukewarm by the time it was served. Residents and staff reported dissatisfaction with the quality and temperature of the food, and staff acknowledged that delays in delivery contributed to the issue.
A resident with severe cognitive impairment and a history of falls sustained a laceration after falling in the dining room and was sent to the ER. The facility's investigation into the incident was incomplete, as required witness statements from staff were missing, despite established procedures for incident documentation.
A resident with Alzheimer's, depression, and anxiety was physically abused by a staff RN in response to the resident's aggressive behavior. The RN kicked the resident multiple times, which was witnessed by a Nursing Assistant. The facility's investigation substantiated the abuse, resulting in the RN's termination.
A resident with epilepsy and dementia experienced multiple falls and seizures after returning from a hospital stay, but the facility failed to ensure timely medical evaluation. Despite elevated Phenytoin levels, the resident was not seen by a medical provider until 13 days after readmission, leading to further health decline and repeated hospitalizations.
A resident with severe dementia and other conditions was injured during a mechanical lift transfer due to inadequate supervision. The facility's policy required two trained staff for such transfers, but only one staff member was actively involved, leading to the resident falling and sustaining a head injury. Interviews confirmed that the second staff member was merely observing, contrary to the policy.
A resident with dementia and severe cognitive impairment was physically abused by an RN who pushed them, causing a fall. The incident occurred after the RN's shift had ended, and the abuse was substantiated by the facility's investigation, leading to the RN's termination.
The facility failed to conduct annual performance reviews for five NAs, as required by WAC 388-97-1680. Personnel records showed missing or outdated reviews, placing residents at risk. Interviews revealed a flawed process where HR distributed forms that were not returned, and the Director of Nursing did not receive necessary forms. The Administrator acknowledged the broken process.
The facility failed to ensure proper hand hygiene and PPE use among staff, leading to potential exposure to MDROs. Staff members were observed not performing hand hygiene before and after resident contact and entering EBP rooms without PPE, despite facility policies and CDC guidelines.
A facility failed to honor a resident's right to make their own healthcare decisions by incorrectly designating a representative without consent. The resident, with chronic obstructive pulmonary disease and kidney disease, was able to make decisions but was overridden by their son-in-law, who was mistakenly treated as their representative. This led to a refusal of requested medication, violating the resident's rights.
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) as required for residents receiving Medicare-covered services. A resident with Alzheimer's did not receive the NOMNC within the required notice period, and another resident with a history of falls did not receive the SNFABN. Staff acknowledged the failure to provide timely notices.
The facility failed to ensure a sanitary and homelike environment in Hall C, the shower room, and several resident rooms. Observations revealed a strong urine odor in Hall C, damaged furniture, and a shower room in disrepair. Resident rooms had worn furniture and strong urine odors. Staff acknowledged the issues, noting that the furniture and room conditions were not up to standard.
The facility failed to notify the Ombudsman of transfers for two residents, one with Alzheimer's and dementia and another with a leg fracture and depression. Documentation of the required notices was missing, as confirmed by staff interviews, indicating non-compliance with the facility's notification process.
The facility failed to provide a complete Bed Hold Notice during hospital transfers for two residents, resulting in incomplete documentation and lack of information on bed hold charges. Interviews revealed that staff did not follow the expected procedure, risking residents' awareness of their rights and potential charges.
The facility failed to update the PASARR for two residents with new mental health diagnoses, including depression, anxiety, and dementia with behavioral disturbance. Despite the diagnoses being added to their records, the PASARRs were not updated, indicating a breakdown in the process. Staff interviews confirmed the oversight but did not provide an explanation for the failure.
A resident with severe cognitive impairment and multiple diagnoses, including dementia and dysphagia, did not receive consistent oral care as required by physician orders. Observations showed the resident's mouth was coated with a thick white film, and staff interviews revealed uncertainty about whether oral hygiene had been performed. The Director of Nursing acknowledged the system for assisting with oral care was ineffective.
The facility failed to implement resident preferences for outdoor activities, affecting multiple residents who expressed a desire to go outside. Despite care plans indicating the importance of outdoor activities, residents reported not being invited or given opportunities to go outdoors. Staff interviews revealed a lack of initiative in facilitating these activities, with some staff unaware of their role in assisting residents outside.
The facility failed to provide necessary restorative care to two residents, leading to a potential reduction in range of motion. One resident with hand contractures was not wearing prescribed splints, and another resident with severe dementia had no documented restorative therapy program. Staff interviews revealed confusion and miscommunication regarding the implementation of restorative programs, contributing to the deficiency.
A resident receiving enteral feeding through a PEG tube was at risk due to inappropriate connections between the tube and feeding spike set, leading to potential contamination and leakage. A nurse used a paper towel for traction on the slippery connection, a method not officially trained or sanctioned. The Director of Nursing and Administrator expected staff to report equipment issues, but this was not done, resulting in the deficiency.
A resident with COPD and heart failure did not receive continuous oxygen as prescribed while being transported within the facility. Observations showed the resident without oxygen on multiple occasions, and staff confirmed the lack of portable oxygen for in-facility use, relying on oxygen concentrators instead.
The facility failed to maintain complete and individualized clinical records for residents receiving foot care. Residents with significant medical conditions had identical podiatry notes, and there was a lack of communication between the podiatrist and nursing staff. Observations showed untreated foot issues, and staff interviews revealed that podiatry records were not reviewed or communicated effectively.
The facility failed to report an abuse allegation to the State Agency in a timely manner for two residents with Alzheimer's disease. A staff member allegedly pushed and yelled at the residents and kicked one resident's walker. The DNS did not report the incident, believing an anonymous report by a NA sufficed, contrary to facility policy requiring immediate reporting.
Failure to Timely Review and Act on Urinary Lab Results Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that physician orders from a urologist were completed and reviewed according to professional standards of practice for a resident with a history of diabetes, obstructive uropathy, and dementia. The resident, who was frequently incontinent and required extensive assistance with activities of daily living, experienced a change in urinary condition, including painful urination and hematuria. Orders were given for a urinalysis (UA) with culture and sensitivity (C & S), but there was no documentation that the UA was completed as ordered prior to a scheduled cystoscopy. After the cystoscopy, another UA was ordered and collected, but the results were not reviewed or acted upon in a timely manner. The medical record showed that the UA with C & S results, which indicated the presence of multi-drug resistant bacteria, were not reviewed by the facility's medical provider until 14 days after collection. During this period, the resident exhibited increased behavioral symptoms, including aggression and lethargy, but the pending laboratory results were not referenced or addressed in interdisciplinary team meetings or provider notes. Communication breakdowns occurred among licensed nurses, the medical provider, and the director of nursing, with staff assuming others had received and addressed the results. The director of nursing was unaware of the pending UA with C & S until contacted by the resident's representative. The delay in reviewing and acting upon the laboratory results contributed to the resident's hospitalization for septic shock due to urosepsis. Interviews with staff and the resident's representative confirmed that the facility did not respond promptly or thoroughly to the resident's change in condition, and the laboratory results were not followed up in accordance with facility policy or professional standards. The failure to ensure timely review and response to critical laboratory findings resulted in harm to the resident.
Failure to Notify Physician and Representative of Repeated Medication Refusals
Penalty
Summary
Facility staff failed to notify the resident's representative and physician of multiple medication refusals by a resident with diagnoses including dementia, heart failure, and diabetes mellitus. The resident, who had severely impaired cognition and required significant assistance with daily activities, was prescribed several medications to manage diabetes, including Glipizide, Humalog insulin, and Lantus insulin. The Medication Administration Record showed frequent refusals of these medications, particularly insulin, with some medications refused up to 22 out of 24 opportunities. Despite these repeated refusals, there was no documentation in the nursing progress notes indicating that the resident's representative or medical provider had been notified. Interviews with facility staff revealed inconsistent practices regarding notification of medication refusals. Some staff stated they would notify nursing management or the medical provider after more than one refusal, while others relied on verbal notifications or attempted to document notifications in the medical record. The Director of Nursing Services confirmed that notifications should have been made for these refusals, especially for medications with significant health impacts. The resident was subsequently admitted to the hospital for hyperglycemia and altered mental status, and the resident's representative reported being unaware of the extent of the medication refusals prior to the hospitalization.
Failure to Monitor Changes, Assess Wounds, and Provide Specialized Services
Penalty
Summary
The facility failed to thoroughly evaluate and monitor significant changes in a resident's respiratory condition and increased sedation from medications, resulting in actual harm. One resident with multiple diagnoses, including a recent fracture, heart disease, and chronic pain, exhibited signs of respiratory distress, confusion, and lethargy over a two-day period. Despite staff observations of abnormal skin color, slow responses, and complaints of pain and shortness of breath, there was a lack of timely and thorough assessment, delayed completion of ordered diagnostic tests, and inadequate monitoring of medication side effects. The resident ultimately experienced an opioid overdose and aspiration pneumonia, requiring emergency hospital intervention. Another resident with end-stage renal disease and a history of pressure injuries experienced a worsening coccyx wound that was not promptly assessed or reported to the provider. Nursing staff documented the wound's deterioration but failed to complete a full assessment, obtain measurements, or notify the provider in a timely manner. Communication breakdowns among staff and the interdisciplinary team led to a four-day delay in addressing the wound, during which the resident experienced severe pain. Staff interviews revealed confusion about wound assessment responsibilities and a lack of training in staging pressure injuries. Additionally, the facility did not follow through with specialized services for two residents. One resident with Alzheimer's disease and malnutrition was observed repeatedly leaning to one side in their wheelchair without the prescribed positioning wedge, as staff were unaware of the care plan and equipment needs due to poor communication between therapy and nursing. Another resident with a history of liver transplantation and chronic hepatitis did not receive timely referrals to a gastroenterologist or hepatologist as ordered, with staff citing workload and oversight as reasons for the delay. These failures placed residents at risk of not receiving necessary care and services to prevent decline in health and mobility.
Failure to Monitor and Address Significant Weight Loss in Resident at Nutritional Risk
Penalty
Summary
The facility failed to ensure that a resident at risk for weight loss received appropriate nutritional review and intervention. The resident, who had a history of skin breakdown, protein-calorie malnutrition, post-surgical recovery from a fractured thigh, rheumatoid arthritis, and urinary tract infections, experienced a significant unplanned weight loss of 18.67% over 40 days. Despite facility policies requiring regular nutritional assessments and weight monitoring, there was only one documented nutrition assessment shortly after admission, with no follow-up assessments or progress notes for nearly two months. Observations and interviews revealed that the resident consistently consumed less than the targeted amount of food, with meal intake ranging from 25% to 75%. Staff did not routinely offer alternative food options when the resident refused meals, and there was a lack of documentation regarding reasons for meal refusals or what alternatives were provided. The resident's care plan identified them as being at nutritional risk, but interventions were not effectively implemented or monitored, and significant weight changes were not communicated to the interdisciplinary team, physician, or dietitian as required by facility policy. Further, key staff members, including the ARNP, case manager, and registered dietitian, were unaware of the resident's significant weight loss and nutritional decline. The dietitian noted discrepancies in weight documentation and gaps in communication about the resident's condition. The resident was eventually hospitalized with low protein levels, electrolyte imbalance, and aspiration pneumonia, highlighting the lack of coordinated care and timely response to the resident's nutritional needs.
Failure to Provide Adequate Supervision and Proper Use of Fall Prevention Devices
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of repeated falls, epilepsy, and lack of coordination did not receive adequate supervision and proper use of fall prevention devices as outlined in their care plan. The resident, who was dependent on staff for activities of daily living and enrolled in hospice care, was transferred to a drop seat wheelchair by a nursing assistant. However, the staff member failed to engage the drop-down seat into the reclining position, which was a required intervention to prevent the resident from falling forward. As a result of this omission, the resident fell forward out of the wheelchair in the dining room, sustaining a laceration to the left forehead that required hospital intervention for bleeding control and stitches. The incident was unwitnessed, and the facility's incident reporting log confirmed the fall and injury. Staff interviews revealed that the required post-fall procedures were followed after the incident, but the administrator acknowledged that the investigation into the event had not been completed at the time of the survey.
Failure to Accurately Review and Validate PASARR Documentation on Admission
Penalty
Summary
The facility failed to accurately review and validate Preadmission Screening and Resident Reviews (PASARR) for three out of five residents reviewed. Specifically, residents were admitted with diagnoses such as dementia, depression, anxiety, and obsessive-compulsive disorder, and were receiving psychotropic medications. However, their PASARR documentation did not consistently reflect these diagnoses or the need for a Level II evaluation, as required. For example, one resident's PASARR indicated no serious mental illness (SMI) despite documented depression and anxiety, while another's PASARR failed to list depression or OCD, even though both were present upon admission. Interviews with staff revealed that the admissions process involved reviewing PASARRs prior to admission, but there was no consistent verification of PASARR information against residents' actual diagnoses. Staff reported challenges in obtaining corrected PASARRs from hospitals and were not always aware when PASARRs were inaccurate. Additionally, there was confusion among staff regarding responsibility for verifying PASARR accuracy and awareness of updated PASARR processes, despite recent training. These lapses resulted in residents being admitted with incomplete or incorrect PASARR documentation.
Failure to Complete Timely OBRA Registry Verification for Nurse Aides
Penalty
Summary
The facility failed to ensure that Omnibus Budget Reconciliation Act (OBRA) registry verifications were completed for five nurse aides prior to their employment and provision of direct, unsupervised care to residents. Personnel files for these nurse aides showed either delayed verification or no documentation of OBRA registry checks, with one staff member's registry verified over five months after starting work and others lacking any verification at the time of review. The facility's policy required screening potential employees for a history of abuse, neglect, and mistreatment by checking licensing boards and registries, but this process was not followed as required. Interviews with Human Resources and the Administrator confirmed that OBRA registry verifications were not completed timely for the affected nurse aides, and that the issue was only identified during an internal audit. The lack of timely registry verification meant that the facility did not confirm whether these nurse aides met competency evaluation requirements or had any disqualifying findings before they began working with residents.
Failure to Maintain Safe and Sanitary Resident and Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, comfortable, and sanitary environment in multiple resident rooms and shower rooms, as evidenced by direct observations and resident interviews. Specific deficiencies included bathrooms with persistent water on the floor, stained and cracked flooring with exposed cement, mildew odors, damaged drywall and paint, missing trim with jagged edges, and deep gouges in walls and doors. In the shower rooms, there were missing tiles, cracked flooring, exposed concrete, black and brown substances on tiles, and significant soap scum buildup on handrails. These environmental issues were present in five out of eight resident rooms and two out of three shower rooms reviewed. Interviews with staff revealed that the maintenance director was not consistently informed of these issues due to a lack of regular facility rounds and reliance on staff to report problems through an electronic maintenance log. The maintenance director confirmed that room checks were only performed when residents moved or were discharged, and that ongoing issues were not being systematically identified or addressed. The administrator acknowledged that the expected process of daily rounds and regular interdisciplinary checks was not followed, resulting in these deficiencies being overlooked.
Failure to Refer Resident with Indwelling Catheter for Urologist Assessment
Penalty
Summary
A resident was admitted to the facility with a urinary retention catheter following a hospital stay, during which the catheter was placed and the resident developed a urinary tract infection (UTI). The resident had a history of heart disease and was alert and oriented at the time of admission. The medical record indicated that the resident was not on a urinary catheter prior to admission and had experienced multiple UTIs and antibiotic treatments since being at the facility. Observations and interviews confirmed the ongoing use of the urinary catheter and repeated episodes of UTIs. Despite the resident's repeated UTIs and continued use of the urinary catheter, there was no evidence that the facility referred the resident to a urologist to assess the necessity of the catheter or to determine the cause of the recurrent infections. The Resident Care Manager confirmed that no referral had been made to obtain further evaluation or orders regarding the catheter's continued use or possible removal. This lack of referral and assessment contributed to the deficiency cited in the report.
Failure to Provide Safe and Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents requiring continuous oxygen therapy. For one resident with anemia and heart disease, staff did not follow physician orders to monitor oxygen levels every shift, clean the oxygen concentrator filter weekly, or replace oxygen tubing and nasal cannula every seven days. Observations revealed the resident's oxygen tubing was cloudy and unlabeled, the nasal area and skin behind the ears were irritated and red, and there was no sterile water attached to the concentrator for humidification. Staff were unaware of the missing humidification and labeling, and the oxygen concentrator filter was found to be dirty with visible dust buildup. For another resident with interstitial pulmonary disease and dementia, staff failed to ensure continuous oxygen delivery as ordered. The resident was observed multiple times with an empty portable oxygen tank, resulting in an oxygen saturation reading of 86%. The resident expressed feeling unwell, and staff were unaware that the oxygen tank was empty. Physician orders required verification that oxygen saturation remained above 92% during transfers and showers, but this was not monitored or maintained. These failures were identified through direct observation, interviews, and record review.
Failure to Monitor and Administer High-Risk Medications Appropriately
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary drugs due to inadequate monitoring, administration, and care planning for high-risk medications. For one resident with chronic lymphocytic leukemia and dementia, the care plan did not address cancer, the use of cytotoxic medication, or include interventions for monitoring adverse side effects or guidance for specialized handling. During medication administration, staff were observed not using gloves when handling Imbruvica, a cytotoxic medication, and staff interviews revealed a lack of awareness regarding necessary precautions and monitoring for side effects such as hemorrhage. For another resident with a history of liver transplantation, liver cancer, and chronic hepatitis, the physician's orders for Tacrolimus did not specify the need for administration at the same time each day, which is required to maintain therapeutic blood levels. The resident's medication administration records showed multiple instances where Tacrolimus was given late, early, or missed entirely. Additionally, laboratory tests to monitor therapeutic levels of Tacrolimus had not been obtained since admission, and the care plan did not address the transplant, immunosuppressive therapy, or monitoring for side effects and special administration instructions. Staff interviews indicated a lack of knowledge regarding the handling and monitoring of both cytotoxic and immunosuppressant medications. The contracted pharmacist confirmed the need for routine monitoring and administration protocols but had not ordered necessary lab tests, and the DON acknowledged the absence of additional monitoring or education for residents on immunosuppressant therapy. These deficiencies were observed and confirmed through record review, staff interviews, and direct observation.
Failure to Serve Palatable and Appropriately Tempered Meals
Penalty
Summary
The facility failed to provide appetizing and palatable meals to three residents, as evidenced by multiple observations and interviews. Meal temperatures were initially within guidelines when checked prior to service, but significant delays occurred between meal preparation and actual serving. For example, meal trays were prepared and placed in carts, but were not served to residents until 17 minutes later. When meals were finally served, test trays and resident meals were found to be below appropriate serving temperatures, with hot foods such as chicken fried steak and green beans served cold or lukewarm, and cold items like milk and pineapple above the recommended cold temperature. Residents reported dissatisfaction, describing their meals as cold, not appetizing, and not tasty. Staff interviews confirmed the issue, with dietary and administrative staff acknowledging that meals were not at the correct temperatures and that delays in meal service contributed to the problem. The facility's own policy required prompt notification and delivery of meals, but this was not consistently followed, resulting in residents receiving food that was not palatable or at a safe and appetizing temperature.
Failure to Thoroughly Investigate Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate a fall involving a resident with dementia, muscle weakness, lack of coordination, and a history of repeated falls. The resident was admitted with severe cognitive impairment and was dependent on staff for activities of daily living. On the date of the incident, the resident fell in the dining room, resulting in a laceration to the left forehead and subsequent transfer to the emergency room for evaluation and treatment. Review of the facility's incident reporting log and investigation documentation revealed that witness statements were missing from the investigation of the fall. Interviews with staff confirmed that witness statements were not obtained or could not be located for the incident. Staff members described the expected procedure of reporting and documenting incidents, including the completion of witness statement forms by all staff present. However, it was acknowledged by both the Resident Case Manager and the Administrator that the required witness statements were not included in the investigation file for this incident. This lack of documentation indicated that the facility did not complete a thorough investigation as required.
Resident Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, which was substantiated through an investigation. The resident, who had been admitted with Alzheimer's Disease, depression, and anxiety, exhibited severe cognitive impairment and required assistance with personal care. The resident was involved in an incident where they displayed agitated and aggressive behavior, attempting to kick a staff member. In response, the staff member, identified as a Registered Nurse, retaliated by kicking the resident in the left lower leg multiple times. The facility's investigation confirmed the abuse, leading to the termination of the staff member's employment. Witnesses, including a Nursing Assistant, corroborated the incident, stating they observed the staff member kick the resident four times. The Director of Nursing immediately removed the staff member from the floor and conducted a skin assessment on the resident, finding no injuries. A Resident Representative acknowledged the resident's occasional aggressive behavior but did not believe it justified the staff's abusive response.
Failure to Ensure Timely Medical Evaluation for Resident
Penalty
Summary
The facility failed to ensure timely medical evaluation for a resident who experienced a decline in condition and multiple falls after returning from a hospital stay. The resident, diagnosed with epilepsy and dementia, had severely impaired cognition and was independent in daily tasks. However, they experienced seizures, falls, and head injuries, leading to multiple hospital transfers. Despite elevated Phenytoin levels noted in the hospital discharge summary, the facility staff did not question the continuation of the medication or ensure the resident was seen by a medical provider promptly. The resident was readmitted to the facility with elevated Phenytoin levels, but the staff did not arrange for a timely evaluation by the facility's medical provider. The resident continued to experience falls and seizures, resulting in further injuries and hospital visits. The facility's staff, including the Resident Care Manager and Infection Preventionist, acknowledged that residents should be seen by a medical provider within a week of hospital readmission, but this was not done for the resident in question. Interviews with facility staff, including the Director of Nursing and Medical Director, confirmed the expectation for residents to be evaluated within a week of hospital readmission. However, the resident was not seen by the facility medical provider until 13 days after readmission, despite multiple emergency room visits and elevated medication levels. This delay in medical evaluation contributed to the resident's continued health decline and repeated hospitalizations.
Failure in Safe Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure safe supervision and handling during mechanical lift transfers, resulting in harm to a resident. The policy titled Safe Resident Handling/Transfer Equipment required two trained staff to operate a mechanical lift for dependent lifting, transferring, or repositioning. However, during a transfer, only one staff member, Staff C, a Nursing Assistant, was actively involved in the process, while another staff member, Staff F, an LPN, was merely observing and did not assist. This lack of adherence to the policy led to a mechanical lift accident. The incident involved a resident with severe dementia, brain cysts, and mood disorders, who was totally dependent on staff for transfers. The resident was being transferred from a wheelchair to a bed using a mechanical lift when one of the sling straps loosened from the lift bar, causing the resident to fall and sustain a head laceration. The resident required hospital evaluation and treatment, including six staples to the head. Interviews revealed that Staff C had requested assistance from Staff F, but Staff F did not participate in the transfer, contrary to the facility's policy requiring two staff members to be actively involved. Staff E, responsible for staff development, confirmed that both staff members should have hands-on involvement during such transfers. The facility's administrator acknowledged the unsafe practice of having only one staff member conduct the transfer.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff, as evidenced by an incident involving a registered nurse (RN) identified as Staff C. The incident occurred when Staff C pushed a resident, who had been exhibiting increased wandering behaviors, causing the resident to fall. This action was taken while attempting to redirect the resident out of another resident's room. The facility's investigation substantiated the abuse, with statements from other staff members corroborating that Staff C admitted to pushing the resident in response to being hit in the chest by the resident. The resident involved had been admitted with diagnoses of dementia, malnutrition, and anxiety, and was noted to have severe cognitive impairment. The facility's policy explicitly prohibited abuse and mistreatment of residents, and the Director of Nursing confirmed that physical force was never acceptable. The investigation revealed that Staff C's shift had ended prior to the incident, and they should not have been on the floor with residents. The incident was documented in the medical record, and the abuse was substantiated, leading to the termination of Staff C's employment.
Failure to Conduct Annual Performance Reviews for Nursing Assistants
Penalty
Summary
The facility failed to complete annual performance reviews for five Nursing Assistants (NAs), which is a requirement under WAC 388-97-1680. The personnel records for Staff R, T, U, V, and W showed either missing or outdated performance reviews. Staff R had only one review dated two years after their hiring date, while Staff T, U, and W had no documented reviews at all. Staff V had a single review from 2019, despite being hired in 2015. This lack of compliance with the annual review requirement placed residents at risk of receiving care from potentially unqualified staff. Interviews with facility staff revealed a breakdown in the process for conducting these reviews. Staff Y, the HR/Payroll Manager, described a flawed system where performance review forms were distributed to management but often not returned. Staff B, the Director of Nursing Services, indicated that they were responsible for the reviews but did not receive the necessary forms from HR. The Administrator, Staff A, acknowledged awareness of the issue, admitting that the process for annual performance reviews was ineffective.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBPs) and proper hand hygiene practices among staff members, which are critical measures to prevent the transmission of multidrug-resistant organisms (MDROs) in skilled nursing facilities. Observations revealed that six staff members, including registered nurses and nursing assistants, did not perform hand hygiene before and after resident contact, while handling food trays, or when moving between tasks in the dining area. This lack of adherence to hand hygiene protocols was observed multiple times, with staff members touching resident plates, cutting food, and serving meals without washing their hands or using gloves. Additionally, the facility did not ensure the use of personal protective equipment (PPE) in rooms designated for enhanced barrier precautions. Staff members were observed entering EBP rooms without donning the required PPE, despite the presence of signage indicating the need for such precautions. Interviews with staff confirmed a lack of awareness and adherence to the facility's infection control policies, which are based on CDC guidelines. These failures placed all residents at risk for exposure to MDROs and potential serious medical complications.
Failure to Honor Resident's Right to Make Healthcare Decisions
Penalty
Summary
The facility failed to honor a resident's right to make their own healthcare decisions by incorrectly designating a representative without the resident's consent. Resident 16, who was admitted with chronic obstructive pulmonary disease and kidney disease, was found to have moderately impaired cognition but was still able to make their own decisions. Despite this, the facility allowed the resident's son-in-law to act as their representative without proper documentation or consent from the resident. The son-in-law refused consent for an antidepressant medication that the resident had requested, which was against the resident's wishes. The facility's admissions process was flawed, as the Admissions Coordinator completed the paperwork with the son-in-law without verifying the legal authority or speaking directly with the resident. The admission agreement clearly indicated that no representative was designated, yet the son-in-law was treated as such. This oversight led to a violation of the resident's rights, as they were not allowed to exercise their right to make their own healthcare decisions, despite being cognitively intact at the time of admission.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) as required for residents receiving Medicare-covered services. Specifically, Resident 37 did not receive the NOMNC within the required two-day notice period before the end of their Medicare Part A stay, and there was no documentation of an SNFABN being issued. Resident 37, diagnosed with Alzheimer's disease and requiring maximum assistance for activities of daily living, continued to stay in the facility without exhausting their Medicare benefits. The Business Office Manager acknowledged the failure to provide timely notice. Additionally, Resident 162, who had a history of falls and was admitted with a broken hip and tailbone, did not receive the required SNFABN before their last covered day of skilled services. The Minimum Data Set Coordinator confirmed that both Resident 37 and Resident 162 should have received the SNFABN. The facility's Administrator also acknowledged the necessity of completing and delivering these notices in a timely manner according to regulations.
Facility Fails to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment in Hall C, the shower room, and several resident rooms. Observations over a week revealed a persistent strong odor of urine in Hall C, with staff acknowledging the issue but unable to identify its source. The furniture in Hall C was in disrepair, with peeling leather, gouges, and fecal matter observed on a chair and the floor beneath it. The shower room was dimly lit, with missing tiles exposing concrete, and a ceiling fan coated with lint. The grout lines in the shower tiles showed discoloration, and the shower door had paint scrapes and smears of unknown substances. In the resident rooms, furniture was worn and damaged, with dressers and nightstands showing scratches and missing handles. The bathrooms had strong urine odors, sticky floors, and missing paint or trim. Staff interviews revealed that the furniture surfaces were not cleanable, and there were ongoing issues with removing urine odors from the flooring. The Director of Nursing Services and Housekeeping Supervisor acknowledged the deficiencies, noting that the furniture and room conditions were not up to standard and required attention.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to the representative of the Office of the State Long Term Care Ombudsman for two residents reviewed for transfer or discharge notice requirements. This deficiency was identified during interviews and record reviews. The facility's policy, revised on 11/15/2022, mandates that a written notice of transfer or discharge must be provided to the Ombudsman when the facility initiates a discharge of a resident transferred to a hospital or other acute care setting. Resident 38, who had Alzheimer's disease and dementia with severely impaired cognition, was transferred to the emergency department following a change in health condition. However, there was no documentation of a notice of transfer or discharge to the Ombudsman in the resident's medical record. Similarly, Resident 59, who had a right leg fracture and depression with moderately impaired cognition, was transferred to the hospital and did not return to the facility. There was no documentation of a notice of transfer or discharge to the Ombudsman for this resident either. Staff interviews confirmed the absence of such documentation, indicating a failure to adhere to the facility's notification process.
Failure to Provide Bed Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to issue a written notice of bed hold at the time of hospital transfer for two residents, which is a requirement to inform residents or their representatives about their right to hold their bed and any associated charges. For Resident 16, who had chronic obstructive pulmonary disease and kidney disease, the Bed Hold Notice Policy and Authorization form was incomplete, lacking the monetary rate for the per day charge and a resident signature. The form contained illegible handwriting and signatures, indicating a lack of proper documentation. Similarly, for Resident 38, who had Alzheimer's disease, the Bed Hold Notice Policy and Authorization form was also incomplete, missing the daily monetary amount to hold the bed and documentation of whether the resident or their representative wanted to hold the bed. Interviews with facility staff revealed that the expected procedure was not followed, as the nursing staff should have completed the form with the required information and ensured it was signed appropriately. This oversight placed the residents at risk of not being informed about their rights and potential charges during their hospital stay.
Failure to Update PASARR for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASARR) for two residents, which is a federally required form to prevent inappropriate placement in nursing homes. Resident 16 was admitted with diagnoses including chronic obstructive pulmonary disease, kidney disease, and depression. Despite a diagnosis of depression being noted in a provider progress note and added to the resident's admission record, there was no documentation of an updated PASARR to reflect this mental health condition. Similarly, Resident 52 was admitted with diagnoses including bipolar disorder and later received new diagnoses of anxiety and dementia with behavioral disturbance. The admission PASARR indicated a mood disorder but did not include these additional mental health conditions. There was no documentation of an updated PASARR for these new diagnoses. Interviews with facility staff revealed a breakdown in the process of updating PASARRs when new mental health-related diagnoses were added, as the Director of Nursing Services and the Administrator acknowledged the failure but could not explain why the process was not followed for these residents.
Failure to Provide Consistent Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide consistent oral care for a resident who was dependent on staff for activities of daily living (ADL). The resident, who had diagnoses including dementia, dysphagia, muscle weakness, and contractures, was admitted with a physician's order for oral care every shift. Observations over several days revealed that the resident's teeth and mouth were consistently coated with a thick white film, indicating a lack of proper oral hygiene. Interviews with staff members, including nursing assistants and a registered nurse, revealed uncertainty about whether the resident's oral care had been performed, despite the expectation that staff would provide all necessary personal care for dependent residents. The Director of Nursing Services acknowledged that the system in place to assist with residents' oral care was not functioning effectively. The facility's policy on ADLs, revised in May 2023, stated that residents unable to perform ADLs would receive the necessary assistance to maintain good personal and oral hygiene. However, the observations and staff interviews indicated that this policy was not being followed, resulting in unmet care needs for the resident.
Failure to Implement Resident Preferences for Outdoor Activities
Penalty
Summary
The facility failed to implement resident preferences for outdoor activities, affecting five out of six residents reviewed for activities. The facility's policy, dated February 1, 2023, mandates that residents' preferences and choices should be incorporated to enhance their self-worth. However, observations and interviews revealed that residents were not provided opportunities to go outside, despite their expressed desires and care plans indicating the importance of outdoor activities for their well-being. Resident 56, with diagnoses including COPD, dementia, and heart failure, expressed a strong desire to go outside, but reported rarely having the opportunity due to staff being too busy. Similarly, Resident 7, who has anoxic brain damage, dementia, and depression, stated they were bored and not invited to go outdoors, despite their care plan highlighting the importance of outdoor activities. Residents 13, 14, and 25 also expressed a desire to go outside, with Resident 13 describing the facility as "like a prison" due to the lack of outdoor access. Interviews with staff members, including the Activities Director and Nursing Assistants, revealed a lack of initiative in facilitating outdoor activities. The Activities Director mentioned that outdoor group activities were only provided during certain months, and staff were not actively offering residents the opportunity to go outside. Nursing Assistants stated they were not responsible for taking residents outdoors, and some were informed they could not do so. The Administrator indicated that residents needed to request outdoor access and be assessed for wandering freely, but this process was not effectively communicated or implemented.
Failure to Implement Restorative Care for Residents
Penalty
Summary
The facility failed to provide necessary services to prevent a reduction in range of motion for two residents, identified as Residents 2 and 15, who were reviewed for range of motion and/or use of splints. Resident 2, who was admitted with diagnoses including dementia, dysphagia, muscle weakness, and contractures in both hands, had a physician's order for daily use of hand splints. However, multiple observations revealed that Resident 2 was not wearing the prescribed splints or alternatives like rolled washcloths, as required. Staff interviews indicated a lack of clarity and adherence to the restorative therapy schedule, contributing to the deficiency. Resident 15, also with severe dementia and dependent on staff for daily care, was observed with hands in a fist position without any splints or washcloths to prevent contractures. Despite having contractures, there was no restorative therapy program documented in their physician orders. Interviews with staff revealed confusion and miscommunication regarding the implementation and responsibility for restorative programs, with the physical therapy department, MDS coordinator, and resident care managers not effectively coordinating to ensure the resident received necessary care. The deficiency was further highlighted by the lack of a restorative program for Resident 15, as confirmed by staff interviews. The physical therapy department was expected to provide a restorative plan to the MDS coordinator, but this process was not completed, leaving Resident 15 without the necessary interventions to prevent further decline. The Director of Nursing Services acknowledged the expectation for a restorative plan to be implemented, but the failure in communication and execution led to the deficiency observed by the surveyors.
Inappropriate Enteral Feeding Practices
Penalty
Summary
The facility failed to ensure appropriate treatment and services related to enteral feeding for a resident, identified as Resident 52, who was dependent on tube feeding through a percutaneous endoscopic gastrostomy (PEG) tube. The deficiency was observed when inappropriate connections were used between the PEG tube and the tube feeding spike set, leading to potential contamination and loss of caloric intake due to fluid leakage. During observations, it was noted that a brown paper towel was wrapped around the end of the tube feeding spike set and the receiving end of the PEG tube, with dried formula splatters on the floor and the pole holding the tube feed. Interviews with staff revealed that the Registered Nurse, identified as Staff J, used the paper towel to maintain traction on the slippery tube feeding spike set, despite not being trained to do so. Staff J admitted to devising this method independently due to the lack of proper equipment. The Director of Nursing Services, Staff B, stated that licensed nurses were expected to report equipment issues to administrative staff for resolution. The Administrator, Staff A, also expected licensed nurses to ensure all necessary equipment and supplies were available before starting procedures and to report any missing items to the Resident Care Manager or DNS.
Failure to Provide Continuous Oxygen Supply
Penalty
Summary
The facility failed to ensure a continuous supply of oxygen for a resident, identified as Resident 56, who required continuous oxygen due to chronic obstructive pulmonary disease (COPD) and heart failure. The resident was observed on multiple occasions without their prescribed oxygen supply while being transported within the facility. On one occasion, the resident was brought into the dining room without oxygen and was visibly short of breath, holding their oxygen tubing in hand. Staff later retrieved an oxygen concentrator from the resident's room. Another observation noted the resident being returned to their room without oxygen, and staff had to go back to get the oxygen machine. Interviews with facility staff revealed that the facility did not have portable oxygen available for use within the facility, relying instead on oxygen concentrators that require electricity. Staff members acknowledged that the resident would be without oxygen for a few minutes during transport within the facility. The Director of Nursing Services stated that continuous oxygen monitoring was expected for the resident when moving throughout the building and that a physician order would be needed to transfer the resident without oxygen. If such an order was denied, portable oxygen tanks would be used to ensure continuous oxygen supply during movement within the facility.
Incomplete and Non-Individualized Podiatry Records
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurate for three residents who were reviewed for foot care. The residents involved had significant medical conditions, including dementia, multiple sclerosis, Alzheimer's disease, and paraplegia, which made them dependent on staff for activities of daily living and resulted in impaired cognition. The podiatry notes for these residents were not individualized and were identical for each resident, indicating a lack of proper documentation and communication regarding the care provided. Observations revealed that one resident had visible foot issues, such as black crust and thick, flaky toenails, which were not adequately addressed. Interviews with staff, including a Licensed Practical Nurse, Resident Care Managers, and the Director of Nursing Services, highlighted that there was no effective communication or hand-off process between the podiatrist and the nursing staff. The podiatrist's notes were not reviewed by nurses or care managers, and the records from the podiatrist's visits were delayed, leading to a lack of awareness about the specific care provided to each resident.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report an allegation of abuse/neglect to the State Agency in a timely manner for two residents, both diagnosed with Alzheimer's disease and having severely impaired cognition. The incident involved a staff member allegedly pushing and yelling at the residents and kicking one resident's walker. The Director of Nursing Services (DNS) was informed of the incident by a nursing assistant (NA) who had reported the abuse anonymously to the State Agency. However, the DNS did not make an official report from the facility, mistakenly believing the NA's anonymous report fulfilled the facility's reporting obligation. The facility's policy required immediate reporting to the State Agency, within two hours for serious bodily harm allegations and within 24 hours for non-serious bodily injury allegations. The Administrator acknowledged that the facility's normal process was not followed, as the anonymous report by the NA did not meet the requirement for a facility report. This oversight placed the residents at risk for unidentified and ongoing abuse/neglect, as the facility did not ensure the proper reporting protocol was followed.
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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