Lea Hill Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, Washington.
- Location
- 32049 109th Pl Se, Auburn, Washington 98092
- CMS Provider Number
- 505528
- Inspections on file
- 17
- Latest survey
- September 19, 2025
- Citations (last 12 mo.)
- 61
Citation history
Health deficiencies cited at Lea Hill Rehabilitation And Care Center during CMS and state inspections, most recent first.
Two residents with limited English proficiency were not provided with the required interpreter services or communication aids as outlined in their care plans. Staff failed to use phone translators, language line services, or communication binders during care, resulting in ineffective communication and unmet needs for these residents.
Staff failed to maintain cold food at or below 41°F during meal service, as Jello dessert cups were served at temperatures of 45°F and 50°F, contrary to facility policy and food safety standards. Staff interviews confirmed the importance of proper cold food temperatures, but the deficiency was observed during lunch preparation.
A resident receiving medications via gastric tube did not have privacy maintained when a nurse left medical information unsecured and visible, left the room door open, and did not use the privacy curtain while exposing the resident's abdomen. Both the nurse and DON confirmed that privacy and confidentiality were not upheld as required by facility policy.
The facility did not provide or document nonpharmacological interventions before administering psychotropic medications to three residents with depression, anxiety, or mood disorders. Additionally, staff failed to complete required AIMS assessments and did not monitor for adverse side effects or target behaviors in a resident receiving antipsychotic and antidepressant medications, contrary to facility policy.
The facility did not provide required written notifications of hospital transfers to two residents and their representatives, nor did it consistently notify the Ombudsman as required. These residents, who had conditions such as stroke and heart failure, were transferred to the hospital without receiving timely written explanations or information about their appeal rights.
Surveyors identified that three residents' MDS assessments were not completed accurately, including failure to document participation in restorative nursing programs, omission of an anxiety diagnosis, and incorrect coding regarding pressure ulcer risk and presence. Staff confirmed these discrepancies after reviewing the residents' records.
A resident with depression and anxiety did not have their PASRR Level 1 assessment updated to reflect worsening mental health symptoms and ongoing treatment, despite facility policy requiring periodic review and revision. Staff acknowledged the need for a Level 2 evaluation but did not initiate it, resulting in the resident not being properly assessed for necessary behavioral health services.
Three residents did not have comprehensive care plans addressing their specific needs, including one on continuous oxygen therapy without a plan for respiratory care or Covid-19, another with hemiplegia lacking instructions on repositioning frequency, and a third with diabetes and insulin orders but no diabetes management plan. Staff confirmed these omissions and the absence of required documentation.
Surveyors found that staff did not clarify physician orders for pain medications, resulting in unclear dosing and pain level parameters for several residents. Medications were administered outside of prescribed guidelines, and necessary lab monitoring for medications such as cholesterol-lowering agents and thyroid medications was not completed. Staff also failed to implement nonpharmacological pain interventions and did not consistently monitor for signs of abnormal blood glucose in residents with diabetes.
Three residents dependent on staff for ADLs did not receive required assistance with personal hygiene, nail care, shaving, bathing, or getting out of bed. Observations showed residents remained in bed with unmet hygiene needs, and staff interviews confirmed that expected care, such as nail trimming and shaving, was not provided or documented as required by care plans.
Staff did not consistently complete required weekly skin assessments for two residents, failed to perform a post-fall assessment after a resident's fall, omitted a restorative nursing referral for a resident discharged from therapy, and did not monitor a tube-fed resident's weight as ordered. These deficiencies were confirmed through record review, observation, and staff interviews.
A resident receiving tube feeding did not have the amount of enteral formula and fluids accurately documented or reconciled with physician orders. Nursing staff failed to total and verify the amounts administered, and the feeding bottle lacked proper labeling. The DON confirmed that staff were expected to document these amounts each shift, but this was not done.
A registered nurse left medications unsecured on a medication cart during administration, and a supplement with an altered expiration date was found on a medication cart. Both the nurse and DON acknowledged that medications should be secured and properly labeled, and that expired medications should be discarded to ensure resident safety.
Staff did not consistently use PPE or follow Enhanced Barrier Precautions for residents with infection risks, failed to perform hand hygiene between resident contacts during meal service, and did not maintain sanitary practices when delivering food items. These actions were contrary to facility policy and placed residents at risk for infection.
The facility failed to provide required written transfer/discharge notices to two residents during hospitalizations, as per their policy. Resident 21 experienced multiple hospital transfers without receiving written notifications, and staff interviews revealed confusion about responsibility for these notices. Similarly, Resident 29 was transferred without documented notification, highlighting a systemic issue in the facility's discharge process.
The facility failed to maintain food safety standards in its kitchens, with ineffective surface sanitizer solutions, improperly sealed ice cream tubs, and dented cans stored improperly. Additionally, a contamination risk was identified due to dust and grime on a door mechanism above the meal preparation area. These deficiencies placed residents at risk for food contamination and foodborne illnesses.
The facility failed to clarify and follow Physician's Orders (POs) for several residents, leading to potential risks. A resident had unclarified pain medication orders, another directed ointment application against the PO, and a third had duplicate medication orders. Additionally, staff did not notify a physician of high blood sugar levels for a resident, administered pain medication incorrectly, and failed to document pain levels numerically. Furthermore, a staff member signed off on an incorrect air mattress setting for a resident.
The facility failed to maintain proper infection control practices, including hand hygiene and glove changes, during resident care and cleaning tasks. CNAs did not change gloves or perform hand hygiene between dirty and clean care, and a nurse did not use a barrier for a glucometer. A housekeeping aide also failed to change gloves or disinfect equipment, risking cross-contamination.
The facility failed to maintain Advanced Directives (ADs) in the records of four residents, compromising their right to have their care preferences honored. Despite residents having ADs and designated Powers of Attorney (POA), the documents were not readily available in their records, as expected by facility policy. Staff interviews confirmed that ADs should be scanned into records promptly, but this was not done, leaving the facility without essential documentation for emergent and end-of-life care decisions.
The facility failed to thoroughly investigate unwitnessed falls for two residents, leading to incomplete documentation and risk of further falls. A resident with severe memory impairment experienced an unwitnessed fall, but the investigation lacked key details and witness statements. Another resident with progressive memory loss had an incomplete incident report after a fall, with sections left blank. The Nursing Services Director expected thorough investigations, but no further information was provided.
A facility failed to update the PASRR assessment for a resident with depression, who was receiving antidepressant medication. The initial Level 1 PASRR did not reflect the resident's mental health condition, and the facility staff did not update it upon admission. The Social Services Director confirmed the inaccuracy and the need for an update.
The facility failed to update care plans for two residents, leading to discrepancies in care. One resident's plan was outdated regarding fall risk interventions, while another's plan inaccurately reflected medication orders and fall mat placement. Staff acknowledged the need for updates, but the care plans remained unchanged.
A resident with severe memory impairment and dementia was not assisted with their hearing aids (HAs) as required by their care plan, leading to communication difficulties. Observations showed the resident without HAs during meals and interactions, despite staff acknowledging the importance of HAs for effective communication.
The facility failed to provide adequate mealtime supervision for a resident with swallowing difficulties, leading to unsupervised eating with straws present, contrary to care plan instructions. Additionally, fall prevention measures were not implemented for two residents, as non-slip film was missing from a resident's chairs and another resident's bed was not kept in the lowest position as required.
The facility failed to provide appropriate toileting care for continent residents, leading to dignity issues and increased risk of UTIs. A resident with a history of UTIs was directed to use their brief, delaying diagnosis and treatment due to an expired urine collection container. Additionally, improper catheter care was observed for a resident with a suprapubic catheter, with staff showing a lack of training and understanding of care procedures.
A facility failed to document the enteral feeding intake for a resident with a feeding tube, leading to the administration of more formula and water than prescribed. The care plan required specific amounts of formula and water, but staff only marked check marks instead of recording actual amounts. Observations showed the resident received excess nutrition, and staff interviews confirmed the lack of documentation and deviation from the feeding schedule.
The facility failed to provide proper oxygen care and signage for three residents, leading to potential risks. A resident with COPD received oxygen therapy against physician orders, while another had their oxygen tubing not changed as scheduled. Additionally, rooms of residents using supplemental oxygen lacked required warning signs, posing safety risks.
A resident with memory loss was prescribed a sleep aid without proper monitoring or non-pharmacological interventions. Staff interviews confirmed the lack of a sleep monitor and non-drug interventions, risking unnecessary medication use.
The facility failed to ensure two residents were free from unnecessary psychotropic medications. One resident's antidepressant dosage was increased without attempting a Gradual Dose Reduction (GDR) or documenting behavioral concerns, despite no symptoms of depression. Another resident's antidepressant effectiveness and side effects were not monitored or documented as required.
Failure to Provide Functional Communication Systems for Non-English Speaking Residents
Penalty
Summary
The facility failed to ensure that two residents with limited English proficiency were provided with effective communication systems as required by their care plans and facility policy. Both residents had documented needs for interpreter services or communication aids due to language barriers, but staff did not consistently use the available resources such as phone translators, language line services, or communication binders during care interactions. Observations showed that staff attempted to communicate with the residents in English, which the residents did not understand, and did not utilize the prescribed communication methods. For one resident with multiple medical conditions and no memory issues, the care plan specified the use of phone translators and interpretive services. Despite this, staff were observed providing care and medications without using any translation devices, resulting in the resident being unable to communicate their needs effectively. On several occasions, the resident was observed calling out in their preferred language, and staff responded in English without using translation aids. The resident had to resort to using simple English words and gestures to communicate basic needs, and staff acknowledged not using the required communication tools. The second resident, whose primary language was not English, also had a care plan intervention for a communication binder, but repeated observations confirmed that no such binder was available. Staff did not attempt to use interpreter services or communication boards, and instead communicated in English or assumed the resident did not need anything. Interviews with staff and the resident's representative confirmed that the prescribed communication aids were not being used, and the resident's needs may not have been adequately assessed or met due to the language barrier.
Cold Food Served Above Safe Temperature During Meal Service
Penalty
Summary
During lunch preparation, staff failed to maintain cold food at the required temperature of 41 degrees Fahrenheit or lower, as specified in the facility's Food Temperature Policy. Observations showed that Jello dessert cups were removed from the pantry refrigerator and placed on trays, while another tray of Jello cups was sitting on ice outside the pantry. When temperatures were checked, the Jello from the refrigerator measured 45 degrees Fahrenheit, and the Jello on ice in the cart measured 50 degrees Fahrenheit. Staff interviews confirmed that maintaining cold food temperatures below 41 degrees Fahrenheit is essential for food safety and to reduce the risk of foodborne illness. However, the Jello served to residents did not meet this standard, as it was above the required temperature at the time of service. The deficiency was identified through observation, temperature checks, and staff interviews, in accordance with the facility's policy and regulatory requirements.
Failure to Ensure Privacy During Medication Administration
Penalty
Summary
Staff failed to ensure privacy and confidentiality for a resident during medication administration via gastric tube. During observation, a registered nurse left the medication cart unattended with the resident's medical information visible and unsecured on the computer. The nurse then entered the resident's room, left the door open to the hallway, and did not pull the privacy curtain. While administering medications through the resident's gastric tube, the nurse exposed the resident's abdomen and GT site without providing privacy. Interviews with the nurse and the Director of Nursing confirmed that staff are expected to protect resident health information and provide privacy during care by closing doors or pulling privacy curtains. Both staff members acknowledged the importance of maintaining resident privacy and confidentiality, as outlined in facility policies and resident rights documentation. The incident was found to be inconsistent with facility policies regarding HIPAA compliance and resident dignity.
Failure to Provide Nonpharmacological Interventions and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to implement and document nonpharmacological interventions prior to administering psychotropic medications for three residents diagnosed with depression, anxiety, or mood disorders. Specifically, two residents received daily antidepressant medications without any documented physician orders for nonpharmacological interventions, and staff confirmed that such interventions should have been in place. Additionally, for one resident receiving both an antipsychotic and an antidepressant, there was no evidence that staff attempted nonpharmacological interventions prior to medication administration. Further deficiencies were identified in the monitoring and assessment of residents receiving psychotropic medications. For one resident on an antipsychotic, staff did not complete the required Abnormal Involuntary Movement Scale (AIMS) assessment, nor did they monitor for adverse side effects or specific target behaviors associated with the medications. Interviews with facility staff confirmed the absence of required documentation and monitoring, which was expected according to facility policy.
Failure to Provide Required Written Transfer/Discharge Notifications
Penalty
Summary
The facility failed to provide required written notifications regarding transfer or discharge to the hospital for two residents. Specifically, the facility did not give written notice to the residents and/or their representatives at the time of transfer or within 24 hours, as mandated by policy and regulation. For one resident, written notification was only provided for one of several hospital transfers, and for another resident, no written notification was provided for either of their hospitalizations. The facility's policy requires that such notifications include the reason and basis for transfer, the effective date, the location, and an explanation of appeal rights, and that evidence of notification to the Ombudsman be maintained. Record reviews and staff interviews confirmed that the required notifications were not consistently provided to the residents, their representatives, or the Ombudsman. The Director of Nursing acknowledged that written notifications were not given for certain transfers, and the Social Services Director confirmed that the Ombudsman was not notified in at least one instance. The residents involved had significant medical conditions, including stroke and heart failure, and were transferred to the hospital due to changes in their medical status.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, resulting in discrepancies between the residents' actual conditions and what was documented. For one resident with a history of brain bleed and right side weakness, the MDS did not reflect participation in a Restorative Nursing Program (RNP) for range of motion, despite documentation and care plans indicating that such services were provided up to five times a week. Staff confirmed the inaccuracy upon review of the resident's record. Another resident with diagnoses of depression and anxiety was not accurately coded for anxiety on the MDS, even though psychiatric notes and preadmission screening documented both conditions and ongoing treatment needs. Additionally, a third resident with malnutrition and cancer was documented on the MDS as not having or being at risk for pressure ulcers, despite staff identifying and treating a pressure injury to the resident's tailbone. Staff acknowledged that the resident should have been coded as at risk for pressure ulcers and that the MDS required modification.
Failure to Update PASRR Assessment for Mental Health Changes
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) assessments were updated to reflect changes in a resident's mental health status. According to facility policy, staff are required to review and update PASRR screenings periodically and as needed, based on changes in a resident's condition. For one resident with a diagnosis of depression and anxiety, the PASRR Level 1 screening was not revised despite evidence of worsening symptoms and ongoing treatment with antidepressant medication. The resident's medical record and a psychiatrist's note indicated a gradual worsening of depression and anxiety, necessitating further evaluation. During an interview, the Social Services Director acknowledged responsibility for reviewing and correcting PASRR Level 1 and 2 assessments and confirmed that the PASRR Level 1 for this resident was inaccurate. The staff member stated that a PASRR Level 2 evaluation was required but was not initiated, and the Level 1 screening was not updated to reflect the resident's current mental health needs. This oversight resulted in the resident not being properly assessed for necessary mental health services as required by facility policy and regulatory standards.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for three residents, as required by policy and regulation. For one resident with continuous high-concentration oxygen therapy and a recent history of Covid-19, there was no care plan addressing either the oxygen therapy or Covid-19 precautions, despite physician orders and ongoing respiratory care needs. Staff confirmed that these care plans were missing and acknowledged their importance for ensuring appropriate respiratory care. Another resident with a history of stroke and hemiplegia required two-person assistance for mobility and repositioning. While the care plan instructed staff to use two people for repositioning, it did not specify the frequency of repositioning, nor was there documentation that repositioning was being offered or performed as needed. A third resident with diabetes and unstable blood glucose levels had physician orders for two types of insulin but lacked a care plan addressing diabetes management. This resident reported frequent symptoms of low blood glucose and expressed concern about insulin orders. Staff interviews confirmed that care plans for these conditions were not in place, contrary to facility policy.
Failure to Clarify Medication Orders and Monitor Labs
Penalty
Summary
Surveyors identified that the facility failed to ensure physician orders for pain medications were clear and included necessary parameters, such as dosing and pain level indications, for multiple residents. For example, one resident had orders for both over-the-counter and opioid pain medications, but the orders did not specify at what pain levels each medication should be administered. Staff administered medications outside of the prescribed parameters and did not clarify ambiguous orders with the provider. Another resident had a pain patch order lacking dosage and application site instructions, which staff also failed to clarify. Additionally, the facility did not obtain or monitor laboratory values for medications that require lab monitoring. Residents receiving cholesterol-lowering medications, high-dose supplements, and thyroid medications did not have corresponding lab results in their records to ensure the medications were safe and effective. Staff interviews confirmed that these labs were not obtained, despite the expectation that they should be. The facility also failed to ensure that pain management included nonpharmacological interventions and that staff monitored for signs and symptoms of hypo- or hyperglycemia in residents with diabetes. One resident with diabetes reported frequent symptoms of low blood glucose, and there was no documentation of staff monitoring for these symptoms or implementing nonpharmacological pain interventions. Staff confirmed that these practices were expected but not followed.
Failure to Provide Required ADL Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were dependent on staff for personal hygiene and mobility. For one resident with right-sided weakness, observations over several days showed they remained in bed with long fingernails containing black debris, despite care plans indicating staff should assist with personal hygiene and provide nail care weekly and as needed. Staff interviews confirmed that expected ADL assistance, including nail care, was not provided as required. Another resident with bilateral arm weakness required staff assistance for personal hygiene, including bathing, oral care, and shaving. Observations revealed the resident had long facial hair, and staff interviews indicated that shaving was not performed or documented as expected. A third resident, dependent on two staff for hygiene, bathing, transfers, and positioning, was observed lying in bed on multiple occasions, with no documentation of being offered showers or assistance to get out of bed, despite care plans and family preferences for daily mobility and showers. Staff interviews confirmed that bed baths were offered instead of showers and that there was no place in the records to document these activities.
Failure to Complete Required Assessments and Care Interventions
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents’ care plans in several areas. For two residents, staff did not complete weekly skin assessments as required. One resident with malnutrition and cancer had a care plan intervention for weekly skin checks, but there were gaps of up to three weeks between documented assessments, and some skin checks were recorded on the treatment administration record without corresponding assessment forms. Another resident, at risk for pressure ulcers following major surgery, also did not receive weekly skin checks as ordered, with a gap of nearly five weeks between documented assessments. In another instance, staff did not complete a post-fall assessment for a resident who experienced a fall in the bathroom while being assisted by staff. The resident was at moderate risk for falls, and facility policy required a fall assessment after each incident, but no updated assessment was found in the records following the event. Additionally, a resident discharged from therapy services did not receive a referral to a restorative nursing program to maintain range of motion, despite the therapy department’s usual practice and the resident’s ongoing need for assistance with daily activities. The therapy discharge summary lacked documentation of a referral, and both the restorative coordinator and rehab director confirmed the omission. The facility also failed to monitor a resident’s weight according to physician orders. One resident receiving tube feeding had a physician order for monthly weight monitoring, but records showed missing weights for several months. The care plan included an intervention to monitor weight per order, but this was not consistently implemented. These failures were confirmed by staff interviews and record reviews.
Failure to Accurately Document and Administer Ordered Enteral Nutrition
Penalty
Summary
The facility failed to ensure that enteral nutrition was administered in accordance with physician orders and professional standards for a resident receiving tube feeding. Specifically, the staff did not accurately document or reconcile the amount of enteral formula and fluids administered with the amounts ordered by the physician. The facility's policy required that tube feedings be administered per physician orders and that staff evaluate the amount of feeding to ensure the resident received the correct nutrition and hydration. However, review of the resident's health records showed discrepancies between the ordered and administered amounts, and staff did not total or verify the amounts delivered as required. Observation and interviews revealed that a registered nurse stopped the tube feeding pump without verifying or documenting the total amount of formula and water administered, and the feeding bottle lacked a start date or time. The nurse admitted to not calculating the total administered and relied solely on the order for guidance. The Director of Nursing confirmed that staff were expected to total and document the amounts each shift, but this was not done. The resident involved was dependent on tube feeding for more than half of their daily caloric intake and required specific amounts of formula and water as ordered by the physician.
Failure to Secure and Properly Label Medications During Administration and Storage
Penalty
Summary
Staff failed to ensure proper storage and labeling of medications during medication administration and storage review. On two separate occasions, a registered nurse dispensed pills and liquid medications into a cup and left them, along with respiratory inhaled medications, unsecured on top of the medication cart before walking away. The nurse acknowledged that medications should be secured in a locked cart before leaving them unattended, and the DON confirmed that staff are expected to secure medications to ensure resident safety. Additionally, a review of the West Medication Cart revealed a supplement bottle with its original expiration date crossed off and a new date handwritten next to it. A licensed practical nurse stated that the supplement was brought in by a family member and that staff should not accept medications with altered expiration dates. The DON stated that expired medications should be discarded to ensure residents receive medications with the correct potency.
Failure to Follow Infection Control Protocols and Sanitary Practices
Penalty
Summary
Staff failed to use appropriate Personal Protective Equipment (PPE) and follow Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters and other infection risks. For one resident with a urinary catheter, there was no EBP signage or PPE available at the room, contrary to facility policy. Another resident with an EBP sign posted had medications administered by a nurse who did not wear the required PPE, despite acknowledging the expectation to do so. A third resident with a catheter and EBP signage had their catheter bag emptied by a CNA who did not wear a gown as required, later admitting to forgetting the precaution. Hand hygiene (HH) practices were not consistently followed during meal service. One CNA delivered meal trays to multiple resident rooms, handled used items, and moved between rooms without performing HH between resident contacts or after touching items in the rooms. Another CNA also failed to perform HH between resident contacts during meal delivery, acknowledging the expectation but stating they forgot. Sanitary practices were not maintained during meal service, as one CNA dropped a mustard packet on the floor and then delivered it to a resident without cleaning or replacing it. The CNA recognized this was not appropriate for infection prevention. These observed failures were in direct violation of the facility's infection prevention and control policies, as well as state regulations.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to implement a system to ensure residents received the required written notices at the time of transfer or discharge, or as soon as practicable. This deficiency was identified for two residents who were reviewed for hospitalizations. The facility's policy, revised on 09/06/2023, required that a written transfer notification be provided to the resident or their representative in a language and manner they could understand, including the reason for transfer, effective date, and location. However, this policy was not followed, as evidenced by the lack of written notifications for the residents involved. Resident 21 was transferred to the hospital multiple times for various medical issues, including lethargy, diaphoresis, blood in urine, a fall, and blood in stool. Despite these transfers, there was no evidence that written notifications were provided. Interviews with staff revealed confusion about who was responsible for sending these notices, with different staff members assuming it was the responsibility of others. Similarly, Resident 29 was transferred to an acute care hospital, but there was no documentation of written notification being provided. Staff interviews confirmed that written notices were not given for hospital discharges, indicating a systemic issue in the facility's discharge notification process.
Food Safety Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to ensure that resident meals were prepared in accordance with professional standards of food safety in both of its kitchens. During an observation, it was noted that the surface sanitizer solutions were not maintained at effective concentrations, as indicated by test strips that failed to change color. The Dining Services Director, Staff P, confirmed the importance of maintaining the correct concentration for effectiveness and acknowledged the absence of readily available test strips. Additionally, the facility's storage practices were inadequate, with ice cream tubs in a freezer not properly sealed, risking deterioration, and dented cans of fruit cocktail and peaches stored with other cans, which Staff P admitted should be returned to the vendor due to potential spoilage. Further observations revealed that the lunch service area had a contamination risk due to a buildup of dust and grime on a slatted metal door and its mechanism, located directly above the steam table where meals were prepared. Staff P acknowledged the contamination risk posed by the unclean door and mechanism. These deficiencies in food safety practices placed residents at risk for food contamination, foodborne illnesses, and spoiled food, as the facility did not adhere to professional standards for food storage, preparation, and cleanliness.
Deficiencies in Physician's Orders and Documentation
Penalty
Summary
The facility failed to ensure that Physician's Orders (POs) were clarified and followed correctly for several residents, leading to potential risks for unmet care needs and other negative health outcomes. For Resident 2, there were two pain medication orders without parameters to guide staff on which medication to administer, as confirmed by Staff E, the Resident Care Manager. Similarly, Resident 242 had an order for a non-steroidal ointment that was not clarified, resulting in the resident directing the application areas, which was not in line with the order. Resident 238 had duplicate orders for pain and nausea medications without clear instructions, increasing the risk of incorrect administration. The facility also failed to follow POs for other residents. Resident 13 had a PO to notify the physician if blood sugar levels were between 351 and 400, which was not done on nine occasions. Additionally, Resident 240 received a narcotic pain medication for a pain level lower than the prescribed threshold. Furthermore, the facility did not document pain levels numerically for Residents 13, 8, 28, 238, and 240, instead using checkmarks, which was against the expected documentation practice. Lastly, the facility failed to ensure that staff signed only for care provided. For Resident 8, a PO required the air mattress to be set to a specific comfort level, but it was observed at an incorrect setting. Despite this, Staff F signed off on the treatment administration record as if the correct setting was verified. This discrepancy was confirmed during an interview with Staff F, highlighting a failure in accurately documenting care provided.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to consistently adhere to proper hand hygiene and glove-changing protocols, as well as maintaining cleanliness of shared medical equipment, which placed residents at risk for healthcare-associated infections. During an observation, two CNAs were seen providing pericare to a resident with diarrhea without changing gloves or performing hand hygiene between dirty and clean care. The CNAs acknowledged the lapse in protocol, which was confirmed by the Infection Control Nurse as a breach of expected practices to prevent infections. Additionally, a registered nurse failed to use a barrier between a shared glucometer and a resident's over-the-bed table during a blood sugar check, and did not clean the table afterward. This was acknowledged by the nurse as a failure to follow proper procedures. Furthermore, a housekeeping aide was observed cleaning a public bathroom and a resident's bathroom without changing gloves or performing hand hygiene between tasks, leading to potential cross-contamination. The aide also failed to disinfect equipment before reuse, further compromising infection control measures.
Failure to Maintain Advanced Directives in Resident Records
Penalty
Summary
The facility failed to obtain and have Advanced Directives (ADs) readily available in the records of four residents, which compromised their right to have their preferences and choices honored during emergent and end-of-life care. Resident 240, who was admitted with no memory impairment and clear communication abilities, stated they had an AD and a family member as their Power of Attorney (POA), but no ADs were found in their records. Similarly, Resident 241, with complex medical diagnoses, was identified to have an AD and a family member as their POA, but the ADs were not found in their records until later discovered in a pile of unprocessed documents. Resident 238, also with no memory impairment, had their admission documentation completed by a family member who was their POA, yet their ADs were missing from the records. Resident 13, who had impaired thinking abilities and a history of traumatic brain dysfunction, heart failure, and memory loss, was identified to have a legal health and financial care authority who signed their admission paperwork. However, no ADs were available in their records. Interviews with staff revealed that ADs were expected to be scanned into the resident's records promptly, but this was not done, leaving the facility without crucial documentation to guide care according to the residents' wishes. The deficiency was noted under WAC 388-97-0280(3)(c)(i-ii).
Incomplete Investigation of Resident Falls
Penalty
Summary
The facility failed to thoroughly investigate unwitnessed falls for two residents, which placed them at risk for further falls and other negative health outcomes. Resident 3, who had severe memory impairment and medically complex diagnoses, experienced an unwitnessed fall on April 6, 2024. The investigation into this fall was incomplete, as it did not identify when the resident last used the toilet, if the call light was on, or when the resident was last seen by staff. Additionally, no witness statements were obtained from the staff who found the resident or any other staff members. Resident 13, who had a diagnosis of progressive memory loss disease and a history of falls, experienced a fall on June 16, 2024. The incident report for this fall was incomplete, with several sections left blank, including the resident's level of pain, mental status, and predisposing environmental factors. Staff B, the Nursing Services Director, stated that they expected incident reports to be complete and thorough, but no further investigative information was provided.
Inaccurate PASRR Assessment for Resident with Depression
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASRR) assessment accurately reflected the mental health conditions of Resident 238. The resident, who was admitted on June 25, 2024, had multiple medically complex diagnoses, including depression, and was receiving antidepressant medication. However, the Level 1 PASRR completed prior to admission on June 20, 2024, did not indicate any Serious Mental Illness (SMI) indicators. Upon admission, the facility staff did not update the Level 1 PASRR to include the resident's diagnosis of depression, which required treatment with medication. During an interview, the Social Services Director acknowledged the importance of accurate and updated Level 1 PASRRs for residents with SMI and confirmed that Resident 238's PASRR was not accurate and needed updating.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans (CPs) were updated to reflect the current care needs of two residents, leading to potential risks for unmet care needs. For Resident 3, the CP was not updated despite changes in the resident's activity level and fall risk. The resident, who had severe memory impairment and a history of falls, was observed being taken to their room without encouragement to stay in a common area, contrary to the outdated intervention in their CP. Staff acknowledged that the intervention was no longer appropriate due to the resident's increased tiredness, but the CP had not been revised to reflect this change. Similarly, Resident 21's CP was not updated to accurately reflect their current medical orders and care needs. The resident, who had moderate memory impairment and was on anticoagulant medication, had discrepancies in their CP regarding the medication and the placement of a fall mat. Observations showed the fall mat was only on the left side of the bed, consistent with the physician's order, but the CP incorrectly indicated mats on both sides. Staff confirmed that the CP should have been updated to remove the anticoagulant medication and correct the fall mat placement, but it was not.
Failure to Assist Resident with Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident, who was assessed to require hearing aids (HAs) for effective communication, was provided with the necessary assistance to use them. The resident, who had severe memory impairment and complex medical diagnoses including dementia, was observed on multiple occasions without their HAs, despite the facility's policy and the resident's care plan indicating the need for daily use of HAs. The care plan specifically required nursing staff to ensure the resident's HAs were in place every morning and functioning properly. Observations over three consecutive days showed the resident without their HAs during meals and interactions with staff, leading to communication difficulties. Staff, including the Nursing Services Director, acknowledged the importance of the HAs for the resident's communication and admitted that assistance should have been provided. Despite the presence of the HAs in the resident's room, staff did not offer help to the resident to use them, resulting in repeated communication attempts and unnecessary barriers to interaction.
Inadequate Supervision and Fall Prevention Measures
Penalty
Summary
The facility failed to provide adequate mealtime supervision for Resident 88, who had a history of severe memory impairment, dementia, and swallowing difficulties. Despite being assessed to require close supervision when eating and having a care plan that specified no straws and the need for assistance from a CNA, Resident 88 was observed eating breakfast unsupervised with straws in their beverages. This lack of supervision and the presence of straws contradicted the care plan and placed Resident 88 at risk for aspiration, as evidenced by their coughing during the observation. Additionally, the facility did not ensure fall interventions were in place for Resident 3, who had severe memory impairment and a history of repeated falls. The care plan required non-slip film on the resident's personal chairs to prevent falls, but observations on multiple occasions showed the non-slip film was not in place. Staff acknowledged the importance of this intervention and confirmed its absence during the survey. For Resident 21, who had moderate memory impairment and was at risk for falls, the facility failed to maintain the bed in the lowest position as required by the care plan. Observations showed the bed was raised higher than allowed, and staff admitted the bed was not kept in the lowest position due to practical issues with the over-bed table. This oversight was acknowledged by staff, who noted the bed should not have been raised so high.
Deficiencies in Toileting and Catheter Care
Penalty
Summary
The facility failed to provide appropriate toileting care for continent residents, leading to dignity issues and increased risk of urinary tract infections (UTIs). Resident 339, who required maximum assistance with toileting due to irritable bowel syndrome and other health issues, reported that staff directed them to use their brief instead of assisting them to the toilet. This was observed when staff instructed Resident 339 to defecate in their brief, contrary to the resident's preference and the facility's policy. Resident 340, who had a history of kidney failure and frequent UTIs, also reported being directed to use their brief despite being aware of their need to use the bathroom. This resident expressed concerns about the risk of developing another UTI due to this practice. A urine sample collected for Resident 340 was not processed because the collection container was expired, delaying diagnosis and treatment. Staff interviews confirmed that the facility's policy was to assist continent residents to the toilet, but this was not consistently practiced. Additionally, the facility failed to provide proper catheter care for Resident 18, who had a suprapubic catheter. Observations showed the catheter bag was uncovered and touching the floor, and the resident reported pain at the catheter site. Staff were observed to be unsure of proper care procedures for suprapubic catheters, and the catheter bag was not placed in a privacy bag as required. Staff interviews revealed a lack of training and understanding of catheter care, contributing to inadequate care and potential risk of infection.
Failure to Document Enteral Feeding Intake
Penalty
Summary
The facility failed to properly assess, monitor, and document the enteral feeding intake for Resident 8, who was receiving nutrition through a feeding tube due to difficulty swallowing and impaired mobility following a stroke. The resident's care plan specified that they were to receive 720 mL of enteral feeding formula and 547 mL of free water over 12 hours, with staff required to document the amounts administered. However, the Medication Administration Record (MAR) showed that staff only marked check marks instead of recording the actual amounts of residuals and enteral nutrition administered, which was against the physician's orders. Observations revealed that Resident 8 received more enteral formula and water than prescribed, as the feeding pump indicated 1004 mL of formula and 720 mL of water were administered, exceeding the prescribed amounts. Interviews with staff, including a Licensed Practical Nurse, a Registered Dietician, and the Nursing Services Director, confirmed the lack of documentation and the deviation from the prescribed feeding schedule. The staff acknowledged the importance of documenting the total amounts of enteral formula and water to monitor the resident's nutritional intake and potential weight changes or edema.
Failure to Provide Proper Oxygen Care and Signage
Penalty
Summary
The facility failed to provide oxygen treatments as ordered for three residents, leading to potential risks for over or under oxygenation, respiratory discomfort, and oxygen-related accidents. Resident 2, who had cardiorespiratory diagnoses including heart failure, high blood pressure, COPD, fluid in the lungs, and respiratory failure, was provided oxygen therapy when their oxygen saturation was 93% or higher on multiple occasions, contrary to the physician's order to hold oxygen therapy if saturation surpassed 92%. Resident 241, with chronic respiratory failure and COPD, had their oxygen tubing not changed as scheduled, with no date on the tubing observed, despite a physician's order to change it weekly. Additionally, the facility did not place oxygen warning signs outside the rooms of residents using supplemental oxygen, as required by their policy. Observations showed that the rooms of Residents 2, 88, and 241 lacked signage indicating oxygen use. Staff interviews confirmed the importance of such signage for emergency response and to prevent oxygen-related accidents, as oxygen is combustible. The absence of these signs was a direct violation of the facility's policy and posed a safety risk.
Failure to Monitor and Address Resident's Sleep Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically in the case of a resident with a progressive memory loss disease. The resident was prescribed an over-the-counter sleep aid medication for difficulty sleeping, as per a physician's order. However, there were no instructions for staff to monitor the number of hours the resident slept each night, nor was there a comprehensive care plan goal developed to address the resident's sleeping problem. Additionally, there were no interventions in place to guide staff on non-pharmacological methods to assist the resident with sleep or to monitor the effectiveness of the sleep aid medication. Interviews with facility staff revealed that a sleep monitor should have been implemented to track the effectiveness of the sleep aid, and non-pharmacological interventions should have been provided, but these measures were not in place. Both the Resident Care Manager and the Nursing Services Director acknowledged the absence of these necessary interventions and monitoring procedures. This oversight placed the resident at risk of receiving unnecessary medications and potential adverse side effects.
Failure to Monitor and Reduce Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 21 and 238, were free from unnecessary psychotropic medications. For Resident 21, the facility did not attempt a Gradual Dose Reduction (GDR) for an antidepressant medication despite the resident not exhibiting symptoms of depression. The resident's medication was increased twice without documented behavioral concerns or justification for the continued dosage. Psychiatry consultation notes indicated that Resident 21 was calm, pleasant, and did not present with symptoms of depression, yet no GDR was attempted, and no justification was documented for the continued use of the antidepressant. For Resident 238, the facility did not monitor or document the effectiveness or side effects of the antidepressant medication as required. The resident had multiple complex medical diagnoses, including depression, and was receiving an antidepressant. However, there was no evidence of behavior monitoring or documentation to assess the medication's effectiveness. Staff E acknowledged that behavior monitoring should have been conducted to determine the medication's effectiveness, but it was not done.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
