Life Care Center Of Federal Way
Inspection history, citations, penalties and survey trends for this long-term care facility in Federal Way, Washington.
- Location
- 1045 South 308th Street, Federal Way, Washington 98003
- CMS Provider Number
- 505188
- Inspections on file
- 33
- Latest survey
- March 18, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Life Care Center Of Federal Way during CMS and state inspections, most recent first.
The facility failed to develop and implement comprehensive care plans for several residents, leading to potential risks for unmet care needs. A resident with a gastrointestinal infection lacked a care plan for bathing needs, while another using a tilt-in-space wheelchair had no plan detailing its use. Additionally, a resident requiring oxygen therapy had a care plan not reflecting physician orders, and others had missing plans for bed rails and diabetes management. Staff acknowledged the importance of comprehensive care plans.
The facility failed to conduct quarterly care conferences for several residents and did not update a resident's care plan despite changes in their eating assistance needs. The absence of a Social Services Director and non-adherence to policy contributed to these deficiencies, placing residents at risk for unmet care needs.
The facility failed to clarify physician orders for three residents, leading to potential risks in care. A resident had bed rails without a physician order, another was on antidiabetic medication without monitoring orders, and a third lacked blood sugar monitoring despite diabetes. Additionally, three residents had no parameters for as-needed pain medications, risking inappropriate pain management.
The facility failed to maintain a safe environment by allowing hot water temperatures to exceed safe limits, not assessing a resident's wheelchair for safety, and leaving sharps and chemicals accessible in a shower room. A resident used a tilt-in-space wheelchair without a safety assessment, and staff left a shower room unsecured, exposing residents to potential hazards.
The facility's Dietary Manager lacked the necessary certification to perform their duties, as they had not completed the required training. The previous Dietary Director's early departure left Staff J in charge without proper qualifications. Additionally, the facility's RD did not work full-time, as they were also responsible for another facility, working only two days a week. This deficiency risked inadequate food and nutrition services for all residents.
The facility failed to document education and consent for influenza and pneumococcal vaccinations for four residents. Three residents received the influenza vaccine without documented education, and there was no record of the pneumococcal vaccine being offered or their historical immunization status. Another resident's records lacked documentation of both vaccines being offered for the 2024-2025 season. The Infection Preventionist admitted to not obtaining and scanning immunization records into the residents' health records.
The facility failed to educate four residents and one staff member on the benefits and potential side effects of the COVID-19 vaccine, as required by their policy. Interviews revealed that the Infection Preventionist did not provide or document the necessary education, and the Director of Nursing confirmed the expectation for such education and documentation.
The facility did not ensure that nursing aides received the required training for continued competency, as evidenced by the lack of training documentation for Staff CC. An interview and record review revealed that since Staff CC's hire, there were no records of training on critical topics such as abuse prevention, infection control, and resident rights. The facility also lacked a staff development coordinator to track mandatory and specialized training needs.
The facility failed to honor the dignity and preferences of two residents. One resident was repeatedly disturbed at night for vitals and toileting, denied sleep medication, and addressed with terms they disliked. Another resident was not given adequate notice or preparation time for a care conference, leaving them feeling undignified. Staff acknowledged the need for better communication and adherence to the facility's dignity policy.
The facility failed to obtain consent for the Covid-19 vaccination for four residents, psychotropic medication for a resident with multiple mental health diagnoses, and the use of a tilt-in-space wheelchair for a cognitively intact resident. Staff acknowledged the absence of consent documentation, highlighting a lapse in ensuring residents' rights to be informed and to consent to their care.
The facility failed to ensure Advanced Directives (AD) were in place for three residents, as required. A resident with heart failure and a kidney condition, and two residents with moderate memory impairment and other diagnoses, had no AD documentation or evidence of being informed about their rights to formulate an AD. Staff interviews confirmed the lack of assistance provided to these residents.
The facility failed to maintain a safe and homelike environment, with observations of gouges and exposed drywall in resident rooms and a nightstand with exposed rough wood. A resident reported issues with cold water in their bathroom sink. The Maintenance Director was unaware of these issues, as they were not communicated by floor staff.
The facility failed to provide required written transfer notifications to two residents and their representatives, as well as to the LTCO, during hospitalizations. Staff interviews revealed that the social service department did not fulfill its responsibility to issue these notifications, impacting residents' ability to make informed decisions.
The facility failed to provide written notification of its bed hold policy to residents and/or their representatives at the time of hospital transfer, affecting three residents. Interviews revealed that the social service department and unit care coordinators did not provide the necessary notice, and documentation was absent in the residents' records. The DON emphasized the importance of informing residents of their rights and associated costs.
The facility failed to complete and incorporate PASRR Level II evaluations into the care plans for two residents with mental health needs. One resident with dementia and a history of stroke showed aggressive behavior, but no Level II referral was documented despite changes in condition. Another resident with dementia, anxiety, depression, and PTSD required a Level II evaluation, but no referral was made. Staff cited understaffing as a reason for not completing necessary screenings.
The facility failed to complete PASRR assessments for two residents, leading to a deficiency in the screening process. One resident with anxiety and depression did not receive a necessary level II evaluation, while another with dementia and bipolar disorder was not referred for a level II assessment after transfer. Staff interviews confirmed the PASRR process was not completed accurately, risking the residents' access to needed mental health services.
A resident with limited English proficiency did not receive necessary communication assistance as outlined in their care plan. The facility failed to provide translation services and communication aids, leading to potential miscommunication and unmet care needs. Staff interviews confirmed the oversight and the importance of providing these services.
A resident with a gastrointestinal infection requiring isolation and moderate memory impairment did not receive adequate bathing assistance over an 18-day period, despite needing substantial to maximal help. The care plan lacked directions for bathing needs, and the resident expressed a desire for assistance. An LPN confirmed the resident did not receive the necessary care.
The facility failed to monitor edema in three residents receiving diuretic medication, lacking physician orders for edema assessment and monitoring. Staff acknowledged the absence of documentation and the importance of monitoring edema every shift to manage conditions like heart failure and prevent complications.
The facility failed to provide fresh water to residents, leading to a risk of dehydration. Observations showed that residents were not offered fresh water unless they asked, contrary to facility policy. Staff interviews confirmed that water was not proactively provided, despite expectations from the Unit Care Coordinator and DON. This deficiency affected multiple residents, some with memory impairments or medical conditions requiring hydration.
A resident with COPD did not receive appropriate respiratory care as the oxygen flow rate was set incorrectly at 3 LPM instead of the prescribed 2 LPM. Additionally, the oxygen tubing was found disconnected from the concentrator. Staff interviews revealed a lack of awareness of the specific oxygen order, highlighting a failure to adhere to professional standards and physician's orders.
The facility failed to obtain informed consent and conduct a safety assessment before implementing bed rails and positioning a bed against the wall for two residents. One resident had bed rails installed without consent, and another had their bed placed against the wall without a safety assessment. Staff acknowledged the oversight, and the DON confirmed the expected procedures were not followed.
A facility failed to evaluate a resident with depression for mental health services, despite ongoing behaviors such as refusals of care and agitation. Staff documented these behaviors but did not assess them or notify the provider, as required. Interviews revealed a lack of communication and follow-up, placing the resident at risk for untreated mental health issues.
The facility failed to monitor medication refrigerator temperatures, leading to improper storage in one unit, and did not dispose of expired medications in another. Additionally, a resident with dementia had another resident's medication left in their room, posing a safety risk. Staff interviews revealed a lack of clarity and responsibility regarding these issues.
The facility failed to maintain confidentiality of resident records on the 100 hall medication cart. An LPN and an RN left a list with resident health information unsecured and in view. Both staff acknowledged their responsibility to protect resident information but did not comply. The DON confirmed the expectation to secure resident information to uphold privacy rights.
A facility failed to coordinate care with hospice services for a resident with Multiple Sclerosis, lacking a coordinated Care Plan and proper documentation. Staff interviews revealed confusion about hospice schedules and inadequate training, while the hospice binder and medical records were incomplete.
The facility failed to store respiratory equipment properly for a resident, did not follow physician orders for contact precautions for another resident with an MDRO infection, and did not implement Enhanced Barrier Precautions for a resident with pressure injuries. Staff were observed not using PPE correctly, and signage was missing or incorrect, as confirmed by facility staff.
The facility failed to provide necessary training and specialized training for staff, affecting their ability to meet residents' care needs. Staff I, K, and CC lacked documentation of required training, and the facility's training program did not include specialized training for dementia, behavioral health, or hospice care. Interviews revealed a lack of awareness and documentation of hospice care training, crucial for residents receiving such care.
The facility failed to ensure POLSTs were properly followed for three residents. A miscommunication during a Code Blue led to incorrect CPR initiation for a resident with selective treatment orders. Additionally, two residents' POLSTs were not readily available, risking unwanted lifesaving treatments.
A resident on hospice care, requiring two caregivers for bed mobility and incontinence care, fell and sustained an inoperable leg fracture when a caregiver attempted to provide care alone. The care plan and Kardex lacked information about the resident's use of an air mattress, contributing to the incident. The facility's investigation confirmed the caregiver's failure to follow the care plan, despite adequate staffing.
The facility failed to provide written explanations for room changes for four residents, who were moved without notice or documentation. This led to frustration and distress among the residents, with one resident discharging themselves against medical advice. Staff interviews revealed a lack of adherence to the facility's policy on room change notifications.
The facility failed to assess and monitor the use of air mattresses for residents, leading to deficiencies in care planning, informed consent, and staff training. A resident fell and was injured due to inadequate care planning and lack of staff training on air mattress use. Other residents were also found using air mattresses without proper documentation or consent, highlighting systemic issues in the facility's management of these devices.
The facility failed to thoroughly investigate injuries of unknown origin for two residents. One resident with Alzheimer's dementia had a facial bruise that was not properly documented or investigated. Another resident with memory impairment had a bruise on their eye, but the investigation lacked necessary details to rule out abuse or neglect. The facility's policy required thorough investigations within five days, which was not followed.
Two residents in a facility experienced inadequate pressure ulcer care, leading to significant harm for one resident. Despite being dependent on staff for care, Resident 1's Moisture Associated Skin Damage (MASD) progressed to a Stage 4 pressure ulcer with osteomyelitis due to a lack of preventative measures and failure to follow treatment orders. Resident 2 also did not receive necessary interventions, such as an air mattress and recommended wound care, resulting in an unstageable pressure ulcer. The facility's failure to adhere to professional standards of practice placed residents at risk for further skin breakdown.
A resident with cognitive impairments and incontinence was suspected of having a UTI, but the LTC facility failed to collect a urine sample for testing despite a practitioner's order. The resident's condition worsened, leading to hospitalization with severe sepsis and kidney infection. The facility did not document further attempts to collect the sample or communicate effectively with the practitioner or the resident's representative.
A resident diagnosed with dementia and psychotic disorder, known for verbal and physical aggression, punched another resident twice on the shoulder. The incident was triggered by the victim's vocalizations and disruptive behavior, which irritated the aggressor. The facility did not provide adequate supervision or address known triggers for the aggressive resident's behavior. Interviews revealed that the victim, who was confused and disruptive, could not recall the incident.
The facility failed to report an incident where one resident allegedly threw a plate at another, causing injury. The incident was documented but not entered into the reporting log, and the Director of Nursing denied its occurrence. The Administrator acknowledged the reporting failure.
The facility failed to thoroughly investigate abuse allegations involving two residents. One resident reported being hit by objects thrown by their roommate, while another incident involved a resident hitting another due to noise irritation. The facility did not complete proper incident reports or conduct thorough investigations, leaving residents at risk of continued abuse.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure comprehensive and implemented care plans for six residents, leading to potential risks for unmet care needs and negative health outcomes. Resident 139, who required substantial assistance with bathing and had a gastrointestinal infection, did not have a care plan addressing their bathing needs. Staff acknowledged the omission, indicating the care plan should have included directions for bathing type and frequency. Resident 63, with a history of heart failure and using a manual wheelchair, was observed in a tilt-in-space wheelchair without a care plan detailing its purpose or proper use. Similarly, Resident 6, who required oxygen therapy, had a care plan that did not reflect the physician's order to increase oxygen during respiratory distress. Staff confirmed the importance of aligning care plans with physician orders. Other deficiencies included Resident 8, who had bed rails without a corresponding care plan, and Resident 69, whose bed was against the wall without a care plan addressing safety concerns. Resident 14, treated for prediabetes, lacked a diabetes care plan. Staff interviews highlighted the necessity of comprehensive care plans to ensure staff awareness and proper care delivery.
Failure to Conduct Care Conferences and Update Care Plans
Penalty
Summary
The facility failed to facilitate quarterly care conferences for five residents and did not revise care plans as required for one resident. The facility's policy mandates that care plans be reviewed and revised after each Minimum Data Set (MDS) assessment, which occurs at least quarterly. However, residents 63, 77, 8, 14, and 64 did not have care conferences held as per the policy. Resident 63, who had intact memory, expressed a desire to participate in care conferences but was not given the opportunity due to the absence of a Social Services Director. Resident 77, with moderate memory impairment, and other residents also did not have documented care conferences since their admission or baseline care plan. Resident 80's care plan was not revised despite changes in their eating assistance needs. Initially, the care plan required staff to provide one-on-one assistance with eating. However, interviews revealed that Resident 80 often fed themselves and did not consistently receive assistance. Staff interviews indicated that Resident 80's mood influenced their need for assistance, and the care plan was not updated to reflect these changes. The Director of Nursing acknowledged that the care plan should have been updated once the resident's needs changed. The lack of care conferences and failure to update care plans placed residents at risk for unmet care needs and other negative health outcomes. The facility's policy requires care conferences to be held within 48 hours of admission, quarterly, and upon request by the resident or their representative. The absence of a Social Services Director and failure to adhere to policy contributed to these deficiencies, as confirmed by staff interviews.
Deficiencies in Physician Orders and Pain Management
Penalty
Summary
The facility failed to ensure physician orders were clarified for three residents, leading to potential risks in their care. Resident 8 had bilateral quarter bed rails in use without a physician order, despite an evaluation indicating their use. Staff interviews confirmed the absence of a necessary physician order for the bed rails, which was expected by the facility's Director of Nursing. Resident 14, who had moderate memory impairment and was diagnosed with prediabetes, was prescribed an antidiabetic medication without a corresponding physician order to monitor for signs and symptoms of low or high blood sugar levels. This oversight was acknowledged by staff, who emphasized the importance of such monitoring to maintain safe blood sugar levels. Resident 13, with a history of diabetes and chronic pain syndrome, lacked physician orders to monitor blood sugar levels despite being on medications that could affect these levels. Additionally, there were no parameters for the administration of as-needed pain medications for Residents 13, 14, and 8, which could lead to inappropriate pain management. Staff interviews highlighted the necessity of having parameters to prevent overmedication or undermedication and the importance of implementing nonpharmacological interventions for pain relief.
Facility Fails to Maintain Safe Environment and Assess Wheelchair Safety
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards in two of its units, specifically Units 100 and 200. Observations revealed that hot water temperatures in several rooms exceeded the facility's safety policy limit of 120 degrees Fahrenheit, with temperatures reaching as high as 125.1 degrees Fahrenheit. This posed a risk of burns to residents, particularly those with conditions that increase their susceptibility to such injuries. Interviews with maintenance staff indicated that a component failure in the hot water line led to these unsafe temperature levels. Additionally, the facility did not ensure that a tilt-in-space wheelchair provided to a resident was assessed for safety prior to use. The resident, who had intact memory and a history of heart failure and traumatic fracture, was using the wheelchair as a placeholder due to their longer frame. However, there was no evidence of a safety assessment being conducted for this wheelchair, and the therapy department had not reassessed it as part of their quarterly evaluations. The Director of Nursing expressed that all wheelchairs should be periodically assessed for safety. Furthermore, the facility failed to store sharps and chemicals safely in one of the shower rooms. A certified nursing assistant left a resident unattended in the shower room, where razors and a bottle of disinfectant cleaner were accessible. The staff member admitted to not having a key to lock the cabinet containing these items, which should have been secured to prevent resident access. The Director of Nursing confirmed the expectation that such items be stored behind locked doors to ensure resident safety.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager, referred to as Staff J, possessed the required qualifications to perform their duties in the facility's kitchen. Staff J admitted during an interview that they had not completed the necessary dietary manager training. This situation arose because the previous Dietary Director left earlier than expected, leaving Staff J in charge without the proper certification. Additionally, the facility's Registered Dietician (RD), identified as Staff Q, did not work full-time at the facility, as they were also responsible for a sister facility. Staff Q confirmed that they only worked at the facility on Tuesdays and Thursdays, which did not meet the full-time requirement when the dietary manager lacked the necessary certification. This deficiency placed all residents at risk of receiving meals prepared by staff without the required competencies and skills to provide adequate food and nutrition services.
Failure to Document Vaccine Education and Administration
Penalty
Summary
The facility failed to provide necessary education and documentation for influenza and pneumococcal vaccinations for four residents. Specifically, Residents 8, 14, and 13 received the influenza vaccine without documented education on its risks and benefits, and there was no record of the pneumococcal vaccine being offered or their historical immunization status. Resident 64's records lacked documentation of both influenza and pneumococcal vaccines being offered for the 2024-2025 season, as well as their historical immunization status. During an interview, the Infection Preventionist acknowledged the absence of documentation for education and consent for the influenza vaccines for these residents. They also admitted to not obtaining and scanning the residents' immunization records from the department of health into their health records. The Infection Preventionist emphasized the importance of educating residents and obtaining consent prior to vaccine administration to ensure residents are informed about the risks and benefits, as well as the necessity of verifying vaccination status upon admission to prevent communicable diseases.
Failure to Educate on COVID-19 Vaccination
Penalty
Summary
The facility failed to provide education on the benefits and potential side effects of the COVID-19 vaccination to four out of five sampled residents and one sampled staff member. Specifically, Residents 8, 14, 13, and 64 did not have documented evidence of receiving education about the COVID-19 vaccine's benefits and potential side effects. Additionally, Resident 64 was not offered the COVID-19 booster vaccine for the 2024-2025 period. Staff U, a Restorative Aide, also did not receive the required education on the vaccine's risks and benefits. Interviews with facility staff revealed a lack of awareness and adherence to the facility's COVID-19 Vaccination Program Policy. Staff I, the Infection Preventionist, admitted to not educating staff and residents on the vaccine and failing to document the education provided. The Director of Nursing, Staff B, confirmed the expectation that Staff I should educate and document the education for all employees and residents. This oversight placed residents, their representatives, and staff at risk of not being able to make informed decisions regarding their medical care.
Failure to Ensure Required Training for Nursing Aides
Penalty
Summary
The facility failed to implement a system to ensure that nursing aides received the required training for continued competency, specifically for one nursing aide, Staff CC. This deficiency was identified during an interview and record review conducted by Staff C, the Regional Director of Clinical Services. It was found that since Staff CC's hire date, there were no training documents related to essential topics such as abuse, neglect, exploitation, infection control, communication, resident rights, or cultural competency. Additionally, the facility lacked a staff development coordinator to track nursing assistants' continuing education and annual training requirements, including mandatory topics and those related to the special needs of the resident population.
Failure to Honor Resident Dignity and Preferences
Penalty
Summary
The facility failed to uphold the dignity and preferences of Resident 31, who was admitted with a cognitive communication deficit and required assistance with personal care. Despite expressing a desire to be consulted on decisions and daily routines, Resident 31 reported being woken up multiple times during the night for vitals and toileting, which disrupted their sleep. The resident also requested as-needed sleep medication, which was denied by the nursing staff without consulting the provider. Additionally, Resident 31 felt disrespected by staff addressing them with terms they did not prefer and was disturbed by loud noise from other residents' televisions at night. Resident 16, who had intact memory and communication abilities, was not given adequate notice or preparation time for a care conference. The resident's collateral contact was not informed about the conference, and Resident 16 was awoken without warning by the former Social Services Director and other staff, leaving them without time to dress or groom themselves. This lack of preparation was noted as undignified by Resident 16, who expressed frustration over the situation. Interviews with staff revealed a lack of adherence to the facility's dignity policy, which emphasized respecting residents' preferences and individuality. Staff acknowledged the need for designated quiet times and better communication with residents regarding their care preferences. The facility's failure to honor residents' preferences and provide adequate notice for care conferences resulted in feelings of diminished self-worth and embarrassment for the residents involved.
Failure to Obtain Resident Consent for Vaccinations, Medications, and Equipment
Penalty
Summary
The facility failed to obtain resident consent for the administration of the Covid-19 vaccine for four residents. Specifically, Residents 8, 14, and 13 received the Covid-19 vaccination without documented consent, and Resident 64 was not offered the vaccine for the 2024-2025 booster, nor was consent obtained. This lack of documentation and consent was confirmed by Staff I, the Infection Preventionist, who acknowledged the absence of consent records for these residents. Additionally, the facility did not secure consent for the administration of psychotropic medication for Resident 14. The resident, who had diagnoses including anxiety disorder, depression, bipolar, and psychotic disorder, was administered an antipsychotic medication starting on May 24, 2024, but consent was not obtained until January 10, 2025, over seven months later. Staff F, the Unit Care Coordinator, admitted that consent should have been obtained prior to the medication's administration. Furthermore, the facility failed to obtain consent for the use of a tilt-in-space wheelchair for Resident 63, who was cognitively intact and expressed concerns about awaiting training for the wheelchair. The resident was observed in the wheelchair, which cannot be adjusted by the user, without any record of consent being obtained. Staff B, the Director of Nursing, confirmed that consent should have been obtained prior to the use of the wheelchair.
Failure to Ensure Advanced Directives for Residents
Penalty
Summary
The facility failed to implement a system to ensure that Advanced Directives (AD) were in place for three residents reviewed for ADs. The facility did not provide information indicating that residents were informed, educated, or offered assistance to formulate an AD. This deficiency was identified through record reviews and interviews with staff and residents. Specifically, Resident 63, who had intact cognition and diagnoses including heart failure and a kidney condition, had no AD documentation on file, nor was there evidence that they received materials explaining their right to formulate an AD. Similarly, Resident 14, who had moderate memory impairment and diagnoses including a drop in blood pressure with change in position and high cholesterol, stated they did not have an AD and were not offered assistance in obtaining one. Resident 77, with moderate memory impairment and diagnoses including diabetes and Parkinson's, also had no AD documentation or evidence of being informed about their right to formulate an AD. Staff interviews confirmed the lack of documentation and assistance provided to these residents, highlighting a systemic failure to ensure residents' rights to formulate an AD were upheld.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for residents, as evidenced by observations of multiple rooms with deep gouges and exposed drywall behind the head of resident beds. These deficiencies were noted in several rooms across two units, specifically Units 400 and 100. Additionally, a nightstand in one of the rooms had its trim ripped off, exposing rough wood. These conditions were observed during a survey conducted on various dates in March 2025. Furthermore, a resident reported that the water in their bathroom sink was consistently too cold, requiring a wait of at least five minutes for it to warm up. The Maintenance Director, Staff Y, acknowledged that it was their responsibility to maintain a homelike environment but was unaware of the needed repairs in the affected rooms. Staff Y stated that they relied on floor staff to report maintenance issues through a communication book, but these issues had not been communicated to the maintenance department.
Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to provide timely and required written notifications to residents and their representatives regarding transfers or discharges, as well as to the State Long-Term Care Ombudsman (LTCO). This deficiency was identified for two residents who were hospitalized. Resident 8, who had no memory impairment, was hospitalized for respiratory symptoms but did not receive a written transfer notification. Similarly, Resident 69, who had moderate memory impairment and whose representative participated in their assessment, was also hospitalized without receiving the necessary written notification. Interviews with staff revealed that the social service department did not provide the required written transfer notices to residents or notify the LTCO of resident transfers. Staff members acknowledged the oversight, with the Social Service Assistant admitting to not providing the notices and the Unit Care Coordinator confirming that residents or their representatives did not sign to acknowledge receipt of the transfer notification forms. The Regional President stated that it was the responsibility of the social service department to ensure these notifications were provided.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to residents and/or their representatives at the time of transfer to a hospital or within 24 hours, as required by their policy. This deficiency was identified for three residents who were reviewed for hospitalizations. Resident 8, who had no memory impairment, was hospitalized for respiratory symptoms but did not receive the required notification. Similarly, Resident 69, who had moderate memory impairment and whose representative assisted in their assessment, was hospitalized without the representative receiving the bed hold policy notification. Resident 64, who had no memory impairment and an indwelling urinary catheter, also did not receive the notification upon hospitalization. Interviews with staff revealed that the social service department and unit care coordinators did not provide the necessary written notice of the bed hold policy to residents or their representatives at the time of transfers. Staff E, a Social Service Assistant, confirmed the lack of notification, while Staff F, a Unit Care Coordinator, acknowledged the absence of documentation in the residents' records. The Director of Nursing, Staff B, stated that nurses were expected to provide and document the notification, emphasizing the importance of informing residents of their rights and the costs associated with holding their bed during hospitalization.
Failure to Complete and Incorporate PASRR Level II Evaluations
Penalty
Summary
The facility failed to ensure that a Level II Preadmission Screening and Resident Review (PASRR) evaluation was completed and incorporated into the Care Plan for two residents. Resident 26, who had non-Alzheimer's dementia, depression, and a history of stroke, exhibited behavior problems such as aggression towards staff. Despite a Level I PASRR screening indicating that Level II services were not required, a significant change in Resident 26's condition was noted, but no documentation showed a Level II referral was made. Similarly, Resident 43, who had non-Alzheimer's dementia, anxiety, depression, and PTSD, required a Level II evaluation referral according to their Level I PASRR screening. However, there was no documentation of a Level II referral being made for Resident 43. Interviews with facility staff revealed that the social services department was understaffed, which hindered the review and completion of PASRR Level II screenings. Staff acknowledged the importance of these referrals for addressing mental health needs but admitted that the facility was not actively working on PASRR Level II referrals and lacked a process to update PASRR screenings for residents with changes in condition. This oversight placed residents at risk for unmet mental health care needs and other negative health outcomes.
Failure to Complete PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were completed for two residents, leading to a deficiency in the screening process. Resident 64, who was admitted with diagnoses including anxiety disorder and depression, had indicators of Serious Mental Illness (SMI) on their PASRR level I assessment. However, no level II evaluation was conducted, as it was incorrectly determined that the resident did not show indicators of SMI. This oversight left the resident at risk of not receiving necessary mental health services. Similarly, Resident 69, who was admitted with diagnoses including dementia, depression, and bipolar disorder, had a PASRR level I assessment completed at a sister facility, which indicated the need for a level II referral due to SMI indicators. Upon transfer to the current facility, the PASRR level I was not reviewed for accuracy and completion, and no level II referral was made. Staff interviews revealed that the PASRR process was not completed accurately, which was crucial for ensuring residents received the mental health services they needed.
Failure to Provide Communication Assistance for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide necessary communication assistance to Resident 77, who was identified as needing an interpreter due to a language barrier. The resident's primary language was not English, and the care plan specified that translation services and communication assistive devices should be provided. However, during an observation and interview, Resident 77 reported that they were unaware of any translation assistance or devices available to them, and no communication aids or translator service phone numbers were found in their room. Staff interviews revealed that the Unit Care Coordinator acknowledged not providing the required communication aids as outlined in the care plan. The Director of Nursing also confirmed the expectation that staff should provide communication boards and translation service contact information to residents with limited English proficiency. The lack of these services placed Resident 77 at risk of miscommunication and unmet care needs, as they were unable to effectively communicate with staff.
Failure to Provide Bathing Assistance to Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically bathing, to a resident who was dependent on staff assistance. Resident 139, who was admitted with a highly transmissible gastrointestinal infection requiring isolation, required substantial to maximal assistance with bathing due to moderate memory impairment. Despite the facility's policy to assist residents unable to perform their own ADLs, Resident 139 received only one bed bath over an 18-day period, with only one documented refusal of bathing. The care plan for Resident 139 did not include directions addressing their bathing needs, and there was no other care plan addressing the need for bathing assistance. During an interview, Resident 139 expressed a desire for assistance with bathing and showed signs of poor hygiene, such as long and soiled fingernails. Staff X, an LPN, acknowledged the importance of providing bathing assistance and confirmed that Resident 139 did not receive the required assistance.
Failure to Monitor Edema in Residents
Penalty
Summary
The facility failed to ensure that three residents with edema received the necessary care and services in accordance with professional standards of practice. Resident 8, who had a diagnosis of heart failure with edema, was receiving diuretic medication but did not have a physician's order to assess and monitor edema. Staff F confirmed the lack of documentation for monitoring the resident's edema, which should have been done every shift to manage heart failure with edema effectively. Resident 13, diagnosed with heart failure with edema and kidney failure, also received diuretic medication but lacked a physician's order to assess and monitor edema. The facility failed to monitor the resident's weight as per physician orders, with only 10 out of 27 opportunities being documented. Staff F acknowledged the importance of monitoring edema and weight changes to prevent fluid overload or dehydration. Resident 64, who had bilateral lower extremity edema, was on diuretic medication but similarly lacked a physician's order for edema monitoring. Staff F and the Director of Nursing both stated that edema should be monitored every shift, and weight should be monitored more frequently for residents with edema.
Failure to Provide Fresh Water to Residents
Penalty
Summary
The facility failed to ensure fresh water was offered to five residents, leading to a risk of dehydration and decreased quality of life. Observations and interviews revealed that residents were not provided with fresh water unless they specifically requested it. This was contrary to the facility's policy, which stated that fluids should always be available to residents, and a hydration cart may be utilized. Residents 8, 14, 13, 69, and 64 were observed multiple times without fresh water available, and they reported that staff did not offer fresh water proactively. Staff interviews confirmed the deficiency, with a Certified Nursing Assistant stating that residents received fluids only on their meal trays unless they asked for more. The Unit Care Coordinator and the Director of Nursing both expressed that staff were expected to offer fresh water every shift and emphasized the importance of doing so to ensure residents remain hydrated. Despite these expectations, the observations indicated a consistent failure to provide fresh water, placing residents at risk of dehydration.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 43, who required oxygen therapy due to a diagnosis of chronic obstructive pulmonary disease (COPD). The resident's care plan and physician's orders specified that oxygen should be administered at a flow rate of 2 Liters Per Minute (LPM) continuously via nasal cannula. However, multiple observations revealed that the oxygen flow rate was set at 3 LPM instead of the prescribed 2 LPM. Additionally, during one observation, the oxygen tubing was found disconnected from the concentrator and lying on the floor, indicating a failure to ensure proper oxygen delivery. Interviews with staff members, including a Licensed Practical Nurse (LPN) and the Unit Care Coordinator, confirmed the discrepancies in oxygen administration. The LPN was unaware of the specific oxygen order and mistakenly believed the flow rate could be set between 2 to 3 LPM. The Unit Care Coordinator emphasized the importance of checking oxygen levels, tubing connections, and settings to ensure the correct rate is administered. The Director of Nursing also stated that oxygen should be administered according to the physician's orders and that nurses should regularly check residents' oxygen needs. These failures in adhering to the prescribed oxygen flow rate and ensuring proper equipment setup placed the resident at risk of respiratory discomfort and decreased quality of life.
Failure to Obtain Consent and Conduct Safety Assessment for Bed Rails and Bed Positioning
Penalty
Summary
The facility failed to obtain informed consent and conduct a safety assessment before implementing bed rails and positioning a bed against the wall for two residents. For one resident, bilateral quarter bed rails were installed without documented consent, despite an evaluation for their use being conducted. An observation confirmed the presence of these bed rails, and staff acknowledged the oversight in obtaining consent, emphasizing its importance to ensure the resident's agreement with the installation. For another resident, the bed was positioned against the wall without a safety assessment or consent. Staff interviews revealed that the expected protocol of obtaining consent and completing a safety assessment was not followed. The Director of Nursing confirmed that staff were expected to adhere to these procedures to prevent potential injuries or entrapment, but they were not executed in these cases.
Failure to Address Resident's Mental Health Needs
Penalty
Summary
The facility failed to ensure that Resident 80, who was diagnosed with depression and other cognitive issues, was evaluated for potential mental health services to address ongoing behaviors. Despite being on an antidepressant medication, Resident 80 exhibited behaviors such as refusals of care, agitation, and refusals to eat, which were documented by the staff on multiple occasions in March 2025. However, there was no evidence that the facility assessed these behaviors or notified the resident's provider of these changes, as required by the care plan. Interviews with staff revealed a lack of communication and follow-up regarding Resident 80's refusals of care. Staff E, a Social Services Assistant, stated they would have contacted the family if they had been aware of the refusals. Staff H, the Unit Care Manager, acknowledged that staff were expected to report refusals of care, but this did not occur. The Director of Nursing, Staff B, confirmed that the facility should have notified the doctor about Resident 80's refusals, as it could impact their overall care. The failure to notify the provider and assess the resident's behaviors placed Resident 80 at risk for untreated mental health issues.
Medication Storage and Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure proper monitoring and storage of medications and biologicals, leading to several deficiencies. In the 100/200 unit medication room, the refrigerator temperature was observed to be 49 degrees Fahrenheit, which is above the recommended range of 36 to 46 degrees. There was no temperature log available to confirm routine monitoring. Interviews with staff revealed a lack of clarity regarding who was responsible for checking the refrigerator temperatures, with the Infection Preventionist, Director of Nursing, and Regional VP all expressing uncertainty about the process. In the 300/400 unit medication room, expired medications were found, including an antibiotic with a use-by date of 03/06/2025 and a suspension powder that expired in 2023. The Unit Care Coordinator admitted responsibility for disposing of expired medications but failed to do so. Additionally, a bottle of medicated powder with another resident's name was found on Resident 31's nightstand. Resident 31, who has a cognitive communication deficit and non-Alzheimer's dementia, was at risk due to this oversight. Staff interviews confirmed that medications should not be left in residents' rooms, especially for those with confusion.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility failed to ensure the confidentiality of resident records for one of the four medication carts reviewed, specifically the 100 hall medication cart. During observations and interviews, it was noted that both a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) left a list containing health information of all residents on the 100 hall unsecured and in view when they walked away from their medication carts. Both staff members acknowledged their responsibility to maintain confidentiality of resident information but admitted to not doing so. The Director of Nursing (DON) confirmed the expectation that all resident information should be secured before staff leave it unattended, emphasizing the importance of maintaining confidentiality for residents' right to privacy.
Lack of Coordination with Hospice Services for Resident
Penalty
Summary
The facility failed to ensure effective coordination of care between the facility and hospice staff for Resident 25, who was receiving hospice services for conditions including Multiple Sclerosis and muscle weakness. The facility did not develop a coordinated Care Plan that included the hospice plan of care or a description of services provided by both the facility and hospice. The Kardex and medical records lacked documentation of the hospice plan of care and visit notes, and the hospice binder at the nurse's station was incomplete, containing only the demographics page of Resident 25's hospice admission. Interviews with staff revealed a lack of communication and coordination between the facility and hospice services. Staff were unsure of the hospice nurse's schedule and did not receive training on hospice care. The Unit Care Coordinator acknowledged the importance of integrating hospice services into the Care Plan but noted that hospice documentation was not consistently placed in the hospice binder. The Director of Nursing stated that coordination with hospice was crucial but was unsure where hospice notes were kept, and these notes were not scanned into the resident's medical record.
Infection Control Deficiencies in Equipment Storage and PPE Use
Penalty
Summary
The facility failed to properly store respiratory equipment for Resident 69, who was admitted with no respiratory infections but later transferred to an acute care hospital for a respiratory illness. Upon return, a physician ordered respiratory medication via a Small Volume Nebulizer (SVN) machine. Observations revealed that the SVN machine was stored on the roommate's nightstand instead of Resident 69's area, which was confirmed by both the Unit Care Coordinator and the Director of Nursing as inappropriate for infection prevention. For Resident 84, who had a Multidrug-resistant Organism (MDRO) infection and required contact precautions, the facility did not follow the physician's order. Instead of implementing the required contact precautions, Enhanced Barrier Precautions were observed, which did not align with the physician's directive. The Director of Nursing acknowledged that the signage on the door did not reflect the correct precautions. Resident 25, who had pressure injuries, was not provided with the necessary Enhanced Barrier Precautions (EBP) during care. Staff were observed not wearing protective gowns while providing care, and there was no EBP signage on the door. Additionally, a housekeeping staff member improperly disposed of a gown outside the room, contrary to protocol. The Infection Preventionist and other staff confirmed the lack of proper signage and adherence to EBP protocols, indicating a need for further training.
Deficiency in Staff Training and Specialized Care
Penalty
Summary
The facility failed to ensure that qualified nursing staff received necessary training and specialized training, affecting four out of five staff members sampled for training. Specifically, Staff I (Infection Preventionist), Staff K (LPN), and Staff CC (CNA) did not have documentation of receiving training upon hire or annual training as required by the facility's assessment. The facility's training program was found lacking, as there was no Staff Development Coordinator to track training, and the responsibility was left to staff to seek out training themselves. The available online training curriculum did not include specialized training for dementia care, behavioral health, or hospice care. Interviews with various staff members revealed a lack of awareness and documentation regarding specialized training, particularly in hospice care, which was crucial given the number of residents receiving such care. Staff S (CNA) confirmed not receiving hospice care training, and Staff H (Unit Care Coordinator) and Staff B (Director of Nursing) were unaware of any specialized hospice training being provided. This deficiency placed residents at risk for unmet care needs and a diminished quality of life, as the staff were not adequately prepared to meet the specific needs of residents requiring specialized care.
Failure to Implement POLST System
Penalty
Summary
The facility failed to implement a system to ensure Physician's Orders for Life Saving Treatments (POLSTs) were properly followed for three residents. For Resident 32, a miscommunication occurred during a medical emergency when a Code Blue was announced. Staff I, the Infection Preventionist, initially provided incorrect information from the POLST book, leading to the initiation of CPR on Resident 32, who had a selective treatment order. The root cause of this error was identified as the organization of the POLST book by room number rather than by resident name, which led to the incorrect identification of the resident's treatment preferences. For Residents 16 and 60, the facility failed to ensure that their POLST forms were readily available. During a review, it was found that there was no POLST for Resident 16 in the POLST book or in the resident's chart, and a new POLST form was needed. Similarly, there was no POLST for Resident 60 in the POLST book. These deficiencies placed the residents at risk of receiving unwanted CPR or other lifesaving treatments, as their treatment preferences were not easily accessible to the staff.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure staff provided care according to a resident's care plan, resulting in a fall and injury. The resident, who was on hospice services and dependent on staff for bed mobility and incontinence care, was supposed to be assisted by two caregivers as per their care plan. However, during an incident, a caregiver attempted to provide incontinence care alone, without the required assistance, leading to the resident rolling off an air mattress and sustaining an inoperable leg fracture. The care plan and Kardex did not include information about the use of an air mattress, which was a factor in the incident. The facility's investigation revealed that the caregiver did not follow the care plan, which required two caregivers for bed mobility and incontinence care. Despite having enough staff on duty, the caregiver did not seek assistance, resulting in the resident's fall and subsequent injuries. The investigation also noted that the facility's documentation showed multiple instances where only one caregiver was provided for the resident's care, contrary to the care plan requirements. Interviews with staff confirmed the failure to adhere to the care plan, which led to the resident's fall and injury.
Failure to Provide Written Notification for Room Changes
Penalty
Summary
The facility failed to provide a written explanation to residents and/or their representatives for facility-initiated room changes for four residents. These residents were cognitively intact and required therapy services at the facility. The facility's policy required that residents receive a written explanation for room changes, an opportunity to see the new location, meet the new roommate, and ask questions about the move. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and written notifications for the room changes. Resident 14 experienced a room change from a private room to a shared room without any documented discussion or written explanation. This resident expressed frustration and suicidal ideations due to the lack of communication and subsequently discharged themselves against medical advice. Similarly, Resident 13 was moved to a room with two other people without advanced notice or a written explanation, and their new roommates were not informed about the move. Resident 11 was also moved without notice or a written explanation, and they were told the move was due to the hall being for sicker people. Resident 12 was moved from a private room to a shared room without any choice or notice, and no written explanation was provided. Interviews with staff revealed that the facility had a Room Change Notification form that was supposed to be completed and provided to residents, but these forms were not found in the records of the affected residents. Staff admitted to not following the facility's policy and being unaware of the requirements for moving residents to different rooms.
Deficiencies in Air Mattress Use and Monitoring
Penalty
Summary
The facility failed to develop and implement a comprehensive system for the use of air mattresses for residents, which led to several deficiencies. The facility did not assess the residents' needs for air mattresses, determine the required settings, or recognize the risk factors associated with their use. Additionally, the facility did not inform or educate residents or their representatives about the risks, such as falls and injuries, associated with air mattresses. There was also a lack of informed consent from residents or their representatives for the use of these devices. Furthermore, the facility did not implement a resident-directed care plan for the use of air mattresses, monitor the mattress function, condition, and individualized pump settings, or re-evaluate the ongoing use of air mattresses to ensure their necessity. The report highlights specific cases where these deficiencies were evident. For instance, Resident 1, who was on hospice services and dependent on staff for mobility, fell out of bed and sustained injuries because the caregiver did not follow the care plan requiring two-person assistance. The care plan was not updated to reflect the use of an air mattress, and there was no consent form for its use. Similarly, other residents, such as Residents 2, 3, 4, 5, 6, and 7, were found to be using air mattresses without proper documentation, consent, or care planning. In many cases, the care plans and Kardex did not reflect the use of air mattresses, and there were no physician orders or directions for monitoring the mattress functions. Interviews with staff revealed a lack of training and awareness regarding the use of air mattresses and their settings. Staff members, including nursing assistants and nurses, were not trained to modify care for residents using air mattresses or to adjust the pump settings. The facility also lacked a policy or procedure for assessing and monitoring air mattresses, and there was no corporate guidance on their use. This lack of training and policy contributed to the deficiencies observed, placing residents at risk of falls and injuries.
Incomplete Investigation of Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that incident reports were completely and thoroughly investigated for two residents with injuries of unknown origin. Resident 4, who had Alzheimer's dementia and other medical conditions, was found with a bruise on the left side of their face. The facility's incident report log was incomplete, and there was no documentation to support that the bruise was investigated to rule out abuse or neglect. Staff interviews revealed that the incident was reported late to the State Agency and was not investigated as required. Resident 7, who had memory impairment and behavioral symptoms, was discovered with a bruise on their left eye. The investigation report concluded that the bruise was related to the resident's confusion, combativeness, and medication use. However, the report lacked vital information necessary to rule out abuse or neglect, and it did not identify safety interventions to prevent reoccurrence. Staff acknowledged the deficiencies in the investigation process. The facility's policy required that allegations of abuse, including injuries of unknown source, be thoroughly investigated within five working days. The policy also required a written summary of the investigation to include a review of all circumstances surrounding the incident. The failure to adhere to these policies left residents at risk for unidentified abuse and/or neglect.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for two residents with pressure ulcers, leading to significant harm for Resident 1. Resident 1, who was admitted for skilled rehabilitation, had multiple medical diagnoses and was dependent on staff for daily care. Despite being incontinent and having Moisture Associated Skin Damage (MASD) upon admission, the care plan did not include preventative measures such as repositioning or off-loading. The lack of appropriate interventions and failure to follow physician orders resulted in the MASD developing into a Stage 4 pressure ulcer with osteomyelitis. Resident 1's pressure ulcer was not adequately managed, as evidenced by the absence of treatment orders for the MASD and the failure to implement recommended wound care treatments. The wound care notes documented the progression of the ulcer from unstageable to Stage 4, with increasing size and depth, and the presence of multiple bacteria indicating a risk for infection. Despite recommendations to change the treatment regimen, the facility continued to apply both Iodosorb and Santyl ointments simultaneously, contrary to the wound care provider's orders. Resident 2 also experienced inadequate care, as their care plan did not include necessary interventions for pressure ulcer prevention and management. Upon admission, Resident 2 had multiple open wounds and was assessed to require an air mattress for pressure redistribution, which was not provided. Additionally, the facility failed to implement the recommended treatment for Resident 2's left hip pressure ulcer, as there was no documentation of the Santyl ointment being applied. The facility's inaction and lack of documentation for both residents highlight a failure to adhere to professional standards of practice, placing residents at risk for further skin breakdown and diminished quality of life.
Failure to Monitor and Address Suspected UTI Leads to Hospitalization
Penalty
Summary
The facility failed to provide resident-focused care by not consistently monitoring, assessing, and evaluating a resident's condition, and by not implementing physician orders in a timely manner. This deficiency was identified in the case of a resident who was admitted with a spinal fracture and assessed as always incontinent of urine, requiring incontinence care from staff. The resident, who had cognitive impairments and communication deficits, exhibited behaviors that suggested a possible urinary tract infection (UTI). Despite a request from the resident's representative to check for a UTI, the facility did not successfully collect a urine sample for testing. The practitioner ordered a urine lab test, but the facility's staff failed to collect the sample due to the resident's incontinence and refusals. Documentation showed only one attempt to collect the urine sample, and no further attempts were made. The staff did not notify the practitioner or the resident's representative about the inability to collect the sample, nor did they implement any new interventions despite the resident's worsening condition. The resident's condition deteriorated, leading to hospitalization with severe sepsis, cystitis, kidney infection, and acute kidney injury. Interviews with the Director of Nursing and the Administrator revealed that the facility did not monitor the resident for UTI symptoms, did not document further attempts to collect a urine sample, and did not communicate effectively with the practitioner or the resident's representative. The order for the urine sample collection was dropped from the electronic medical record, which contributed to the oversight. The resident was eventually sent to the hospital due to a change in their level of consciousness and a decline in their medical condition.
Inadequate Supervision Leads to Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect Resident 2 from physical abuse when Resident 1 punched Resident 2 twice on the shoulder. Resident 1, diagnosed with dementia and psychotic disorder, had a history of verbal and physical aggressive behaviors towards residents. The facility did not adequately supervise Resident 1 or mitigate known triggers for their aggressive behaviors. The incident occurred when Resident 1 became irritated with Resident 2's vocalizations and disruptive behavior, leading to the physical abuse. Staff interviews revealed that Resident 2, who was known to be confused and disruptive, could not recall the incident when asked. Resident 1's dislike for Resident 2's repetitive words led to the physical abuse.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse by one resident towards another was identified and reported to the State Survey Agency as required. Specifically, Resident 3 reported that Resident 4 threw a plate that hit them in the eye and on the toe. This incident was documented in Resident 3's Care Management note and Behavior Note, but it was not entered into the facility's March 2024 Reporting Log. During interviews, Resident 3 confirmed the incident, while Resident 4 denied it. A Certified Nursing Assistant mentioned seeing Resident 3 in Resident 4's space but did not witness the tray being thrown. The Director of Nursing stated that the incident did not occur, and the Administrator acknowledged that the allegation should have been logged. The facility's Abuse - Reporting and Response policy, revised on 10/13/2023, mandates that all alleged violations involving abuse or neglect be reported immediately or within 24 hours if no serious bodily injury occurred. The failure to report this incident placed residents at risk for additional abuse. The deficiency was identified during a review of the facility's records and interviews with the involved parties.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure allegations of abuse were thoroughly investigated for two of four abuse allegations reviewed. In one instance, Resident 3 reported that Resident 4 threw a plate that hit them in the eye and toe. Despite Resident 3's consistent complaints and a history of behavioral issues with Resident 4, the facility did not complete an incident report or conduct a thorough investigation. Staff interviews revealed that some staff found Resident 4's behavior amusing, and there was a lack of documentation and follow-up on the incident, leaving Resident 3 feeling unprotected and fearful. In another instance, Staff D observed Resident 1 hitting Resident 2 on the shoulder due to irritation over noise. The facility's investigation was incomplete, as it did not include interviews with staff on duty or further actions based on other residents' reports of feeling unsafe around Resident 1. The investigation lacked thoroughness, failing to identify the events leading up to the incident or any additional witnesses. The facility's inaction and insufficient investigations placed residents at risk of continued abuse and a diminished quality of life. Staff members were either unaware of or did not follow proper procedures for reporting and investigating abuse allegations, leading to a failure in protecting residents from harm.
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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