Life Care Center Of Mount Vernon
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Vernon, Washington.
- Location
- 2120 East Division Street, Mount Vernon, Washington 98273
- CMS Provider Number
- 505272
- Inspections on file
- 39
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Life Care Center Of Mount Vernon during CMS and state inspections, most recent first.
A resident with epilepsy, muscle weakness, and gait difficulty, who required assistance for transfers and ambulation, experienced multiple falls over a short period. Incident investigations repeatedly identified issues such as self-transfers to a bedside commode (BSC), use of an unsafe four-wheeled walker, environmental clutter, poor lighting, and failure to use the call light, yet the facility did not consistently update the care plan or Kardex with specific fall-prevention interventions. Observations showed the room layout and equipment placement (BSC, walker, bedside table) did not match existing care plan directions, and the bedside table remained unlocked despite a prior fall related to its misuse. Staff, including NACs, LPNs, the DON, and rehab leadership, acknowledged the resident’s impulsive behavior, recurrent falls, and unsafe walker use, but there was no clear documentation of risk/benefit education to the resident and family, no documented conclusions or actions after several falls, and no documented plan to increase supervision despite personal caregivers not being present around the clock.
The facility failed to develop and implement individualized care plans and monitoring for residents after orthopedic surgeries, resulting in unassessed pain, lack of skin checks under compression stockings, and missed interventions for edema and blood clot risk. One resident suffered significant harm due to a blood clot that went undetected for several days, requiring hospital transfer and surgical intervention.
A resident who was dependent on staff for bed mobility and at risk for pressure injuries was not properly assessed after readmission following knee surgery. Staff did not remove compression stockings to inspect the skin, failed to update the care plan, and did not document or report refusals or pain. Multiple unstageable pressure injuries and a deep tissue pressure injury developed before the issue was discovered and the resident was transferred to a hospital.
A resident who underwent a total knee replacement and had risk factors such as atrial fibrillation and peripheral vascular disease did not receive necessary post-surgical assessments or monitoring. Staff failed to remove a compression stocking for skin checks, did not update the care plan, and did not communicate refusals or unclear orders to the provider. The lack of assessment and documentation led to the development of a blood clot, pressure injuries, and required hospitalization.
Multiple residents and a family member reported long wait times for call light responses, with some waiting up to 30-40 minutes for assistance. Staff interviews and direct observation confirmed that the facility was short-staffed on all shifts, leading to delays in meeting residents' basic care needs such as transfers and bed-making. Staffing levels were based on census and a per patient day formula, but staff indicated these levels were insufficient for residents with higher acuity needs.
Surveyors found that the facility failed to maintain complete and accurate medical records for three residents, including missing or inconsistent documentation of weights, lack of follow-up on a hospice referral, inaccurate nursing assessment entries, and incomplete admission assessments. Staff confirmed these documentation lapses, and some issues were repeat deficiencies from prior surveys.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures were not adequately implemented to stop new ulcers from developing.
A resident with kidney failure who required dialysis was transported by wheelchair on foot by staff for an early morning dialysis appointment, during which the resident complained of being cold and expressed dissatisfaction with the lack of vehicle transport. Although staff were aware of the complaints, no grievance was initiated or logged as required by facility policy.
A resident with morbid obesity and existing pressure ulcers developed two new stage three pressure ulcers after a urinary catheter was placed. The facility did not complete a thorough investigation, omitting required interviews and audits, and failed to rule out abuse or neglect. Staff interviews revealed incomplete documentation and lack of follow-through in the investigative process.
A resident with CHF and cellulitis experienced rapid weight gain, swelling, slurred speech, and respiratory distress, but staff failed to thoroughly assess, notify the physician, or document timely interventions. Multiple nursing assistants reported the resident's decline to the assigned RN, who did not act promptly or notify the provider. When the resident became unresponsive, there was a delay in emergency response, and the RN lacked current CPR certification, as did other staff. The resident, who was a full code and not expected to die, passed away unexpectedly.
A resident with a history of heart failure and cellulitis experienced a rapid weight gain and significant change in condition, including slurred speech and swelling, which were observed and reported by multiple NACs. The assigned RN failed to assess the resident promptly, did not notify the physician of the weight gain or change in condition, and did not provide timely intervention. When the resident became unresponsive, NACs initiated CPR and called EMS, while the RN did not assist or direct resuscitation efforts. The facility's investigation was incomplete, lacking staff statements and proper reporting, and the incident resulted in the resident's unexpected death.
A resident with heart failure and cellulitis experienced a significant change in condition, including slurred speech and a swollen arm, which was repeatedly reported by NACs to a nurse who failed to assess or act. Staff had to insist on emergency intervention, but the resident died unexpectedly. The facility did not report the death to the State Hotline, law enforcement, or the coroner, nor did it log the incident or conduct a thorough investigation, despite staff concerns about the nurse's lack of clinical judgment.
The facility did not conduct thorough investigations into multiple incidents, including allegations of abuse and neglect, several falls, a medication error, and a pressure ulcer. In several cases, residents' reports and staff concerns were not fully addressed, required interviews and documentation were missing, and errors in care were not properly identified or followed up on. These failures included not updating care plans, not completing neurological assessments after falls, and not reporting or correcting medication and transcription errors.
The facility did not complete a comprehensive facility-wide assessment, omitting key elements such as resident care needs, staff competencies, physical environment, equipment, services, personnel, contracts, and health information technology resources. The assessment contained outdated information and was confirmed by the Administrator as the most current version available.
Surveyors found that staff failed to interact with residents in a dignified manner during meals, did not provide privacy when assisting with personal care, and left urinary catheter bags uncovered and visible from the hallway. Residents reported staff not responding to requests for help, not knocking before entering rooms, and not documenting or addressing their concerns, resulting in compromised dignity and privacy.
Staff failed to secure a report sheet containing personal health information for 20 residents, leaving it at a bedside where a resident photographed it. The sheet included names, diagnoses, medication details, and code statuses. Another resident received a letter about the breach and expressed distress over the exposure of their private information. The DON was unaware of the incident, while the Regional Director of Clinical Services confirmed the HIPAA violation.
Surveyors observed unclean conditions in multiple resident rooms, including stained privacy curtains, heavy dust on vents and curtain rails, and a resident-reported issue with a shared bathroom not being properly cleaned. Housekeeping staff acknowledged the need to change dirty curtains, and the administrator was aware of ongoing environmental concerns.
The facility did not have an effective system to log, investigate, and resolve resident grievances, as evidenced by repeated unaddressed complaints about food, missing items, and maintenance issues. Residents expressed uncertainty about the grievance process, and staff demonstrated inconsistent understanding and application of grievance procedures, resulting in unresolved concerns and lack of documentation.
The facility did not ensure that a resident's fall prevention care plan was properly reviewed, updated, or implemented, as staff failed to follow specific interventions such as bed positioning and fall mat placement. Additionally, two residents who smoked were not assessed for safe smoking practices, and their care plans lacked necessary interventions, with staff unaware of their smoking status or required supervision.
The facility failed to maintain adequate nursing staff to meet resident needs, resulting in long wait times for assistance, especially during nights and meal periods. Multiple residents reported delays in call light responses and unmet care needs, while staff confirmed that restorative nursing aides were reassigned to direct care, causing the Restorative Nursing Program to be suspended. Care plans and therapy recommendations for range of motion and splint application were not followed due to staffing shortages, and the facility assessment did not address the specific staffing needs of the resident population.
Several residents reported being unable to access or receive adequate support from social services, with some feeling dismissed or ignored when seeking help. The social worker was unable to meet the needs of all residents, particularly those with behavioral health disorders and those on psychotropic medications, due to insufficient staffing and workload. The facility did not adjust staffing or competencies based on resident acuity, resulting in unmet social and emotional needs.
Staff failed to follow proper hand hygiene protocols when handling food and dishes, including not washing hands after handling dirty items and before touching clean ones. Additionally, multiple areas in the kitchen, such as racks, hoods, and prep sinks, were observed to have dust and debris, indicating unsanitary conditions.
The facility did not ensure its QAPI program consistently identified and addressed deficiencies, resulting in repeated findings across multiple areas such as resident rights, care planning, environment, ADLs, quality of care, accident prevention, nutrition, and psychotropic medication use. The Administrator acknowledged the repeat issues and cited a focus on management retention, but could not address actions taken by previous leadership.
A resident recovering from hip surgery did not receive pain management as ordered due to a transcription error that limited Oxycodone dosing and delays related to a pharmacy allergy alert. The resident experienced high pain levels without timely or effective medication, and there was no follow-up on pain relief effectiveness, leading to dissatisfaction and discharge against medical advice.
Two residents with significant cognitive and physical impairments did not have call lights accessible as required by their care plans. One resident was provided with an inappropriate call light device and frequently could not reach it, while another repeatedly had their call light on the floor and out of reach. Staff confirmed that call lights should always be within reach, but this was not maintained.
A resident with a history of bipolar disorder, anxiety, and PTSD was admitted and qualified for a Level II PASARR, which included recommendations for environmental safety, staff approaches, and behavioral interventions. These recommendations were not incorporated into the resident's care plan, and facility staff were unaware of the required updates, resulting in a failure to follow policy for care planning based on PASARR findings.
The facility did not complete required PASRR screenings for three residents with mental health or cognitive diagnoses. One resident remained in the facility beyond a 30-day exemption without further evaluation, another had incomplete documentation of diagnoses leading to a missed Level II referral, and a third had multiple indications for a Level II referral that were not acted upon. Staff interviews confirmed the lack of follow-through and documentation accuracy.
The facility did not update care plans for two residents after significant changes in their medical conditions and treatments. One resident developed new lower extremity edema and was started on a diuretic with recommendations for leg elevation, but these were not reflected in the care plan. Another resident received two different anti-anxiety medications and a behavioral health referral following behavioral changes, yet the care plan was not revised to include these interventions.
A resident with a traumatic brain injury and speech disorder was not provided access to their communication device, as staff were untrained or unaware of its use. The device remained unused in the resident's room, and staff relied on limited hand signals for communication, despite the resident's ability to use the device to express needs when it was made available.
Three residents with significant cognitive and physical impairments did not receive individualized activity programs as outlined in their care plans. One resident was left alone in their room with only music on the TV, another remained in bed without receiving scheduled social visits or group activity participation, and a third expressed boredom while not being included in ongoing group activities. Staff interviews revealed a lack of awareness and implementation of activity care plans, and activity preferences were not consistently assessed or addressed.
Two residents did not receive necessary care and services according to professional standards, including lack of edema management and failure to follow up on specialist referrals. One resident's new onset edema was not properly monitored or addressed per provider orders, and another resident did not have recommended therapy referrals acted upon due to staff communication and workflow issues.
Two residents with decreased mobility developed stage II pressure ulcers due to the facility's failure to implement and document consistent turning/repositioning programs, ensure use of pressure-relieving devices, and conduct thorough skin assessments. Staff were unaware of required interventions, and care plans were not followed, resulting in inadequate prevention and management of pressure injuries.
Two residents with significant contractures and mobility limitations did not receive restorative nursing services, such as range of motion exercises and splinting, as recommended in their care plans and therapy notes. Staff interviews and record reviews confirmed that restorative programs were not implemented due to staffing shortages, and the only restorative-trained staff member was not utilized in that role.
Two cognitively impaired residents did not receive adequate hydration, as fluids were frequently unavailable or out of reach in their rooms, and staff did not consistently offer or provide water as required. Both residents had documented fluid requirements and special dietary needs, but observations and staff interviews confirmed that their hydration needs were not met.
Two residents with depression and behavioral health needs did not receive timely or documented referrals to behavioral health services despite high PHQ-9 scores and provider recommendations. Staff interviews revealed gaps in communication and documentation, resulting in unmet psychosocial needs.
The facility did not act in a timely manner on monthly pharmacist recommendations for two residents, resulting in significant delays in completing ordered lab tests, including a fasting lipid panel and a basic metabolic panel, despite repeated documentation and acknowledgment by nursing and pharmacy staff.
Several residents reported that when they requested snacks outside of scheduled meal times, staff often stated that only limited options like crackers were available, and sometimes no snacks were left late at night. One resident on a pureed diet was given inappropriate snacks such as chips and cookies, with staff unaware of their dietary restrictions. Staff interviews confirmed snacks were expected to be provided, but residents' reports and council meeting minutes documented ongoing concerns about snack availability and variety.
Staff failed to follow infection prevention and control protocols, including proper hand hygiene and PPE use, while caring for two residents—one on enteric precautions for suspected C. Diff and another with severe cognitive impairment. Staff used hand sanitizer instead of handwashing after C. Diff care, did not change gloves or perform hand hygiene between care tasks, and stored clean PPE next to soiled waste, contrary to facility policy and infection control standards.
The facility failed to ensure accurate medication orders for three residents with NPO status, leading to discrepancies in their MARs. Despite having orders for enteral tube administration, the MARs showed oral medication orders. Staff interviews confirmed the errors, acknowledging that medications should not be given by mouth to NPO residents.
The facility failed to uphold resident rights, leading to deficiencies in communication and care. A resident had a follow-up appointment canceled without their knowledge, and another resident's POA was unable to reach the facility or the resident due to unresponsive phone lines. Staff interviews revealed inconsistencies in communication procedures, placing residents at risk for unmet care needs.
A resident reported an incident involving a staff member who acted angrily during repositioning. The facility's investigation was incomplete as it lacked a statement from the involved staff member, Staff F. Interviews with facility staff revealed that the investigation process was not thorough, as expected by the interim DNS.
Instances of harm were reported due to deficiencies in bowel care management, hospice referral, and neurological checks. A resident with a complex medical history, including cancer and lung disease, experienced a bowel impaction leading to hospitalization. Despite being on multiple narcotics known to cause constipation, timely and appropriate bowel care interventions were not provided. The lack of a comprehensive constipation care plan and inadequate monitoring of bowel movements contributed to the resident's condition. Another resident with colon cancer and malnutrition faced complications from irregular bowel movements and insufficient routine laxatives, resulting in symptoms like abdominal pain, vomiting, and altered mental status, ultimately requiring hospitalization. Delays in developing a constipation care plan and inadequate administration of prescribed bowel medications were contributing factors.
The facility did not comprehensively assess and ensure timely and appropriate services to maintain or improve range of motion (ROM) for two residents with contractures. One resident with vascular dementia and muscle weakness developed a significant left-hand contracture, with no documented therapy or staff awareness of the condition. Another resident with an intracranial injury and upper extremity contracture experienced lapses in prescribed ROM interventions, including splint applications and passive exercises. Staff interviews revealed a lack of awareness regarding ROM assessments and therapy referral processes. Staffing challenges during the COVID-19 pandemic contributed to the absence of a restorative program, impacting ROM maintenance.
The facility failed to maintain a clean and homelike environment, with observations of broken blinds in a resident's room and extensive carpet staining throughout the facility. Staff acknowledged the issues but did not take timely action to address them, compromising residents' dignity and quality of life.
The facility failed to prevent physical abuse of a resident by another cognitively impaired resident with a history of aggressive behavior. Despite documented incidents and a care plan, the facility did not provide adequate supervision or effective interventions, leading to repeated altercations and abuse.
The facility failed to report and investigate allegations of abuse and neglect for three residents. One resident alleged inappropriate touching by a nurse, another had an unexplained injury, and a third reported being hit by another patient. Staff failed to report these incidents to the hotline, and the facility did not document them in the state incident reporting log.
The facility failed to ensure the RAI included thorough summaries of the CAA for three residents, leading to incomplete and potentially inaccurate care plans. The assessments lacked comprehensive analysis and did not reflect the residents' goals, preferences, strengths, or needs.
The facility failed to update and revise care plans for six residents, leading to unmet care needs and diminished quality of life. Issues included unaddressed pain management, unreported physical aggression, outdated medication interventions, incomplete restorative nursing care, broken communication devices, and significant weight loss.
The facility failed to complete required annual performance reviews for three NAC staff members, placing all residents at risk for unmet care needs. The Director of Nursing Services confirmed that the evaluations were not completed.
The facility failed to ensure timely completion of PASRR assessments for three residents with significant changes in condition, potentially preventing them from receiving appropriate specialized rehabilitation services.
Failure to Implement and Update Fall-Prevention Interventions for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement and update fall-prevention interventions for a resident with multiple falls. The resident was readmitted with epilepsy, congenital brain anomalies, muscle weakness, and difficulty walking, and the admission MDS showed no cognitive impairment. The resident required set-up assistance for toilet transfers and supervision/touching assistance for ambulation with a walker. Between mid-December and early February, the resident experienced nine falls. Incident investigations documented repeated falls related to self-transfers to a bedside commode (BSC), use of an unsafe four-wheeled walker, and environmental clutter, but the facility did not consistently translate identified issues into care plan updates, Kardex directions, or clear, implemented interventions. One fall investigation on 12/17 documented that the resident fell while using a bedside table as a walker to self-transfer to the BSC, and the only documented intervention was a staff training note that one wheel of the bedside table needed to be locked at all times. However, the current care plan and nursing Kardex contained no instruction to keep the bedside table locked, and subsequent observations showed the bedside table remained unlocked. Another fall on 12/21 occurred when the resident, who required one-person assist for transfers and walking, walked without assistance to the front of the building and fell from a lobby bench; the investigation did not document any interventions to prevent further falls. A 12/24 investigation contained conflicting information about the type of walker used and the location and mechanics of the fall, concluded that the resident used an unsafe four-wheeled walker, and noted that the walker was removed and then given back to the resident, without documentation of risks/benefits education or additional interventions regarding the unsafe walker. Further incident reports showed similar gaps. On 12/31, the resident slipped off the BSC, with predisposing factors including clutter, crowding, poor lighting, balance disorder, and ambulation without staff assistance; there was no documented conclusion or action taken. On 01/23, the resident again fell while using the BSC and an unsafe four-wheeled walker brought in by family, and although the record stated the resident wanted to use the walker despite education, there was no documentation of what risk/benefit information was provided. A 01/25 fall noted the resident was found on the floor after attempting to get up alone, with no documented conclusion or preventive action. On 02/02, the resident fell onto a box fan near the BSC in a cluttered room with a four-wheeled walker, fan, and BSC, and the call light out of reach; the report listed impulsive behavior, poor safety awareness, gait imbalance, and recurrent falls, but again lacked a documented conclusion, actions taken, or interventions addressing the cluttered environment. The resident’s physical therapy evaluation on 01/27 documented the need for supervision or assistance with sit-to-stand, transfers, and toilet transfers, and moderate assistance for walking short distances. The existing fall care plan included older interventions such as placing the BSC close to the bed and ensuring the front-wheeled walker (FWW) was within reach, and encouraging use of both hands on the FWW, but these were not reflected in the actual room setup. Multiple observations in February showed the bed against the wall, a recliner in the middle of the room, the BSC about 10 feet from the bed behind the recliner, the bedside table unlocked next to the recliner, and no FWW in the room, while the four-wheeled walker was at the foot of the bed and away from the recliner. Staff interviews confirmed that the resident was a fall risk, frequently self-transferred to the BSC without using the call light, used an unsafe four-wheeled walker, and did not follow therapy recommendations, yet there was no documentation of detailed risk/benefit education to the resident and family, no consistent care plan updates, and no documented interventions to increase supervision despite staff acknowledging that personal caregivers were not present 24 hours a day. Interviews with behavioral therapy staff and the DON further highlighted the lack of clear information and documentation. Behavioral therapy staff reported that nursing could not explain the multiple falls or the cause of the resident’s right eyelid injury, nor what interventions were in place to prevent further falls. The DON acknowledged that multiple falls were related to self-transfers to the BSC and use of the four-wheeled walker without supervision, and also acknowledged that the room arrangement and equipment placement did not match the resident’s needs, such as the BSC being behind the recliner and the walker not being placed near the recliner. The rehab director stated that the resident was not safe to use the four-wheeled walker and referenced a care conference where a collaborating agency staff member stated the resident had the right to use the preferred walker and the right to fall, but this conference was not documented. Overall, the facility did not adequately evaluate, document, or implement effective fall-prevention interventions in response to repeated falls, did not ensure the environment and equipment matched the care plan, and did not consistently update the care plan and staff directions to reflect the resident’s needs and identified risks.
Failure to Provide Post-Surgical Care Planning and Monitoring
Penalty
Summary
The facility failed to establish and implement appropriate care plans, assessments, and monitoring for residents following orthopedic surgeries, specifically after total knee replacement and hip fracture procedures. For three residents reviewed, there was a lack of individualized care planning and failure to document or provide necessary interventions related to post-surgical care, including the use and monitoring of compression stockings (ted hose) and assessment for edema. Orders for post-surgical care, such as dressing changes, compression stocking use, and monitoring for edema, were not incorporated into the residents' care plans, and staff did not consistently follow or clarify these orders. One resident, who had a recent total knee replacement and a history of atrial fibrillation and peripheral vascular disease, experienced increased pain in the right foot that went unassessed for six days. Staff did not remove the compression stocking to visualize the skin or assess the source of pain, despite the resident's complaints and the presence of risk factors for blood clots. There was no documentation of staff attempts to assess the area, no notification to the provider regarding the resident's pain or refusal (if any) to allow assessment, and no updates to the care plan to reflect the resident's post-surgical needs. When the compression stocking was finally removed, significant discoloration and tissue damage were discovered, leading to hospital transfer and surgical intervention for a blood clot. Interviews with staff revealed confusion and lack of clarity regarding responsibility for care plan updates, assessment protocols, and communication with providers. Staff reported not removing compression stockings for skin checks, not documenting refusals, and not notifying providers of changes in condition or unclear orders. The care plans for other residents with similar post-surgical needs also lacked necessary interventions and monitoring instructions, further demonstrating a systemic failure to provide care according to physician orders and resident needs.
Failure to Assess and Prevent Pressure Ulcers Post-Surgery
Penalty
Summary
The facility failed to complete necessary assessments and implement appropriate interventions to prevent pressure ulcers for a resident who was readmitted after a total right knee arthroplasty. Upon readmission, the resident was identified as being at risk for pressure injuries and was dependent on staff for bed mobility. Despite this, there was no documentation that licensed staff removed the resident's compression stockings to assess the skin on the right leg and foot during the initial and subsequent skin assessments. Staff interviews confirmed that the compression stockings were not removed for visual inspection, and the care plan was not updated to reflect the resident's increased risk following surgery. Over a period of several days, there was no evidence that the resident's right foot was assessed, even though the resident was experiencing increased pain. Staff did not document any refusals of care or notify the medical provider about the inability to assess the resident's skin. When the compression stocking was finally removed, multiple pressure injuries were discovered, including unstageable pressure injuries with black eschar and a deep tissue pressure injury on the right foot. The resident was subsequently transferred to a hospital for further care. Interviews with nursing staff and management revealed that there was a lack of adherence to facility policy regarding daily and weekly skin assessments, especially for residents with devices such as compression stockings. The care plan was not revised after the resident's surgery, and there was no communication with the provider regarding unclear orders for the compression stockings or the resident's pain and refusal to allow assessment. These failures resulted in the development of significant pressure injuries.
Failure to Assess and Monitor Post-Surgical Resident Resulting in Neglect and Pressure Injuries
Penalty
Summary
The facility failed to provide necessary assessments and monitoring for a resident following a total right knee arthroplasty. Despite the resident having diagnoses that increased their risk for complications, such as atrial fibrillation and peripheral vascular disease, there were no physician orders for licensed staff to assess the resident’s right leg, including skin checks, pulse, movement, or sensation after surgery. The care plan was not updated to reflect the resident’s post-surgical needs, and there was no documentation of interventions or monitoring for the right leg. For eleven days after surgery, licensed nurses did not assess the resident’s right foot, and there was no evidence that the compression stocking was removed for proper skin assessment. Documentation in the medical record was lacking regarding any refusals by the resident to allow removal of the compression stocking, and late entries were made only after the resident was hospitalized. Staff interviews revealed that refusals were not communicated to the physician, and staff did not seek clarification on unclear physician orders regarding the use of compression stockings. Multiple staff members confirmed that they did not attempt to remove the compression stocking or notify the provider about the situation, and assumptions were made that other staff or shifts were handling the issue. The resident and their power of attorney both stated that staff never attempted to remove the compression stocking or assess the right foot, despite the resident experiencing significant pain and requesting attention to the area. As a result of these failures, the resident developed a blood clot that restricted blood flow to the right foot, required surgical intervention, and developed several pressure injuries. The lack of assessment, monitoring, care planning, and communication with the provider led to unmet care needs and avoidable skin issues. The facility’s own investigation confirmed the absence of timely notification, documentation, and care planning, which resulted in significant harm to the resident.
Failure to Provide Sufficient Nursing Staff for Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple observations, interviews, and record reviews. Several residents reported extended wait times for call light responses, with one resident stating it could take 30-40 minutes for staff to respond, particularly noting their room was at the end of the hallway. Another resident indicated that staffing levels seemed low, and others described having to wait a long time for assistance without specifying exact durations or shifts. A family member reported that their loved one was left on the toilet for extended periods and that they often had to seek staff assistance in the hallway, especially during mealtimes and weekends. Staff interviews corroborated these concerns, with nursing assistants and other staff members stating that the facility was short-staffed on all shifts. One nursing assistant noted a reduction in the number of staff on their shift, from seven to five, and described delays in providing two-person assistance for residents with higher acuity needs. Continuous observation of call light panels revealed that several call lights remained illuminated for extended periods, with some not being answered for over 15 to 26 minutes. During these times, staff were observed entering rooms without call lights on, and residents were seen waiting for assistance with basic needs such as transferring, bed-making, and napping. The staffing coordinator and facility leadership confirmed that staffing levels were determined based on census and a per patient day (PPD) formula, with adjustments made as census increased. However, staff and anonymous sources indicated that the current staffing did not meet the acuity needs of residents, particularly in halls with a higher number of residents requiring two-person assistance. This deficiency was identified as a repeat citation, indicating ongoing issues with maintaining adequate nursing staff to meet resident needs.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for three of six sampled residents. For one resident, physician orders required daily weights for two days, but documentation was inconsistent: the Medication Administration Record (MAR) was initialed as if weights were obtained, yet no actual weights were recorded for the specified dates. Additionally, the resident's care plan indicated a hospice referral, and progress notes showed the resident and family requested hospice services, but there was no documentation confirming hospice services were initiated or further follow-up, and staff acknowledged that changes in the resident's wishes regarding hospice were not documented. Another resident's care plan specified no male caregivers or nurses, yet a male RN documented an assessment in the resident's chart, despite not entering the room, resulting in inaccurate documentation. For a third resident, the admission/readmission assessment was incomplete, missing key information such as sensory, mood, behavior, nutrition, and other health status areas. Staff confirmed the assessment was not completed timely and lacked required details. These deficiencies were identified through interviews and record reviews, and the issue of incomplete admission assessments was noted as a repeat citation from previous surveys.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents either did not receive necessary interventions for existing pressure ulcers or were not provided with adequate preventive care to avoid the formation of new pressure ulcers.
Failure to Initiate Grievance for Resident's Transportation Complaint
Penalty
Summary
The facility failed to timely initiate a grievance for a resident who voiced complaints regarding transportation arrangements to a dialysis appointment. The resident, who had kidney failure and was dependent on renal dialysis, was transported by foot in a wheelchair by facility staff for approximately 30 minutes to the dialysis center, as no vehicle transport was provided. During this trip, the resident complained of being cold and expressed dissatisfaction with the mode of transportation to both dialysis and facility staff. Despite these complaints, no grievance form was completed, and the incident was not logged in the facility's grievance record for the month. Interviews with facility staff confirmed awareness of the resident's complaints and frustration, including the resident's desire to be discharged from the facility. Staff reported that the resident was dressed in warm clothing and had a blanket, but still complained of being cold during the trip. The facility's grievance policy required prompt resolution and recordkeeping of all grievances, overseen by the executive director or designee. However, the resident's complaints were not documented or addressed through the formal grievance process, as required by policy.
Failure to Thoroughly Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown source for one resident who was admitted with morbid obesity and pressure ulcers. The resident had a urinary catheter placed, and several days later, two new stage three pressure ulcers were discovered on the right thigh near the buttock. The incident report for this event did not include essential investigative steps such as interviews with other residents, audits of other residents with catheters, or interviews with staff who had contact with the resident during the relevant period. Additionally, the report did not rule out abuse or neglect as required by facility policy. Interviews with facility staff revealed that the incident report was incomplete and that responsibility for its completion was not clearly assigned or followed through. The administrator acknowledged that the report was not completed in a timely, accurate, or thorough manner, and that available staff resources were not utilized to assist with the investigation. The director of nursing also stated that they did not participate in the investigation and had delegated the task to another staff member who left it unfinished.
Failure to Assess, Notify Physician, and Ensure CPR-Certified Staff Leads to Resident Harm
Penalty
Summary
A deficiency occurred when staff failed to provide a thorough assessment and timely recognition of a significant change in condition for a resident with a history of congestive heart failure and cellulitis. The resident experienced a rapid weight gain of 18.7 pounds in 24 hours, swelling in the left arm, slurred speech, difficulty breathing, and changes in mentation throughout the day. Despite these symptoms, there was no documentation that the physician was notified of the significant weight gain or the resident's deteriorating condition, as required by the care plan and physician orders. Multiple nursing assistants observed and reported the resident's changes, including incoherence, slurred speech, and abnormal appearance, to the assigned RN. However, the RN did not assess the resident in a timely manner, did not notify the physician, and did not document appropriate interventions. The last recorded vital signs were taken in the morning, and the resident's condition continued to decline throughout the day. When the resident became unresponsive and pulseless, there was a delay in initiating emergency interventions, and the RN did not perform CPR, leaving it to the nursing assistants. Further review revealed that the RN and other staff members lacked current CPR certification, contrary to facility policy requiring all RNs and LPNs to maintain active certification. The facility's failure to ensure adequate assessment, timely physician notification, and the presence of properly certified staff contributed to the resident's unexpected death. The resident was a full code and was not expected to pass away, with plans to return home after rehabilitation.
Removal Plan
- Terminated the staff that failed to assess, treat and notify the physician of Resident 1 regarding their significant change in condition.
- Audited the records of all residents for unidentified changes in condition.
- Educated staff on what to do when a resident has a change in condition.
- Audited employee Cardiac Pulmonary Resuscitation (CPR) certifications to ensure there were an adequate number of staff working each shift with active CPR certifications.
Failure to Assess and Respond to Change in Condition Resulting in Resident Harm
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not conducting a thorough assessment, failing to communicate a significant change in condition to the physician, and not ensuring timely and appropriate response from nursing staff during a medical emergency. The resident, who had a history of congestive heart failure and cellulitis, experienced a rapid weight gain of 18.7 pounds in 24 hours, which was not reported to the physician as required by physician orders. Additionally, the resident exhibited symptoms such as slurred speech, swelling, and unresponsiveness, which were observed by multiple nursing assistants and reported to the assigned nurse, but no timely or adequate action was taken. The assigned nurse did not assess the resident promptly despite repeated notifications from nursing assistants about the resident's deteriorating condition. The nurse also failed to document or notify the physician of the resident's significant weight gain, changes in condition, or the need to increase oxygen therapy. When the resident became unresponsive, nursing assistants initiated CPR and called emergency services, but the nurse did not provide direction or assist with resuscitation efforts. There was also a lack of documentation regarding physician notification following the resident's unexpected death. The facility's investigation into the incident was incomplete, lacking staff statements and failing to report the death to the state hotline or coroner's office. Interviews with staff revealed concerns about the nurse's lack of urgency and inadequate response, as well as a lack of communication and follow-through by facility leadership. The failure to assess, communicate, and respond appropriately to the resident's change in condition resulted in harm to the resident and placed all residents at risk of unmet care needs and potential neglect.
Failure to Report Unexpected Resident Death and Investigate Change in Condition
Penalty
Summary
The facility failed to identify and report an unexpected death of a resident to the State Hotline, law enforcement, and the coroner as required by reporting guidelines. The resident, who had diagnoses including congestive heart failure and cellulitis, was admitted cognitively intact and was not expected to pass away. On the day of the incident, multiple nursing assistants observed significant changes in the resident's condition, such as slurred speech, a swollen arm, and inability to track with their eyes. These concerns were repeatedly reported to the assigned nurse, who did not assess the resident or take appropriate action. Staff had to insist that the nurse check on the resident and contact emergency services. After the resident's death, staff expressed concerns about the nurse's lack of clinical judgment and urgency to both the DON and other supervisors. Despite these events, the facility did not log the incident in the reporting log, notify the State Hotline, law enforcement, or the coroner, as required. The DON and administrator did not conduct a thorough investigation or collect staff statements, and the DON admitted to not consulting the facility's reporting guidelines. Staff interviews revealed that concerns about the nurse's performance were known but not acted upon, and staff were discouraged from escalating the issue. The lack of reporting and investigation prevented the identification of potential abuse or neglect related to the resident's unexpected death.
Failure to Conduct Thorough Investigations of Abuse, Neglect, Falls, and Medication Errors
Penalty
Summary
The facility failed to conduct thorough investigations into multiple incidents involving allegations of abuse, neglect, falls, medication errors, and pressure ulcers. For three residents with allegations of abuse or neglect, investigations were incomplete, lacking resident interviews, root cause analyses, and follow-up on negative findings from other residents. In one case, a resident reported being left in urine for over an hour on multiple occasions, but the investigation did not include a direct interview with the resident or address similar concerns raised by others. Another resident reported rough handling during transfers, but the investigation only included two staff statements and did not address the lack of care plan updates regarding the resident's anxiety and fear during transfers. The facility also failed to thoroughly investigate several falls. In one instance, a resident fell out of bed and later required surgery due to hardware failure, but the fall investigation was incomplete and not updated when the extent of the injury became known. Another resident fell in the bathroom, but the investigation lacked statements from the involved staff and did not resolve conflicting information about the circumstances of the fall. For a third resident, the investigation into two falls did not include required neurological assessments or address staff concerns about inadequate help during mealtimes. Additionally, the facility did not properly investigate a medication error where a resident received a discontinued narcotic medication multiple times. The investigation failed to identify the error as a violation of professional standards and did not include education or disciplinary action for the involved nurses. There were also deficiencies in investigating a pressure ulcer incident and a delay in pain medication, including missing interviews, incomplete documentation, and failure to identify transcription errors or report incidents as required.
Incomplete Facility-Wide Assessment Documentation
Penalty
Summary
The facility failed to document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment provided by the facility was dated 07/30/2024 and included outdated information, such as the names of the prior Administrator and Director of Nursing Services. The documentation only included a Part I template and omitted several required elements. Specifically, the assessment did not address the care needs of the resident population, including types of diseases, conditions, disabilities, and acuity levels. It also lacked information on required staff competencies, physical environment and equipment needs, available services, personnel details, contracts with third parties, and health information technology resources. During an interview, the current Administrator confirmed that the provided assessment was the most current version and that no additional information was available.
Failure to Maintain Resident Dignity and Privacy During Care and Daily Activities
Penalty
Summary
Multiple deficiencies were identified related to the failure to honor residents' rights to dignity, self-determination, and a homelike environment. Observations revealed that staff did not interact with residents in a dignified manner during mealtimes, such as failing to converse with a resident who required assistance with eating. Residents reported feeling rushed during meals, having to wait for staff attention, and being encouraged to finish meals in their rooms against their preferences. Additionally, residents voiced concerns during a council meeting about staff not responding to requests for help, not knocking or waiting for a response before entering rooms, and not providing adequate assistance with personal care and privacy. Further deficiencies were noted in the handling of urinary catheters. Two residents with indwelling urinary catheters were observed with uncovered catheter bags that were visible from the hallway, lacking privacy covers as required. Staff interviews confirmed that the facility was supposed to use privacy bags but had not consistently done so, resulting in residents' urine being visible to others. These observations were made on multiple occasions, and staff were unaware of the ongoing issues until informed by surveyors. Additional concerns included a resident with severe cognitive impairment being assisted with dressing without the privacy curtain drawn, and the room door left open, exposing the resident to view from the hallway. The facility's grievance log did not contain entries for the concerns raised by several residents, indicating a lack of documentation or follow-up on these dignity-related issues. Staff interviews confirmed that they were not aware of many of the residents' concerns until brought to their attention by surveyors.
Failure to Safeguard Resident Health Information
Penalty
Summary
Staff failed to maintain the privacy and confidentiality of residents' medical information when a report sheet containing personal health details for 20 residents was left unsecured at a resident's bedside. The report sheet included names, room numbers, diagnoses, medication administration details, and code statuses. A resident discovered the sheet, took a photograph of it, and expressed distress upon seeing their own diagnosis listed inaccurately. Another resident reported receiving a letter about the breach, which included their vital signs, diagnoses, and address, and expressed concern about the potential for this information to be shared online. During an observation, a report sheet with two residents' weights, room numbers, and bed locations was also found unsecured on a central nurses' cart. The facility's own policy required staff to protect confidential information and not disclose it inappropriately. However, the incident review documented that approximately 18 individuals were affected by the breach when a nurse left the report sheet at a resident's bedside, and the resident took a photo of the form. Interviews with staff revealed that the Director of Nursing was unaware of the incident, while the Regional Director of Clinical Services acknowledged the HIPAA violation and stated that report sheets should be safeguarded for privacy.
Failure to Maintain Clean and Homelike Environment in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean, comfortable, homelike, and safe environment for residents in two of three halls, including several resident rooms. Observations revealed significant cleanliness issues such as large brown stains on the bottom portion of privacy curtains, heavy dust accumulation in ceiling vents and around curtain rails and hooks, and an orange stain with multiple small brown stains on another privacy curtain. These environmental deficiencies were directly observed by surveyors during their visits to the facility. Additionally, a resident reported that their shared bathroom was not adequately cleaned, specifically mentioning the frequent presence of bowel movement on the toilet, which led them to use a different bathroom when visitors were present. Housekeeping staff acknowledged that certain room curtains were dirty and needed to be changed. The administrator confirmed awareness of these environmental concerns and stated that room rounds were being conducted to identify issues, but the environment remained a work in progress. This deficiency was noted as a repeat from a previous survey.
Failure to Log, Investigate, and Resolve Resident Grievances
Penalty
Summary
The facility failed to establish and maintain an effective grievance system to ensure that residents' verbal concerns were initiated, logged, addressed, and resolved in a timely manner. Review of resident council meeting minutes over several months revealed that multiple grievances, such as requests for fresh fruit, complaints about food temperature, and concerns about call light response times, were repeatedly raised by residents but not documented or followed up through the facility's grievance process. The facility's grievance log did not contain any entries corresponding to these concerns, despite their documentation in meeting minutes and repeated verbal reports by residents. Interviews with residents indicated that they were unsure of the grievance process, with some expressing fear of retaliation or uncertainty about how to file a grievance. Several residents reported missing personal items, unresolved maintenance issues, and dietary concerns, none of which were formally logged or investigated according to facility policy. Staff interviews revealed inconsistent understanding and application of the grievance process, with some staff unaware of the need to complete grievance forms or believing that informal resolution was sufficient. The facility's policy required all grievances to be documented, investigated, and resolved with written communication to the resident, but this was not consistently followed. Specific examples included residents reporting missing belongings, unresolved maintenance requests such as a non-functioning television, and dietary issues like inappropriate snacks for a pureed diet. Staff responses varied, with some attempting informal resolution and others unaware of the concerns until prompted by surveyors. The lack of a systematic approach to logging and addressing grievances prevented the facility from identifying care trends and evaluating the effectiveness of any actions taken, resulting in residents repeatedly voicing the same issues without resolution.
Failure to Implement and Update Care Plans for Fall Prevention and Smoking Safety
Penalty
Summary
The facility failed to ensure that a resident's care plan for fall prevention was reviewed, updated, and implemented as required, and also failed to assess and supervise residents who engaged in smoking to prevent injury. For one resident with a history of falls and cognitive impairment, the care plan specified interventions such as keeping the bed in the lowest position and placing a fall mat on the right side of the bed. However, multiple observations showed the bed was not kept in the low position and the fall mat was consistently placed on the left side, contrary to the care plan. Staff interviews revealed that they were unaware of the specific care plan instructions regarding the placement of the fall mat and the bed position, indicating a lack of communication and implementation of the care plan interventions. Additionally, two residents who were known to smoke were not properly assessed for their ability to smoke safely, and their care plans did not include any focus or interventions related to tobacco use. One resident had a documented history of smoking and continued to smoke, with supplies reportedly locked up with a nurse, but there was no record of a smoking safety assessment. The other resident was also identified as a current smoker, but their care plan lacked any mention of tobacco use, and staff were unaware of their smoking status. Interviews with staff, including nursing assistants and LPNs, confirmed that they were not aware of any current smokers in the facility and had not received guidance from the care plans regarding supervision or interventions for smoking. The lack of updated and implemented care plans for both fall prevention and smoking safety resulted in inconsistent interventions and unmet care needs for the residents involved. The facility's interdisciplinary team was not aware of the deficiencies in care plan implementation or the need for updated assessments and interventions for residents who smoked. This deficiency was noted as a repeat issue from a previous survey.
Insufficient Nursing Staff and Suspension of Restorative Nursing Program
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff to meet the needs of all residents, as evidenced by both direct resident interviews and review of facility records. Multiple residents reported long wait times for assistance, particularly during nighttime and meal times, with some residents waiting over an hour for help with toileting and repositioning. Resident council meeting minutes and interviews consistently documented complaints about delayed call light responses and unmet care needs. Staff interviews confirmed that staffing shortages were ongoing, with restorative nursing aides being reassigned to direct care duties, resulting in the suspension of the Restorative Nursing Program (RNP). Record reviews for specific residents revealed that care plans and therapy recommendations for restorative nursing services, such as range of motion and splint application, were not being followed due to lack of available staff. For example, one resident's therapy discharge recommendations for nightly range of motion and stretching prior to splint application were not completed, and another resident's care-planned restorative programs were not occurring. Staff interviews further confirmed that the facility had only one restorative aide, who was consistently assigned to floor duties instead of restorative care, and that efforts to restart the restorative program were hindered by ongoing staffing shortages. The facility assessment did not address staffing needs specific to the resident population and acuity, contributing to the inability to provide required care and services. Staff and administration acknowledged the challenges in hiring and training restorative nursing aides and the impact of staff reassignments on resident care. The lack of adequate staffing led to delays in essential care, such as repositioning, toileting, and restorative services, as well as diminished quality of life for residents, as directly reported by both residents and staff.
Failure to Provide Medically Related Social Services and Resident Support
Penalty
Summary
The facility failed to provide medically related social services necessary for residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Multiple residents reported not being able to access the social worker, not understanding the role of social services, or feeling dismissed when seeking assistance. Specific examples included residents stating they had not met the social worker, were told the social worker did not have time, or were dismissed when requesting meetings. One resident described being told by the social worker to address their needs immediately or not at all, due to the social worker's workload. These issues were corroborated during a resident council meeting, where several residents expressed dissatisfaction and emotional distress related to their interactions with social services. The facility's Director of Social Services (SSD) was responsible for meeting new admissions, conducting care conferences, and participating in clinical meetings, but acknowledged being unable to keep up with required tasks, such as revising PASRRs. The facility assessment indicated a high prevalence of residents with behavioral health disorders and a significant proportion on psychotropic medications, yet the facility did not use this data to comprehensively assess or adjust staffing and competency needs. The administrator confirmed that the current staffing was insufficient to meet resident needs, and the Regional Director of Clinical Services stated that social services were expected to document interactions, follow up on PASRR assessments, and assist with care planning, which was not consistently occurring.
Failure to Maintain Sanitary Food Storage and Preparation Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by multiple observations of improper hand hygiene and unclean food preparation areas. The Food Service Director entered the kitchen from his office, did not wash his hands, put on gloves, and proceeded to prepare chicken for residents. Additionally, a dietary aide was observed handling dirty dishes, placing them in the dishwasher, and then removing clean dishes without washing hands in between. The dietary aide acknowledged that handwashing should occur before touching clean dishes, and the Food Service Director confirmed that staff are expected to wash hands after handling dirty dishes and before handling clean ones. Further observations revealed unsanitary conditions in the kitchen environment. Dust was present on racks above food service and prep areas, including those holding measuring cups and spices. The stove top hood and a fan above the food prep area were also covered in dust. The food prep sink area, where knives were stored, had debris splashes, and the front of the steam table used for food distribution had visible moisture drips. These conditions were not in accordance with the facility's documented sanitation and food safety procedures.
Failure to Sustain QAPI Corrections Leads to Repeat Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) program effectively self-identified deficiencies and developed or implemented effective plans of action to sustain corrections for previously cited deficiencies. Record review showed that the QAPI committee was responsible for compliance and continuous improvement, but repeat deficiencies were identified in multiple areas, including resident rights, investigation and prevention of alleged violations, maintaining a safe and homelike environment, care plan timing and revision, activities of daily living, quality of care, prevention of decrease in range of motion and mobility, accident hazards, nutrition and hydration status, and psychotropic medication use. These deficiencies were noted as repeat findings from previous Statements of Deficiencies on multiple survey dates. During an interview, the Administrator acknowledged the repeat deficiencies and stated an inability to speak to actions taken by prior leadership. The Administrator indicated that the QAPI team's expectation was to follow established processes, hold staff accountable, and maintain consistency, with a current focus on management staff retention. The report does not mention specific residents or patient conditions related to the deficiencies.
Failure to Provide Timely and Accurate Pain Management
Penalty
Summary
The facility failed to provide pain management in accordance with a resident's physician orders, resulting in inadequate pain control for a resident who had recently undergone a total hip arthroscopy. Upon admission, the resident's hospital discharge orders specified Oxycodone 2.5-5mg by mouth every three hours as needed. However, the order was incorrectly transcribed in the facility's electronic medical record as only 2.5mg every three hours, omitting the 5mg option. Additionally, there were documented instances where the resident reported pain levels of 7 or higher, but did not receive the prescribed prn Oxycodone, and instead was given Tylenol. When Oxycodone was administered, there was no follow-up documentation regarding its effectiveness. A delay in receiving Oxycodone from the pharmacy occurred due to an allergy alert related to the resident's documented Hydrocodone allergy, but there was no evidence that the provider was notified of the delay or that alternative orders were requested. The facility's investigation did not identify the transcription error, and the administrator was unaware of the error or the lack of response regarding medication availability. The resident expressed dissatisfaction with pain management, noting delays in receiving medication and inadequate pain relief, which contributed to their decision to discharge against medical advice.
Failure to Ensure Accessible and Appropriate Call Lights for Residents
Penalty
Summary
The facility failed to ensure the physical environment accommodated the needs of two residents, specifically regarding the accessibility and appropriateness of call lights. One resident with a traumatic brain injury and a voice and resonance disorder had a care plan specifying the use of a soft-touch pad call light and that the call light should be within reach. However, multiple observations showed that the resident was provided with a push-button style call light, which was sometimes not functioning and frequently placed out of reach while the resident was in a wheelchair. Another resident, who was severely cognitively impaired and had delusions, also had a care plan requiring the call light to be within reach. Observations on several occasions found this resident lying in bed with the call light on the floor and out of reach. Staff interviews confirmed that call lights should be accessible to residents at all times, but this was not consistently ensured for these residents.
Failure to Incorporate PASARR Recommendations into Care Plan
Penalty
Summary
The facility failed to incorporate the recommendations from a Level II Preadmission Screening and Resident Review (PASARR) evaluation into the care plan for a resident with a history of bipolar disorder, anxiety, and PTSD. The resident was found to be cognitively intact and had qualified for a Level II PASARR due to serious mental health conditions. The Level II psychiatric evaluation included specific recommendations for environmental safety, staff approaches (such as assigning female staff for intimate care due to past trauma with males), and behavioral interventions involving close coordination with the social services department. Despite these recommendations, a review of the resident's care plan showed no evidence that the PASARR findings or suggested interventions were incorporated. Interviews with facility staff, including social services and clinical leadership, revealed a lack of awareness regarding the recommendations and an absence of updates to the care plan. The facility's policy required that PASARR recommendations be included in the person-centered care plan, but this was not followed for the resident in question.
Failure to Complete Required PASRR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that three out of six residents reviewed for Pre-Admission Screening and Resident Review (PASRR) received the required screenings for mental disorders or intellectual disabilities. For one resident with anxiety disorder, major depressive disorder, and PTSD, the initial PASRR Level I was completed as an exempted hospital discharge for a stay under 30 days, but no further PASRR evaluations were conducted after the resident remained in the facility beyond the exemption period. Another resident with anxiety disorder and depression had a Level I PASRR that did not document all relevant diagnoses, resulting in the absence of a required Level II evaluation. A third long-term resident with severe cognitive impairment, delusions, and a diagnosis of bipolar dementia had multiple Level I PASRRs indicating the need for a Level II referral, but no Level II PASRR was ever completed. Interviews with facility staff confirmed that PASRR evaluations were either not completed, not updated, or not accurately documented for these residents. Staff acknowledged awareness of the deficiencies, including missed referrals and inaccurate documentation, and indicated that they were responsible for reviewing PASRRs for accuracy. The facility's policy requires accurate and timely PASRR screenings and referrals, but these were not consistently followed, resulting in the identified deficiencies.
Failure to Update Care Plans Following Changes in Resident Condition and Treatment
Penalty
Summary
The facility failed to review and revise care plans for two residents following significant changes in their conditions and treatment. For one resident with chronic obstructive pulmonary disease, new onset bilateral lower extremity edema was observed, and a provider ordered both a diuretic (Torsemide) and leg elevation while sleeping. Despite these changes, the resident's care plan was not updated to reflect the new diagnosis, medication, or provider recommendations. The care plan printout showed no revisions after the onset of edema or the initiation of new interventions. Another resident with a history of falls, depression, and anxiety experienced behavioral changes, including agitation and confusion, which led to referrals to behavioral health services and the initiation of two different anti-anxiety medications within a two-month period. The resident's care plan did not address the use of anti-anxiety medications, the recent treatment for pneumonia, or the referral to behavioral health services. Interviews with facility staff confirmed that care plans were not updated to reflect these changes in the residents' care needs.
Failure to Provide Access to Communication Device for Nonverbal Resident
Penalty
Summary
Resident 4, who has a traumatic brain injury and a voice and resonance disorder resulting in an inability to speak, was not provided access to their Tobii communication device. Multiple observations over several days showed the device was turned off and placed in the corner of the resident's room, rather than being available for use. Staff interviews revealed that nursing assistants and an LPN had never used the device, with some staff unaware of its existence. Communication with the resident was limited to thumbs up/down or hand signals, despite the resident's care plan indicating the need for alternative communication methods. Collateral contacts and a speech therapist confirmed that the device was not being used due to lack of staff training. When the device was set up by the speech therapist, the resident was able to use it effectively to communicate specific needs, such as requesting a shower. The resident also indicated that staff did not routinely ask about their preferences for water, bedtime, or participation in activities. This deficiency was noted as a repeat issue from a previous survey.
Failure to Provide Individualized Activity Programs for Residents
Penalty
Summary
The facility failed to provide an activity program that met the individual needs of three out of four residents reviewed for activities. For one resident with a history of stroke and vascular dementia, the care plan specified a need for encouragement and support to participate in activities such as listening to music, being around animals, group activities, going outside, and religious events. However, observations showed the resident was consistently alone in their room with only music playing on the TV, and there was no evidence of participation in group or one-to-one activities. Staff interviews revealed a lack of awareness of the resident's care plan and no implementation of a one-to-one activity program, despite the resident's inability to participate in group activities without becoming disruptive. Another resident, who was severely cognitively impaired and had delusions, had a care plan indicating they would accept room social visits at least once per week and attend at least one group activity weekly. Multiple observations over several days found the resident in bed, with no evidence of participation in activities or receipt of one-to-one visits. Staff interviews confirmed that the resident was not receiving any one-to-one visits, and the activities director was not familiar with the resident. A third resident with a traumatic brain injury and speech deficits had a care plan goal to attend at least four group activities per week and show satisfaction with activity opportunities. Observations found this resident alone in their room, expressing boredom, while group activities were occurring elsewhere in the facility. The activities director reported not participating in resident care planning, and activity preferences were not assessed at admission. Documentation of resident participation in activities was limited to one-to-one interactions, which were not occurring for this resident.
Failure to Provide Timely Edema Management and Follow-Up on Specialist Referrals
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards for two residents. One resident with a history of chronic obstructive pulmonary disease, hyperlipidemia, and hypertension developed new onset bilateral lower extremity edema. Despite a provider's order for Torsemide and recommendations to elevate the resident's legs, the care plan was not updated, daily weights were not consistently obtained, and there was no documented reassessment of the edema or implementation of interventions such as leg elevation or compression socks. Staff interviews confirmed that expected monitoring and interventions were not carried out, and the treatment administration record did not reflect necessary actions to address the edema. Another resident with a traumatic brain injury and speech deficits had an after-visit summary from neurology recommending referrals for physical therapy, rheumatology, and speech therapy. The facility did not follow up on these referrals or schedule the recommended appointments. Staff interviews revealed a lack of communication and follow-through due to staffing issues and unclear responsibilities between social services and care coordinators. This deficiency was noted as a repeat issue from a previous survey.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services to prevent pressure ulcers for two residents with decreased mobility and functional ability, resulting in the development of stage II pressure ulcers. For one resident, who was admitted with multiple comorbidities including diabetes, liver disease, cardiac and kidney disease, and was identified as high risk for pressure ulcers, the facility did not implement a timely turning/repositioning program or provide consistent use of pressure-relieving devices such as a heel boot. Documentation showed gaps in weekly skin assessments, inconsistent monitoring of heel boot compliance, and lack of documentation regarding the use and settings of a low air loss mattress. Nursing assistant records did not reflect adherence to or tolerance of repositioning interventions, and there was no evidence of ongoing assessment or re-evaluation of interventions. Observations revealed the resident was often found without the prescribed heel boot, and staff interviews indicated a lack of awareness regarding the resident's skin issues and required interventions. Another resident, who was severely cognitively impaired and had delusions, was care planned to have a foot cradle and wedge to minimize pressure to the feet due to a large blister on the left plantar surface. However, multiple observations showed the resident positioned in bed with both feet pressing against the baseboard, contrary to the care plan and Kardex directives. Staff interviews confirmed that residents should be turned and repositioned every two hours and that the Kardex should be followed, but these interventions were not consistently implemented for this resident. The facility's policy required preventative measures such as repositioning every 2-4 hours and the use of pressure redistribution mattresses, but these were not consistently carried out. Nursing documentation did not demonstrate a proactive approach to skin management, and there was a lack of thorough and ongoing skin assessments, observation for changes in risk factors, and evaluation of the effectiveness of interventions. These failures placed the affected residents and others at risk for the development of pressure ulcers.
Failure to Provide Restorative Nursing Services for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve range of motion (ROM) and mobility for two residents with limited ROM and restorative nursing needs. One resident, with a history of stroke, vascular dementia, and bilateral contractures, was observed in a wheelchair with poor positioning and lacked head support. Staff interviews revealed that the resident was dependent on staff for care and that no exercises or stretches were being performed, despite occupational therapy recommendations for bilateral ROM/stretching and splint application. The resident's treatment record included instructions for hand splint use but did not include the recommended ROM and stretching interventions. Another resident with a traumatic brain injury and contractures had care plans for passive and active assist ROM, as well as splint and brace use, with goals to prevent worsening of contractures. However, record review showed that these restorative programs were not being implemented. Staff interviews confirmed that the facility did not have an active restorative program due to staffing shortages, and the one staff member with restorative training was not being utilized in that role. This deficiency was noted as a repeat from a previous survey.
Failure to Provide Adequate Hydration to Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide adequate hydration for two residents who were both severely cognitively impaired and required assistance to meet their daily fluid needs. For one resident with dementia, observations over several days revealed that fluids were not consistently available at the bedside, and when present, the water was often out of reach. Staff interviews confirmed that this resident did not have a cup and was not receiving water throughout the day, despite expressing thirst and commenting on the taste of water when it was offered with medication. The resident's documented daily fluid requirement was not being met due to these lapses in care. For the second resident, who also had severe cognitive impairment and required nectar-thick liquids, repeated observations showed that no fluids were present at the bedside or in the room during multiple checks across several days. Staff interviews indicated that water should be available and refilled twice daily, with additional offerings for those on special diets, but this was not being done. The resident's daily fluid needs were documented, but there was no evidence that these needs were being addressed, resulting in a failure to provide adequate hydration.
Failure to Identify and Address Behavioral Health Needs
Penalty
Summary
The facility failed to identify and address the mental and psychosocial health needs of two residents with behavioral-emotional health concerns. For one resident with depression, anxiety disorder, and cognitive communication deficit, assessments indicated moderately severe depression, social isolation, and a request for behavioral health services (BHS). Despite documentation of a high PHQ-9 score and a referral being indicated, there was no evidence in the clinical record that a BHS referral was made or that services were provided. Staff interviews revealed a lack of awareness and follow-through regarding the referral process, with no documentation of the referral in the resident's chart. For another long-term resident with severe cognitive impairment and a diagnosis of depression, the provider documented a referral for BHS, but there was no evidence in the record that the resident refused the service or that the referral was completed. The resident's assessment indicated depression and ongoing use of medication, but the required behavioral health interventions were not documented. The lack of timely and documented referrals and follow-up for behavioral health services contributed to the deficiency.
Failure to Timely Address Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to act on consultant pharmacist recommendations from the monthly medication regimen review (MRR) in a timely manner for two residents. For one resident with diagnoses including hyperlipidemia, diabetes, and a history of heart attack, the pharmacist recommended uploading the results of a fasting lipid panel ordered in August. However, the test was not completed until five months later, despite the facility's policy requiring recommendations to be addressed by the next scheduled pharmacist visit. Interviews with facility staff confirmed that the expectation was for MRR actions to be completed within 30 days, but the delay was not explained. For another resident with a history of falls, depression, and anxiety, the pharmacist repeatedly recommended a Basic Metabolic Panel (BMP) to assess kidney function, noting that no such assessment had been done in the past year. This recommendation was documented in multiple monthly reviews and acknowledged by nursing staff and a nurse practitioner, with directions to complete the BMP and repeat it every six months. Despite these repeated recommendations, there was no evidence in the electronic health record that the BMP was ever completed.
Failure to Provide Consistent and Appropriate Snacks to Residents
Penalty
Summary
The facility failed to consistently offer and provide nutritional snacks to residents as ordered or requested, particularly for those who desired snacks at non-traditional times or outside of scheduled meal times. Review of resident council meeting minutes documented concerns from residents about wanting more snacks and a greater variety of snack options. During interviews, several residents reported that when they requested snacks, staff would often state that only saltine crackers or graham crackers were available, and that snack bins were only filled after breakfast and lunch. One resident noted that staff reported there was nothing left when snacks were requested late at night. Another resident, who was on a pureed diet, was given inappropriate snacks such as potato chips and cookies, and reported that staff were unaware of their dietary restrictions and that suitable alternatives like pudding or yogurt were not available. Staff interviews confirmed that the expectation was for snacks to be passed at night and that snacks were included in standard orders. However, the reports from residents and the lack of suitable snack options, especially for those with specific dietary needs or those requesting snacks outside of scheduled times, indicate that the facility did not consistently meet residents' dining preferences and nutritional needs as required.
Failure to Follow Infection Control and Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure staff compliance with infection prevention and control guidelines on two of three units, specifically regarding hand hygiene practices and the handling of soiled materials. Observations revealed that staff did not consistently perform hand hygiene before and after resident contact, after glove removal, or when handling potentially contaminated materials, as required by facility policy. For example, staff were seen using only hand sanitizer after providing care to a resident on enteric precautions for suspected Clostridium difficile (C. Diff), rather than washing hands with soap and water as recommended for C. Diff cases. Additionally, staff were observed carrying soiled linens down the hall without removing masks or performing appropriate hand hygiene, and clean PPE was stored in close proximity to soiled garbage cans, increasing the risk of cross-contamination. Resident 116, who was on enteric precautions for suspected C. Diff, received care from staff who did not follow proper infection control protocols. Staff wore PPE but used only hand sanitizer instead of washing hands after care, and did not remove masks upon exiting the room. Housekeeping staff also failed to perform hand hygiene between glove changes and were unclear about the requirements for enteric precautions, including whether a gown was necessary when handling soiled materials outside the resident's room. Multiple observations confirmed that clean PPE was stored adjacent to soiled waste, further violating infection control standards. For another resident, Resident 266, who was severely cognitively impaired, staff repeatedly failed to perform hand hygiene before entering the room, after providing perineal care, and after changing gloves. Staff assisted with personal care, dressing, and transfers without changing gloves or performing hand hygiene, despite acknowledging during interviews that these steps were required. These lapses in infection control practices were observed on multiple occasions and confirmed through staff interviews, indicating a pattern of non-compliance with established infection prevention protocols.
Inaccurate Medication Orders for NPO Residents
Penalty
Summary
The facility failed to ensure accurate completion of resident records for three residents who were to have nothing by mouth (NPO) but had medication orders indicating oral administration. Resident 1, admitted with dysphagia and malnutrition, had physician orders and a care plan indicating NPO status with an enteral feeding tube. However, their medication administration record (MAR) showed orders for medications to be given by mouth, despite the resident stating they received medications through their enteral tube. Resident 2, with diagnoses including dysphagia, heart failure, and cancer of the tongue, also had physician orders and a care plan indicating NPO status with medications to be administered via an enteral tube. Despite this, their MAR for February and March showed multiple medications ordered to be given by mouth. A Licensed Practical Nurse (LPN) confirmed that all medications were administered through the enteral tube, consistent with the NPO order. Resident 3, admitted with dysphagia and malnutrition, had similar discrepancies. Their physician orders and care plan indicated NPO status with enteral tube medication administration, yet their MAR showed medications ordered to be taken by mouth. Interviews with staff revealed that medication orders were supposed to be reviewed by two licensed nurses to ensure accuracy, including the correct route of administration. However, the orders for these residents were incorrectly entered, and staff acknowledged the errors, confirming that medications should not be given by mouth to residents with NPO orders.
Deficiencies in Resident Communication and Appointment Management
Penalty
Summary
The facility failed to uphold resident rights for two residents, leading to deficiencies in communication and care. Resident 1, who was admitted with chronic obstructive pulmonary disease, coronary artery disease, and left foot pain, had a follow-up appointment canceled without their knowledge or consent. Despite being alert and oriented, Resident 1 was not informed about the cancellation, which was later discovered to have been done by Staff G, the social services assistant, without proper documentation. This lack of communication and documentation led to Resident 1 being upset and their care needs potentially unmet. Resident 2, who had a pneumothorax and cognitive communication deficit, experienced a breakdown in communication when their healthcare Power of Attorney (POA) was unable to reach the facility or the resident. The POA attempted to contact the facility 32 times without success, as there was no answer, directory, or voicemail option available. Observations confirmed the facility's main number was not responsive. Staff interviews revealed inconsistencies in how family members were instructed to contact residents, and the interim Director of Nursing expected phone calls to be answered at all times. These failures in communication placed residents at risk for unmet care needs and decreased quality of life.
Incomplete Investigation of Alleged Staff Misconduct
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged incident involving a resident and a staff member. Resident 3, who was cognitively intact and had a history of a right hip fracture, falls, and atrial fibrillation, reported that a staff member acted angrily during repositioning. The resident recounted that the staff member, identified as Staff F, responded negatively when the resident reached out to them, saying "Don't touch me." This incident was documented by Staff E, an RN Care Manager, but the investigation lacked a statement from Staff F, who was directly involved in the allegation. Interviews with facility staff revealed that the investigation process was incomplete. Staff E, who initiated the investigation, acknowledged the absence of a statement from Staff F, despite the staff member being suspended during the investigation. Staff D, an LPN unit care coordinator, confirmed that they did not obtain a statement from Staff F. Furthermore, Staff A, an interim DNS, expressed that it was expected for all involved staff to be interviewed and provide statements to rule out abuse or neglect. The failure to obtain a statement from Staff F resulted in an incomplete investigation, as noted in the findings.
Deficiencies in Bowel Care Management and Monitoring
Penalty
Summary
The report highlights multiple instances where residents in the facility experienced harm due to deficiencies in bowel care management, hospice referral, and neurological checks. Resident 59, with a complex medical history including cancer and lung disease, suffered from a bowel impaction that led to hospitalization. Despite being on multiple narcotics known to cause constipation, the resident did not receive timely and appropriate bowel care interventions, resulting in severe discomfort and pain. The facility's failure to develop a comprehensive constipation care plan and inadequate monitoring of bowel movements contributed to the resident's deteriorating condition. Similarly, Resident 47, diagnosed with colon cancer and malnutrition, experienced complications related to constipation. The resident's bowel movements were irregular, and despite being on medications prone to cause constipation, there was a lack of routine laxatives prescribed. This deficiency in addressing the resident's constipation needs led to symptoms such as abdominal pain, vomiting, and altered mental status, ultimately requiring hospitalization. The facility's delay in developing a constipation care plan and inadequate administration of prescribed bowel medications contributed to the resident's worsening condition.
Deficiencies in Range of Motion (ROM) Maintenance for Residents with Contractures
Penalty
Summary
The facility failed to comprehensively assess and ensure timely and appropriate services/interventions were provided to maintain, increase, and prevent a decrease in range of motion (ROM) for two sampled residents, Resident 29 and Resident 5. Resident 29, admitted with diagnoses including vascular dementia and muscle weakness, developed a significant left-hand contracture, indicating a lack of appropriate ROM maintenance. Observation revealed Resident 29's left hand in a rigid fist position, with fingers fixed in a seized/clutch-like manner, hindering normal movement. Despite the care plan indicating the need for therapy services and assistance with activities of daily living, there was no documentation of past therapy, and staff were unaware of the contracture, highlighting a gap in assessment and intervention. Similarly, Resident 5, admitted with intracranial injury and contractures, had a history of upper extremity contracture and limited ROM. The care plan outlined interventions for ROM maintenance, including splint applications and passive ROM exercises, but review of records showed lapses in providing recommended services. The resident did not receive additional occupational therapy services as recommended, and documentation indicated non-compliance with the prescribed ROM program. Family members expressed concerns about Resident 5's declining ROM and observed instances where recommended interventions, such as hand splints, were not in place, indicating a lack of consistent care and monitoring. Staff interviews revealed a lack of awareness regarding ROM assessments, risks associated with non-compliance with prescribed interventions, and processes for obtaining therapy referrals. The facility's absence of a restorative program, attributed to staffing challenges during the COVID-19 pandemic, further contributed to the deficiencies in maintaining residents' ROM.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for its residents, as evidenced by observations of stained carpets and broken blinds in multiple rooms. Specifically, broken blinds were observed in a resident's room on three separate occasions over a span of eight days. Additionally, extensive carpet staining was noted throughout the facility, including large stained areas near resident rooms, the main nurses' station, and various halls. These observations were corroborated by interviews with staff members, who acknowledged the issues and indicated that maintenance and housekeeping were responsible for addressing them. However, the problems persisted, indicating a lack of timely action to rectify the deficiencies. The Maintenance Director admitted that broken blinds were a recurring issue and that they typically waited until a resident's room was empty to replace them. The Administrator confirmed that discussions about replacing the stained carpets had been ongoing, and quotes for new flooring were being obtained. Despite these acknowledgments, the facility's failure to promptly address the broken blinds and stained carpets compromised the residents' dignity and quality of life, as they were left in an environment that was neither clean nor homelike.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that Resident 55 was free from physical abuse by Resident 57, who had a known history of unwanted touching and sexual aggression towards other residents. Despite Resident 57's documented history of aggressive behaviors, including hitting and inappropriate touching, the facility did not consistently provide adequate supervision or effective interventions to prevent further incidents. This failure placed residents at risk for abuse, injury, and a potential decrease in quality of life. Resident 57, who was cognitively impaired and diagnosed with vascular dementia with psychotic disturbance, had multiple documented incidents of aggressive behavior towards other residents. These incidents included hitting Resident 55 on multiple occasions, kissing Resident 13 without consent, and attempting to touch Resident 52 inappropriately. Despite these behaviors, the facility's interventions, such as one-on-one supervision, were not effectively implemented or monitored, leading to repeated altercations. The facility's care plan for Resident 57 included interventions to prevent agitation and aggressive behavior, but these were not adequately followed. Staff failed to ensure that Resident 57 did not come into contact with prior victims, and there was a lack of proper documentation and communication among staff regarding Resident 57's triggers and behaviors. This lack of effective supervision and intervention allowed Resident 57 to continue their aggressive behavior, resulting in repeated abuse of other residents.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to implement policies and procedures for reporting allegations of potential abuse or neglect for three residents. Resident 69, who had a diagnosis of psychosis with delusions, made an allegation of inappropriate touching by a nurse. Staff W and Staff X, who were present during the incident, reported the allegation to Staff Y but did not report it to the hotline. Staff Y overheard the conversation but assumed it had already been reported. The facility only began investigating the allegation a week later when it was reported by Staff W to the administration, but by then, the resident's memory was unclear due to delusions, and the resident denied making the statement. Resident 5 had an open area on their back, which was identified by a family member and documented by a provider. The resident's skin assessment from the previous day showed intact skin, and subsequent assessments noted a dressing on the neck but no new skin issues. However, there was no entry for this injury of unknown source in the state incident reporting log, and Staff G and Staff B were unaware of any skin issue for Resident 5. Resident 55, who was readmitted for rehabilitation after a joint replacement, reported to another staff member that another patient had hit them in the head. Staff P overheard this but assumed it had already been reported. There was no entry for this incident in the state incident reporting log, and Staff B stated they had not looked into it due to inconsistent stories from Resident 55. This is a repeat citation from previous surveys, indicating ongoing issues with reporting and investigating allegations of abuse or neglect.
Incomplete Resident Assessment Instrument (RAI) and Care Area Assessments (CAA)
Penalty
Summary
The facility failed to ensure the Resident Assessment Instrument (RAI) included thorough summaries of the Care Area Assessments (CAA) for three residents, leading to incomplete and potentially inaccurate care plans. Resident 5, who had a brain injury and other significant health issues, had an annual CAA assessment that did not comprehensively analyze communication and functional abilities, nor did it include the resident's goals, preferences, strengths, or alternative means of communication. Similarly, Resident 29, diagnosed with vascular dementia and other conditions, had an annual CAA assessment that lacked a thorough analysis for cognition/dementia and psychotropic medication use, and did not reflect the resident's or their representative's goals and preferences. The written problems/needs for both triggers were identical, indicating a lack of individualized assessment. Resident 121, who had a stroke and vascular dementia, had an admission CAA assessment that did not comprehensively analyze nutritional status and urinary incontinence, nor did it include the resident's or their representative's goals, preferences, strengths, or needs. The initial assessment for urinary incontinence indicated a need for a referral to a urologist, but this was not reflected in the CAA. During a Quality Assurance Performance Improvement (QAPI) interview, staff acknowledged that inaccuracies in the MDS would lead to incorrect CAAs and care plans, and emphasized the expectation for CAAs to be accurate, personalized, and goal-oriented.
Failure to Update and Revise Care Plans
Penalty
Summary
The facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for six of eight sample residents. Resident 47, who was admitted with cancer, hip fracture, anxiety, and protein calorie malnutrition, reported severe pain and discomfort. Despite physician orders for pain management and a significant change in the Minimum Data Set (MDS) assessment indicating frequent severe pain, the care plan was not updated to reflect these findings, leaving nursing staff without the necessary information to manage the resident's pain effectively. Resident 55, readmitted for rehabilitation after joint replacement, experienced multiple incidents of physical aggression from another resident. Despite these occurrences, the care plan was not revised to include new interventions to prevent further incidents or address the resident's psychosocial well-being. Similarly, Resident 32's care plan included outdated interventions for anti-anxiety medication that had been discontinued, indicating a lack of timely updates to reflect current medical orders and resident needs. Resident 5, with a history of brain injury and contractures, was supposed to receive restorative nursing care, including passive and active range of motion exercises. However, these treatments were not completed, and the care plan was not updated to reflect the resident's current needs. Additionally, Resident 5's speech-generating device was broken and not documented in the care plan, leaving staff unaware of its importance for the resident's communication. Resident 29 had a broken dental partial that was not addressed in the care plan, despite observations and recommendations from a dental hygienist. Lastly, Resident 121 experienced significant weight loss, but the care plan did not include this critical information, failing to address the resident's nutritional needs adequately.
Failure to Complete Annual Performance Reviews for NAC Staff
Penalty
Summary
The facility failed to complete required annual performance reviews for three Nursing Assistant Certified (NAC) staff members, identified as Staff W, X, and Z, who were reviewed for annual performance review after one year of employment. Staff W was hired on 01/31/2023, Staff X on 08/10/2022, and Staff Z on 10/14/2021. Upon review of their employee files, it was found that no annual performance reviews were provided for the prior year for any of these staff members. In an interview conducted on 04/23/2024, the Director of Nursing Services confirmed that the annual performance evaluations were not completed. This failure to conduct annual performance evaluations and ensure adequate training placed all residents at risk for unmet care needs.
Failure to Complete Timely PASRR Assessments
Penalty
Summary
The facility failed to ensure timely completion of Preadmission Screening and Resident Review (PASRR) assessments for residents with significant changes in condition. Specifically, for three residents, the facility did not update or complete the necessary Level II PASRR evaluations when new diagnoses or behavioral changes occurred. This failure potentially prevented these residents from receiving appropriate specialized rehabilitation services and impacted their quality of life. Resident 10 was admitted with diagnoses including vascular dementia and psychotic disturbance. Despite having a serious mental illness indicator, the PASRR was not revised to reflect the resident's psychotic disorder or the need for antipsychotic medications. The facility did not document any follow-up with the PASRR contractor, leading to an incomplete assessment process. Resident 51 exhibited new verbal and physical aggression and attempted to elope, resulting in an emergency room visit and new psychotropic medication orders. However, the facility did not complete a new PASRR to reflect these significant changes. Similarly, Resident 57, admitted with delusional disorder and severe cognitive impairment, had a PASRR that did not identify the delusional disorder. Although a new PASRR was completed later, the facility failed to follow up with the PASRR Level II evaluator to ensure the assessment was processed.
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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