Life Care Center Of Port Orchard
Inspection history, citations, penalties and survey trends for this long-term care facility in Port Orchard, Washington.
- Location
- 2031 Pottery Avenue, Port Orchard, Washington 98366
- CMS Provider Number
- 505210
- Inspections on file
- 24
- Latest survey
- March 26, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Life Care Center Of Port Orchard during CMS and state inspections, most recent first.
Two residents experienced hospitalization due to the facility's failure to monitor hydration and notify providers of abnormal lab results. One resident, with severe cognitive impairment, showed signs of dehydration and infection but was not promptly treated, leading to a critical condition. Another resident, with moderate cognitive impairment, suffered from poor oral intake and was hospitalized with electrolyte imbalances. Staff interviews revealed inadequate monitoring and communication regarding residents' conditions.
The facility failed to accurately assess MDS for two residents, leading to potential unmet care needs. One resident's MDS did not reflect a required Level II PASRR for depressive disorder, while another resident's MDS failed to code for continuous oxygen therapy despite documented orders. Staff acknowledged these oversights.
The facility failed to implement baseline care plans within 48 hours for two residents, one with a non-healing ulcer and on coumadin therapy, and another with Type 2 Diabetes requiring insulin. The DNS and Resident Care Manager acknowledged the omissions, which were due to a misunderstanding of the care plan timeline requirements.
The facility failed to develop comprehensive care plans for three residents, leading to potential unmet needs. A resident's activity preferences were not included in their care plan, another's oxygen usage was not documented, and a third's use of mobility bars was not care planned. Additionally, a resident with a pressure ulcer lacked specific interventions in their care plan. Staff acknowledged these omissions during interviews.
The facility failed to follow physician orders and maintain proper documentation for several residents, leading to medication errors and unmet care needs. A resident received Lisinopril despite low blood pressure, and another had insulin administered outside prescribed parameters. Daily weights were not recorded for a resident, and insulin was given after meals instead of before. Oxygen was administered at incorrect rates without notifying a physician.
The facility failed to implement or document the bowel protocol for two residents, leading to a deficiency in care. One resident with severe cognitive impairment did not have a bowel movement for seven days, and there was no documentation of interventions. Another resident, who was cognitively intact, did not receive prescribed medication after four days without a bowel movement. Staff confirmed the failure to follow the bowel protocol, placing residents at risk for discomfort.
Two residents in an LTC facility experienced deficiencies in pressure ulcer care due to inadequate monitoring and documentation. One resident with an unstageable heel ulcer lacked consistent assessments, while another developed an ear ulcer from nasal cannula straps, with inconsistent treatment documentation. Staff interviews revealed a lack of adherence to wound care policies.
A resident with diabetes was subjected to significant medication errors when facility nurses administered insulin despite blood glucose levels being below the physician-ordered parameters. This occurred on 20 occasions, as confirmed by the Resident Care Manager, indicating a failure to follow prescribed insulin administration guidelines.
The facility failed to enforce Enhanced Barrier Precautions (EBP) and contact precautions for residents with urinary catheters and multidrug-resistant organisms (MDROs). Staff did not consistently wear gowns and gloves when required, and urinary catheter bags were observed touching the ground. Additionally, there was confusion among staff regarding the implementation of contact precautions outside of resident rooms, leading to residents with MDROs moving freely without appropriate restrictions.
A resident with COPD and chronic respiratory failure experienced a delay in receiving a physician-ordered chest x-ray due to ineffective communication and follow-up by the facility staff. The x-ray was not performed promptly, leading to the resident's hospital admission for pneumonia.
A facility failed to ensure safe transfers for a resident by not using the mechanical lift's manufacturer's recommended sling, resulting in the resident sliding from the sling and experiencing back pain. The staff were unaware of the manufacturer's recommendation to use only their brand of slings, leading to the incident.
Inadequate Hydration and Monitoring Lead to Hospitalization
Penalty
Summary
The facility failed to provide adequate care and services to prevent hospitalization for two residents, primarily due to insufficient monitoring and intervention regarding hydration and abnormal laboratory results. Resident 1, who had severe cognitive impairment and was dependent on staff for activities of daily living, was admitted for aftercare following fractures. Despite being clinically stable initially, the resident's condition declined, with elevated white blood cells and sodium levels indicating potential infection and dehydration. The facility staff did not promptly notify the provider or family of these lab results, and the resident eventually required emergency medical attention for critically low oxygen levels and was diagnosed with multiple conditions, including dehydration and infections, upon hospital admission. Resident 2, with moderate cognitive impairment and requiring substantial assistance, also experienced a decline in condition due to poor oral intake and hydration monitoring. The resident's family expressed concerns about increased lethargy and inadequate fluid intake, which were not adequately addressed by the facility. The resident was eventually hospitalized with hypernatremia and hypomagnesemia, conditions related to poor oral intake, and required intravenous fluids for stabilization. Interviews with facility staff revealed a lack of consistent monitoring and documentation of fluid intake and output, particularly for residents not on fluid restrictions. Staff members were unclear about the process for notifying providers of lab results and changes in resident conditions. The facility's infection preventionist and director of nursing services were not fully aware of the residents' declines or the need for testing during an outbreak, indicating systemic issues in communication and care coordination.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess the Minimum Data Set (MDS) for two residents, leading to potential risks for unmet care needs. Resident 12, who was admitted to the facility, had an Annual MDS that did not reflect the requirement for a Level II Preadmission Screening and Resident Review (PASRR) for a depressive disorder, despite documentation indicating the need for specialized services. Staff H, the Registered Nurse and MDS Coordinator, acknowledged that Resident 12 should have been coded for a Level II PASRR on both annual MDSs. The Director of Nursing, Staff B, confirmed the expectation for accurate MDS coding. Resident 39, admitted with acute and chronic respiratory failure and dependence on supplemental oxygen, had an Admission MDS that failed to code for oxygen usage, despite orders and documentation indicating continuous oxygen therapy. Staff G, a Licensed Practical Nurse, confirmed that Resident 39 had been on oxygen since admission, and Staff H provided documentation showing that oxygen therapy should have been coded during the MDS capture period. This oversight in MDS coding for oxygen therapy was acknowledged by the MDS Coordinator.
Failure to Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, leading to potential risks for unmet care needs. Resident 131 was admitted with a non-healing ulcer on the right foot, requiring daily dressing changes, and was on coumadin therapy, necessitating regular INR testing. However, the baseline care plan did not address these critical health issues, as confirmed by the Director of Nursing Services (DNS), who acknowledged that these elements should have been included. Similarly, Resident 331, who was admitted with Type 2 Diabetes and required insulin, did not have a baseline care plan developed within the required timeframe. The Resident Care Manager confirmed that the high-risk insulin medication should have been included in the care plan. The DNS mistakenly believed that there was a 21-day period to complete a comprehensive care plan, which contributed to the oversight.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement individualized comprehensive care plans for three residents, leading to potential unmet care needs. Resident 1, who was cognitively intact, expressed specific activity preferences that were not included in their care plan, despite being identified as very important. The Activities Director acknowledged that these preferences should have been care planned. Resident 39, also cognitively intact, was observed using supplemental oxygen, but their care plan did not include details about their oxygen usage, which the Director of Nursing Services confirmed should have been included. Resident 44, who was moderately cognitively impaired, used mobility bars for assistance, but their care plan lacked documentation for this equipment. The Resident Care Manager confirmed the absence of a care plan for the mobility bars. Resident 59, with severe cognitive impairment, had a diagnosis of an unstageable pressure ulcer on their left heel, but their care plan did not include specific interventions for this condition. The Resident Care Manager and Director of Nursing Services both acknowledged that the pressure ulcer should have been care planned. These deficiencies were identified during interviews and record reviews, highlighting the facility's failure to address the residents' specific needs in their care plans.
Non-Compliance with Physician Orders and Documentation Failures
Penalty
Summary
The facility failed to adhere to professional standards of practice for several residents, leading to medication errors and unmet care needs. For Resident 21, the facility did not follow physician orders for Lisinopril, administering it despite a systolic blood pressure below the ordered threshold. Additionally, the facility failed to obtain an A1C test as ordered, with no documentation explaining the missed attempts. Furthermore, Resident 21 received aspart insulin multiple times outside the prescribed blood glucose parameters. Resident 1's care was compromised by the facility's failure to record and report daily weights as ordered. Weights were not documented on several occasions, and a nurse erroneously signed off on a weight that was not recorded in the electronic health record. This lack of documentation and adherence to orders could lead to unmonitored weight changes, which were critical for Resident 1's care. Resident 331 received insulin Lispro after meals instead of before, contrary to the physician's orders. Additionally, hydralazine was administered despite a blood pressure reading below the hold parameter, and a lidocaine patch was applied without a specified location. Resident 59's oxygen was administered at a higher rate than ordered, with no documentation of physician notification or order updates. These actions reflect a pattern of non-compliance with physician orders and inadequate documentation, potentially impacting resident safety and care quality.
Failure to Implement Bowel Protocol for Residents
Penalty
Summary
The facility failed to implement or document the bowel protocol for two residents, leading to a deficiency in care. Resident 59, who was admitted with a diagnosis of constipation and severe cognitive impairment, did not have a bowel movement recorded for seven days. Despite having orders for Milk of Magnesia, Bisacodyl, and Fleet Enema to be administered sequentially after specific days without a bowel movement, there was no documentation of these interventions being carried out. Staff interviews confirmed that the bowel protocol was not followed, and there was no documentation of refusal or bowel assessments during this period. Similarly, Resident 1, who was cognitively intact and assessed to be constipated, did not receive the prescribed Milk of Magnesia after four days without a bowel movement. The facility's MAR showed that the as-needed bowel medications were not offered or administered as ordered. Staff acknowledged the failure to administer the medication on the fourth day, as per the resident's bowel management orders. These lapses in following the bowel protocol placed the residents at risk for discomfort and diminished quality of life.
Deficiencies in Pressure Ulcer Monitoring and Documentation
Penalty
Summary
The facility failed to appropriately monitor and document pressure ulcers for two residents, leading to deficiencies in care. Resident 59, who had chronic venous insufficiency, malnutrition, and an unstageable pressure ulcer on the left heel, was not properly assessed or documented. Despite having a scabbed area on the heel, there were no consistent measurements or staging of the wound. The facility's staff did not follow up with weekly assessments or involve the wound care team, resulting in a lack of documentation on the wound's progression or response to treatment. Resident 44, who was moderately cognitively impaired and at risk for pressure ulcers, developed a pressure ulcer on the left ear from nasal cannula straps. The facility's records showed inconsistencies in documenting the presence and treatment of the ulcer. Skin prep orders were not properly managed, leading to multiple administrations within short intervals and incorrect documentation of treatment on both ears instead of the affected one. Observations indicated that the resident was not consistently on oxygen, and staff failed to document the resolution of the ulcer accurately. Interviews with staff revealed a lack of understanding and adherence to the facility's policies on wound care documentation and assessment. Staff members admitted to not following through with expected documentation practices, such as weekly measurements and staging of pressure ulcers. The Director of Nursing Services acknowledged the deficiencies in documentation and the failure to meet expectations for wound care management, highlighting a systemic issue in the facility's approach to pressure ulcer care.
Failure to Adhere to Insulin Administration Orders
Penalty
Summary
The facility failed to ensure that a resident, who was cognitively intact and diagnosed with diabetes, was free from significant medication errors related to insulin administration. The resident had specific physician orders for insulin administration, which included holding Aspart insulin if blood glucose (BG) levels were below 150 and holding Lantus insulin if BG levels were below 100. However, the facility nurses administered insulin on multiple occasions despite BG levels being below the ordered parameters, as evidenced by the Medication Administration Records for January and February 2025. The report highlights 20 instances where insulin was administered contrary to the physician's orders, placing the resident at risk for adverse health outcomes. These errors were confirmed by the Resident Care Manager, who acknowledged that the facility nurses did not adhere to the prescribed insulin administration guidelines. This oversight in following physician orders for insulin administration constitutes a significant medication error, as it directly contravenes the established medical directives for the resident's diabetes management.
Infection Control Deficiencies in EBP and Contact Precautions
Penalty
Summary
The facility failed to enforce Enhanced Barrier Precautions (EBP) for Resident 331, who was on EBP due to having a urinary catheter/foley. During observations, staff members were seen providing care without wearing the required gown and gloves. Staff J, an LPN, administered insulin to Resident 331 without wearing a gown, and Staff L, a CNA, assisted the resident with movement without wearing a gown, despite acknowledging the requirement for gown and glove use in EBP rooms. The Infection Preventionist/Assistant Director of Nursing (IP/ADON) confirmed that staff were expected to wear gowns and gloves when providing care to residents on EBP. The facility also failed to prevent urinary catheter/foley bags from touching the ground for Residents 331 and 39. Observations showed that Resident 331's foley bag and tubing were repeatedly seen touching the ground while the resident was in a wheelchair. Similarly, Resident 39's foley bag was observed touching the ground multiple times, including when being moved through the hallway. Staff confirmed that foley bags should not touch the ground, and the IP/ADON stated that the expectation was for foley bags to be secured without touching the ground. Additionally, the facility did not ensure that contact precautions were understood and followed outside of resident rooms for Residents 39 and 131. Resident 39, who had a history of ESBL and E.coli, was observed with signage for both EBP and contact precautions, yet staff allowed the resident to leave the room without restrictions. Similarly, Resident 131, with a history of MRSA wound infections, was seen self-propelling in a wheelchair in the hallway without adherence to contact precautions. Staff expressed confusion about the implementation of precautions, and the IP/ADON provided inconsistent explanations regarding the necessity of precautions outside of resident rooms.
Delay in Obtaining Physician-Ordered X-Ray
Penalty
Summary
The facility failed to obtain a physician-ordered chest x-ray in a timely manner for a resident with a history of emphysema, COPD, and chronic respiratory failure. The resident was experiencing shortness of breath and a productive cough with thick yellow phlegm, prompting the provider to order a chest x-ray. Despite the order being faxed to the imaging provider, the x-ray was not performed promptly, and the resident's condition worsened, leading to a hospital admission for pneumonia. The delay in obtaining the x-ray was attributed to the facility's reliance on the radiology provider's availability, which was not communicated effectively to the provider or documented in the resident's health record. The staff did not follow up adequately with the radiology provider or the ordering provider to ensure the x-ray was performed in a timely manner. The resident's family expressed concern about the delay, and the resident's Power of Attorney eventually requested transport to the ER for evaluation.
Failure to Ensure Safe Transfers with Manufacturer-Recommended Equipment
Penalty
Summary
The facility failed to ensure safe transfers for a resident when they did not use the mechanical lift's manufacturer's recommended sling, resulting in the resident sliding from the sling. The resident, who was cognitively intact, medically complex, and dependent on staff for transfers, was admitted to the facility and required total assistance with an XL sling for transfers. During a transfer, the resident fell from the lift, leading to back pain and a subsequent hospital evaluation. The incident report documented that the lift and sling were inspected and found to be in working order, and the correct lift and sling were used. However, the fall occurred when the resident shifted her weight, causing the harness on the right shoulder to come off the hook. Staff involved in the transfer confirmed that they were using a purple XL sling from a different manufacturer than the lift, which was against the lift manufacturer's safety recommendations. Further investigation revealed that the facility's staff were not aware of the mechanical lift manufacturer's recommendation to use only their brand of slings. The Director of Nursing and the Administrator confirmed that they were working on implementing the manufacturer's recommendations but had not communicated with the sling company to ensure compatibility prior to the incident.
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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