Life Care Center Of Skagit Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Sedro Woolley, Washington.
- Location
- 1462 West State Route 20, Sedro Woolley, Washington 98284
- CMS Provider Number
- 505318
- Inspections on file
- 32
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Life Care Center Of Skagit Valley during CMS and state inspections, most recent first.
A resident with impaired mobility and multiple comorbidities was admitted with blanchable redness to the buttocks and was identified as at risk for PU development, but the care plan contained only minimal interventions such as weekly skin checks and incontinence care, without individualized measures for the existing redness or documented education on repositioning or support surfaces. Despite facility policies requiring pressure redistribution mattresses, wheelchair cushions, and regular repositioning for at‑risk residents, there were no orders for a pressure‑reducing mattress or wheelchair cushion even after an outside wound care provider diagnosed an unstageable sacral PU and recommended such support surfaces. Wound care orders for cleansing, Santyl application, and foam dressings every three days were not reliably implemented, as evidenced by a dressing observed eight days after its date with moderate drainage, conflicting TAR entries, and an RN who could not recall performing the documented dressing changes or explain the outdated dressing. CNAs reported inconsistent repositioning practices and no specific documentation of repositioning, and a family member learned of the PU only after the resident complained of sacral pain, while staff interviews showed limited awareness of the PU and lack of a system to document positioning, resulting in an avoidable unstageable PU that caused pain and discomfort.
The facility did not ensure that window locks and screens were properly maintained in multiple resident rooms. A family member reported that a resident’s room had a broken window lock and no screen, and that the facility used a screw and later a wooden dowel instead of repairing the locking mechanism, while still communicating that the window was secured. Surveyor observations confirmed one room with no screens, no functional lock on one window panel, and a dowel between windows; another room with intact locks and screens; and a third room with a missing lock knob on one window and a screen with a hole. The Maintenance Director acknowledged using a screw in place of a proper lock, confirmed the window could still be tilted to bypass it, and reported there were no documented maintenance requests, only verbal reports.
A resident with severe cognitive impairment and complex medical needs did not receive adequate social services or advocacy regarding advanced directives. Facility staff failed to document discussions about the resident's wishes, did not facilitate communication with the resident's contacts, and did not provide sufficient assistance in obtaining legal support for a POA, resulting in the resident's preferences not being properly addressed.
A resident's care plans were not updated to reflect their current urinary status and discharge goals, resulting in outdated interventions such as continued catheter care instructions after the catheter had been removed. Staff interviews and documentation confirmed the care plans did not accurately represent the resident's needs.
Two residents with wounds experienced significant gaps and inconsistencies in their clinical records, including missing or delayed weekly skin assessments and incomplete wound documentation. Staff interviews confirmed that required documentation was not consistently completed, leading to records that did not accurately reflect the residents' conditions or care provided.
Multiple areas, including shared bathrooms, a community shower room, and the main dining room, were found to be unclean, poorly maintained, and lacking a homelike atmosphere. Bathrooms had strong odors, broken and stained tiles, and poor lighting, while the shower room had missing tiles, an uneven floor, and was dirty and disorganized. The dining room lacked decor, music, and staff engagement, leaving residents sitting alone and unassisted during meals. Staff and residents confirmed these conditions, which did not meet the facility's policy for a clean and homelike environment.
Several residents who required staff assistance for ADLs, including showering, were observed with poor hygiene such as greasy hair, and records showed they did not consistently receive showers as scheduled. Staff interviews revealed that aides responsible for showers were often reassigned to other duties, leading to missed care, and that lack of documentation indicated showers were not provided. Residents had varying cognitive and physical needs, but all were dependent on staff for hygiene support.
Multiple residents reported dissatisfaction with meal quality, taste, and temperature, citing issues such as tough meats, lack of variety, and cold or unappetizing food. Observations confirmed that meals were served below recommended temperatures and were not visually appealing. Grievances about food quality and temperature were not fully addressed, and staff confirmed limitations in reheating and food preparation due to equipment and menu constraints.
Several residents with intact cognition and specific dietary needs were denied the ability to have outside food items, such as frozen meals and microwave popcorn, heated by staff after the facility changed its policy. The administration cited concerns about food safety, staff workload, and storage limitations, resulting in residents losing the ability to choose and enjoy their preferred meals and snacks. Staff confirmed the directive to stop heating food, and residents and families expressed dissatisfaction with the loss of choice.
The facility did not follow its policy for handling and storing food brought in by family and visitors, as staff were instructed not to heat up food items for residents and only limited storage was provided. The Administrator and DON confirmed these restrictions, which were not consistent with the facility's written procedures for safe food handling.
A resident with severe cognitive impairment was found with a bruise and abrasion on the forehead, but the facility's investigation was limited to a single LPN statement, basic notifications, and a skin check. No neurological assessment or witness interviews were conducted, and the DON acknowledged the investigation was incomplete.
A resident was discharged without the required MDS discharge assessment being completed or transmitted to CMS within the mandated timeframe. The omission was identified after the CMS system flagged the absence of any assessment for over 120 days, and the MDS Coordinator acknowledged the assessment was missed despite daily audit procedures.
A resident with hemiplegia and hemiparesis did not consistently receive prescribed splint and brace interventions to maintain range of motion, as staff only applied splints during restorative therapy sessions and not daily as ordered. Staff interviews revealed confusion about responsibility for splint application when restorative aides were unavailable, and documentation showed minimal evidence of splint use or monitoring.
A resident with malnutrition and dysphagia, who had documented allergies and food dislikes, was served meals containing gluten, mayonnaise, and tomato products despite these being listed as allergies or dislikes. Staff interviews confirmed that limited gluten-free options and lack of alternatives led to the resident receiving inappropriate food items, contrary to facility policy.
Surveyors observed that expired food items were not removed from a nourishment refrigerator, and a cook failed to follow proper hand hygiene and glove use during meal preparation, including handling clean plates and food with bare hands. These lapses in food safety and sanitation were acknowledged by staff and management.
Staff did not follow infection control protocols for three residents requiring different levels of precautions. One resident with a Foley catheter did not receive proper Enhanced Barrier Precautions, as a nursing assistant failed to wear a gown during catheter care. Another resident receiving pericare was assisted by a nursing assistant who did not change gloves between tasks, leading to potential cross-contamination. Additionally, a resident under investigation for C. Diff was not placed on the correct Contact Enteric precautions due to incorrect signage, resulting in staff not using the required PPE or hand hygiene methods.
The facility administration failed to manage resources effectively, leading to deficiencies in care planning, resident environment, and staffing. A resident with chronic pain experienced severe discomfort due to delayed medication administration. Staff interviews revealed issues with medication pass timing and lack of a restorative program. Additionally, the facility struggled with infection control and tuberculosis testing.
The facility did not initiate a grievance process for concerns raised by the Resident Council about call light wait times. Despite residents voicing these issues, the facility failed to log or investigate the grievances, preventing trend identification and resolution. Staff directed residents to submit forms but did not assist, and the administrator noted challenges in addressing grievances without resident participation.
The facility failed to develop comprehensive care plans for several residents, including those with amputations, smoking cessation needs, and nephrostomy care. Observations showed residents without access to call lights and unaddressed pain issues. Staff interviews revealed a lack of awareness and time constraints affecting care plan completion.
The facility failed to update care plans for several residents, leading to discrepancies in care. A resident's care plan was not updated after transitioning to restorative services, another's did not reflect hospice care, and a third's did not address smoking risks. Additionally, a resident was observed using a straw despite care plan restrictions, with staff unaware of this precaution.
The facility failed to provide adequate assistance with ADLs for several residents, particularly in bathing and toileting. A resident with a fracture and chronic conditions was not assisted with toileting due to equipment limitations. Other residents, dependent on staff for bathing, did not receive showers as per their preferences due to staffing issues. Documentation and staff interviews revealed systemic issues in scheduling and providing showers, with the DON and Administrator unaware of the missed care.
The facility experienced significant staffing shortages, resulting in delayed assistance with activities of daily living and medication administration. Residents reported long wait times for help, particularly during nights and weekends. A resident with chronic pain did not receive timely pain medication, and another resident missed scheduled showers due to staff being reassigned to cover floor duties.
The facility failed to administer scheduled medications on time for several residents, resulting in significant delays. A resident with chronic pain reported severe pain due to not receiving their morning medications, while others received essential medications, such as antipsychotic and anticoagulant drugs, hours after the scheduled time. Staff interviews indicated that the medication pass took longer than expected.
The facility failed to maintain sanitary conditions in the kitchen, as staff were observed not wearing required hair and beard restraints. This non-compliance with the facility's policy placed residents at risk of food contamination.
The facility failed to ensure proper infection control practices, as observed with a NAC not performing hand hygiene during meal service and another NAC not changing gloves or washing hands after peri-care. Additionally, incorrect transmission-based precautions were in place for a resident with c. diff, with signage instructing the use of ABHR instead of soap and water. These lapses in protocol were not recognized by the Infection Preventionist or DON.
A facility failed to obtain and maintain Advance Directives for a resident with multiple health conditions, despite the care plan indicating a Power of Attorney (POA) for healthcare. The electronic medical record lacked POA documentation, confirmed by staff interviews. The Admissions Director did not obtain the POA documents at admission, and the Medical Records Director confirmed the absence of the document. An RN-Staff Development Coordinator also could not locate the document, although the resident's daughter had signed the POLST as the POA.
The facility failed to provide a homelike environment and maintain cleanliness for three residents and the conference room. A resident with severe cognitive impairment had a stark room lacking personal decor, while another resident reported unclean windows that had not been addressed despite requests. A third resident's window and TV screen were observed to be dusty and streaked. The conference room also had dirty windows and screens, indicating a broader issue with maintaining a clean environment.
A facility failed to conduct a Significant Change in Status Assessment (SCSA) for a resident who elected Hospice services, as required by the Resident Assessment Instrument (RAI) guidelines. The resident elected Hospice on a specific date, but no SCSA was completed within the required 14-day period. An LPN/MDS Nurse was unaware that the election of Hospice services alone required a SCSA.
A resident was discharged without a complete discharge summary, missing essential components such as a recapitulation of their stay and a final status summary. The facility's policy requires both social services and nursing staff to contribute to the discharge summary, but interviews revealed that the summary was incomplete, and staff were unclear about the resident's post-discharge needs.
The facility failed to provide adequate care for three residents with limited ROM and mobility issues. A resident with rheumatoid arthritis wore a sling without an order, and no follow-up on ROM assessment was conducted. Another resident, at risk for skin breakdown, was left in a wheelchair for hours without repositioning. A third resident with contractures did not consistently receive prescribed brace and splint applications, with documentation gaps and confusion over program oversight.
A resident with malnutrition and bipolar disorder experienced significant weight loss due to the facility's failure to implement nutritional interventions and monitor weight changes. Despite the care plan identifying a risk for weight loss, the facility did not consistently obtain weights or notify appropriate parties. Staff interviews revealed a lack of awareness and communication regarding the resident's weight loss and refusal to be weighed.
A resident with a PEG tube experienced a deficiency in enteral tube feeding management due to the facility's failure to label, date, and replace feeding supplies as required. Observations showed that feeding bags and syringes were not properly managed, and interviews with staff revealed a lack of physician orders and care plan directives for these tasks. This oversight placed the resident at risk for infection and complications.
The facility failed to provide appropriate respiratory care for two residents. One resident with COPD and other conditions was not using prescribed oxygen therapy and CPAP, as observed multiple times, with the concentrator set to zero liters. Another resident used oxygen without a documented physician's order, despite stating its use for sleep apnea. Staff interviews confirmed these deficiencies, highlighting a failure to adhere to professional standards of practice.
A resident with chronic pain syndrome did not receive their scheduled morning pain medications, including Gabapentin, Acetaminophen, and Suboxone, due to delays in the medication pass. The resident reported severe pain levels, and staff confirmed the delay in administering medications, leading to avoidable pain and diminished quality of life.
A resident with Parkinson's disease and moderate cognitive impairment was not provided with care planning meetings to address their care preferences, including bathing frequency and wheelchair comfort. The facility failed to conduct required quarterly care conferences, and staff were unaware of the resident's concerns due to the lack of meetings and documentation.
A facility failed to implement its Antibiotic Stewardship Program effectively, leading to continuous antibiotic administration for a resident without proper documentation or communication with the infectious disease provider. The resident, with a history of kidney stones and antibiotic-resistant infection, received antibiotics without a documented stop date. Staff interviews revealed a lack of awareness and follow-up, indicating a failure in the facility's ASP.
A resident with a history of recurrent UTIs was not adequately monitored or assessed, leading to a lack of a care plan addressing their condition. Despite showing symptoms of a UTI, such as dark amber urine and confusion, vital signs were not consistently documented, and the resident's representative or provider was not notified. The resident's condition escalated to a UTI with sepsis, resulting in hospitalization.
The facility failed to provide timely pharmaceutical services for three residents upon admission, resulting in missed medications. A resident with Bipolar Disorder and Seizure Disorder did not receive prescribed medications due to a lack of verification and notification processes. Another resident with a recent fall and cardiac issues did not receive several medications, including pain ointment, due to pending delivery. A third resident with encephalopathy and psoriasis also missed medications that were on order. There was no documentation of provider notification for any of these cases.
The facility failed to ensure proper nail care for three residents, leading to discomfort and potential injury. One resident with contractures experienced significant pain due to long nails digging into their palms, while two other residents had long, dirty, and jagged nails despite expressing a preference for having them cut. Staff interviews revealed inconsistencies in understanding and executing nail care responsibilities.
Failure to Prevent and Properly Treat an Avoidable Unstageable Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to implement adequate pressure ulcer (PU) prevention measures and to provide ordered wound treatment for a resident at risk for skin breakdown. The resident was admitted with diagnoses including history of falls, muscle weakness, osteoarthritis, and scoliosis, and the hospital discharge summary documented impaired mobility and recent falls but no skin issues. On admission, the facility’s nursing assessment noted blanchable redness to the buttocks, and the admission MDS and CAA identified the resident as at risk for PU development due to limited ability to participate in incontinence care and physical dependence on staff for position changes and offloading. The care plan documented risk for skin integrity breakdown with a goal to maintain intact skin, but interventions were limited to keeping skin clean and dry after incontinence and weekly skin checks, with no individualized interventions addressing the existing buttock redness or the resident’s identified PU risk. Over the ensuing months, Braden Scale scores consistently indicated mild risk for PU development, yet the record from admission through early January contained no documentation of education to the resident or representative regarding repositioning, mattress type, wheelchair cushion use, or other PU prevention measures. Facility policy required, at minimum, a pressure redistribution mattress, wheelchair cushion, and repositioning for residents at risk, but the resident’s medical record from mid-January through mid-February showed no physician orders for a pressure-reducing mattress or wheelchair cushion, despite an outside wound care company’s recommendation for these support surfaces. When the resident’s sacral PU was later assessed by the outside wound company, it was documented as an unstageable PU on the bilateral sacrum, and the plan included specific wound care with Santyl and foam dressings, as well as pressure-reducing support surfaces. The facility’s implementation of ordered wound care was also deficient. A weekly skin integrity assessment on a January date documented a small opening at the top of the gluteal fold, and a provider note the same day described a small, deep, painful open area with surrounding blanchable redness. Subsequent wound care orders directed cleansing with normal saline, application of skin prep and Santyl, and coverage with foam dressing every evening shift every three days. However, when surveyors observed the resident in late February, the resident was on a standard, approximately three‑inch mattress, wearing an incontinent brief, and the sacral PU dressing was wrinkled, clumped, and dated eight days earlier, with moderate red/green/brown drainage. Although the TAR showed that an RN had documented completing dressing changes on two dates after the dressing date, the RN later stated they could not remember performing the dressing changes, reported difficulty finding supplies, and could not explain why the dressing remained dated from the earlier date. Nursing staff interviews revealed inconsistent knowledge of the PU, lack of specific documentation for repositioning, and no charting system to record monitoring of the resident’s positioning, while the ADON could not provide details on the type of mattress or wheelchair cushion used prior to PU development and stated the resident’s PU was considered unavoidable. The report states that this failure resulted in the resident developing an avoidable unstageable PU that caused pain and discomfort and placed residents at risk for skin breakdown, unmet care needs, and diminished quality of life. Additional observations and interviews further illustrated the gaps in PU prevention and care. During the wound observation, the sacral PU measured 1.0 cm by 1.5 cm with 0.3 cm depth, with light pink wound bed and visible slough, and no odor or signs of infection. A bruise was also noted on the resident’s thigh. A CNA familiar with the resident’s care reported assisting with toileting and pericare, stated they had no knowledge of any PU, and indicated they did not reposition the resident when sleeping but did assist with repositioning when the resident was awake. Another CNA stated they repositioned the resident with pillows and that the resident did not refuse repositioning, but confirmed there was no specific charting for repositioning. A family member reported learning of the sacral PU only after hearing the resident complain of sacral pain while being assisted in the bathroom, and staff then attributed the pain to the PU. Overall, the documented and observed inactions included lack of individualized preventive interventions despite identified risk, absence of ordered pressure‑reducing support surfaces, failure to consistently perform and/or document ordered dressing changes, and lack of systematic documentation of repositioning and monitoring, culminating in the development and inadequate treatment of an avoidable unstageable PU. The report explicitly states that the facility failed to implement measures to prevent development of an avoidable PU and failed to provide ordered treatment for the PU for this resident. It further states that the resident experienced harm when they developed an avoidable unstageable PU that caused pain and discomfort, and that this failure placed residents at risk for skin breakdown, unmet care needs, and diminished quality of life. The findings are referenced to WAC 388‑97‑1060(3)(b).
Failure to Maintain Functional Window Locks and Screens in Resident Rooms
Penalty
Summary
The facility failed to maintain safe, functional, and comfortable resident rooms by not repairing broken window locking devices and not ensuring the presence and integrity of window screens in 2 of 3 rooms reviewed. A family member of a resident reported that upon the resident’s move-in, the left window panel in the resident’s room had a broken locking mechanism and no window screen, leaving the window unsecured. The family member stated that instead of replacing the locking mechanism, the facility initially placed a screw in the window frame to limit how far the window could open, but the window could still be tilted to bypass the screw. The family member further reported that the facility later placed a wooden dowel between the sliding windows and had communicated via email that the window lock was secured, despite the ongoing concerns. During observations of three rooms, one room was found to have a screw in the left window frame, no window screens, no locking mechanism on the left side, and a wooden dowel between the windows. Another room had window screens and functional locking mechanisms on both sides. A third room had an intact and functional locking mechanism on the left window, but the right window’s locking mechanism was missing the knob used to operate it, leaving the window in a locked position; the screens were present, but one had a hole in the bottom left corner. The Maintenance Director reported learning of the missing locking mechanism only a few weeks prior and confirmed placing a screw in the frame where the lock would engage, acknowledging that the window could still be tilted to bypass the screw. The Maintenance Director also stated there were no written maintenance requests or documentation for these issues, only verbal communications with nursing staff and the Administrator.
Failure to Provide Social Services and Advocacy for Advanced Directives
Penalty
Summary
The facility failed to provide medically related social services and to advocate for a cognitively impaired resident regarding the development and documentation of advanced directives. The facility's policy required review and updating of advanced directives upon admission, quarterly, and with any change in condition, with the social services director or designee responsible for documenting conversations and assisting with revisions. Despite these requirements, there was a lack of documented conversations with the resident or their collateral contacts about advanced directives, wishes, or rights, and insufficient assistance was provided in obtaining appropriate legal support for the development of a power of attorney (POA). The resident in question had a history of developmental and intellectual disability, anxiety, depression, and significant urinary tract issues, with cognitive assessments indicating severe impairment at multiple points. The resident's mental status fluctuated, and during periods of decline, they became non-communicative and unable to make informed decisions. Despite these challenges, there was minimal documented engagement by social services with the resident or their contacts regarding the resident's wishes for care, advanced directives, or the POA process. Attempts by a family friend to coordinate POA paperwork and discuss advanced directives were not adequately supported or facilitated by facility staff, and care conferences did not consistently include relevant parties or discussions about the resident's preferences. Interviews with staff and collateral contacts revealed that the resident required significant support to make decisions and that there was confusion and lack of clarity regarding who was responsible for advocating for the resident's wishes. The facility did not ensure that the resident's rights and preferences were thoroughly explored, documented, or honored, as evidenced by the absence of care conference notes addressing advanced directives and the lack of communication with the resident's contacts. This failure to provide comprehensive social services and advocacy placed the resident at risk of not having their rights and wishes respected.
Failure to Update and Revise Care Plans to Reflect Resident's Current Needs
Penalty
Summary
The facility failed to ensure that care plans were reviewed, revised, and accurately reflected the current care needs of a resident. Specifically, a resident admitted with perineal and sacral wounds, urinary incontinence, and cognitive impairment had discrepancies in their care documentation. The Quarterly Minimum Data Set (MDS) assessment indicated the resident was continent of bowel and bladder and did not have an indwelling urinary catheter. However, the resident's care plan for an indwelling urinary catheter, last revised months after the catheter was removed, still directed staff to perform catheter care every shift. Nursing assistant documentation for the last 30 days showed the resident was incontinent of bladder with no mention of a catheter, and direct observation confirmed the absence of a catheter. Interviews with staff revealed that the care plan had not been updated to reflect the resident's current status. The MDS Coordinator acknowledged that the care plan should have been updated, and the Social Service Director confirmed that the discharge care plan did not reflect the resident's current discharge goal. These failures resulted in care plans that did not accurately represent the resident's needs or status, as evidenced by outdated interventions and goals.
Inaccurate and Incomplete Wound Documentation for Residents with Skin Integrity Issues
Penalty
Summary
The facility failed to ensure that clinical records were accurate and maintained according to accepted professional standards for two residents with wounds. For one resident, there were significant gaps and inconsistencies in the documentation of weekly skin assessments and wound observations. The resident was admitted with multiple pressure ulcers and moisture-associated skin damage, but the required weekly skin assessments were either missing, marked as refused without follow-up, or left blank for extended periods. Wound observation tools were not completed at the required frequency, with some assessments delayed by several weeks. Observations and interviews confirmed that the documentation did not consistently reflect the resident's actual wound status or the care provided. Another resident with multiple chronic conditions, including multiple sclerosis and malnutrition, also had inconsistent and unclear documentation regarding skin integrity. Weekly skin checks noted open areas on the coccyx, but there was a lack of detailed wound notes or measurements for an extended period. The care plan indicated the presence of a pressure ulcer and follow-up by a wound care clinic, but the medical record did not contain corresponding wound documentation during a critical month. Staff interviews revealed that a new nurse was responsible for some of the incomplete documentation and that there was confusion and inaccuracy in the records related to the resident's skin condition. The facility's own policies required weekly head-to-toe skin inspections and timely, detailed documentation of any wounds or skin alterations. However, the records reviewed showed multiple instances where these requirements were not met, including late entries, missing assessments, and lack of clear wound descriptions. These documentation failures resulted in clinical records that did not accurately reflect the residents' conditions or the care provided, as confirmed by staff interviews and record reviews.
Failure to Maintain Clean, Comfortable, and Homelike Environment in Resident Areas
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment in multiple areas, including two shared resident bathrooms, a community shower room, and the main dining room. Observations revealed that the shared bathrooms had strong, unpleasant odors, sticky floors, broken and stained tiles, poor lighting, and damaged walls. Staff and residents confirmed these conditions, noting persistent odors, moldy or stained areas, and a lack of cleanliness and comfort. The community shower room was found to have missing tiles, no grout, an uneven and sunken floor, dust and dirt accumulation, disorganized medical equipment, overflowing trash cans, and a strong musty odor suggestive of mold or mildew. Staff interviews corroborated these findings, describing the room as dirty, in need of cleaning, and not homelike. In the main dining room, observations during multiple meal services showed that residents often sat alone at bare tables with minimal decor, no music or television, and little to no engagement from staff. Residents were observed waiting for meals in silence, with some staring at the walls or at each other, and staff either absent or standing at a distance without interacting with residents. Staff interviews indicated that music or movies were previously provided but were no longer offered, and that the dining room atmosphere was described as "dead." Residents reported difficulty obtaining assistance in the dining room due to staff inattention. The facility's own policy requires staff to provide a clean, safe, and homelike environment, but observations and interviews demonstrated that these standards were not met in the identified areas. The lack of cleanliness, maintenance, and engagement in these common areas contributed to an environment that was not comfortable or homelike for residents, as confirmed by both staff and resident statements.
Failure to Provide Consistent ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically showering and personal hygiene, for four residents who required varying levels of staff support. Observations over several days revealed that these residents consistently had greasy hair, indicating a lack of proper hygiene care. Documentation in the electronic medical record showed that showers were not provided according to the residents' stated preferences, with some residents receiving fewer showers than scheduled and others having missed or refused showers without evidence of appropriate follow-up or re-approach by staff. Interviews with staff confirmed that shower aides were frequently reassigned to other duties, which contributed to missed showers, and that if care was not documented, it was likely not performed. The residents involved had different cognitive and physical abilities, ranging from cognitively intact but physically dependent to severely cognitively impaired and fully dependent on staff for showers. Despite facility policy requiring assistance with ADLs as needed, the lack of consistent showering and hygiene support was evident through both staff interviews and resident reports. One resident reported being denied a shower due to staff being busy, and another was found to have received only two showers in a 30-day period. The facility's documentation practices and staff allocation contributed to the failure to meet residents' ADL needs.
Failure to Provide Palatable and Properly Heated Meals
Penalty
Summary
The facility failed to provide meals that were palatable, attractive, and served at an appetizing temperature, as evidenced by multiple resident interviews, observations, and review of dietary grievances. Residents reported dissatisfaction with the quality, taste, and temperature of the food, noting issues such as tough meats, lack of variety, overuse of certain seasonings, and inability to access or use a microwave for reheating food. During a group meeting, all residents in attendance expressed that meals were often cold, unappetizing, and not visually appealing, with specific complaints about soggy or hard French fries, smashed buns, and excessive barbecue sauce. Observations of meal service confirmed that food items, such as burgers and fries, were served below recommended temperatures and were not palatable. Review of the facility's grievance log revealed that concerns about undercooked or cold food were not adequately addressed in the facility's responses, which focused on updating preferences or communication rather than resolving the underlying issues. Staff interviews confirmed that the kitchen does not reheat resident foods and that certain equipment, such as a toaster, was unavailable for a period. The Food Services Director acknowledged limitations in food preparation methods due to lack of equipment and noted that menus were determined by corporate, sometimes including items not suitable for the available kitchen setup. The Administrator was aware of some complaints but had not personally evaluated the food quality.
Failure to Honor Resident Food Preferences and Choices
Penalty
Summary
The facility failed to honor and facilitate resident preferences for food, specifically by not allowing residents to have food items from outside sources heated up, despite previous practices and resident requests. This change affected at least four residents, all of whom had intact cognition and specific dietary needs or preferences, such as altered taste due to stroke, diabetes, malnutrition, and personal snack choices. The facility's policy previously allowed for the safe heating of outside food using food thermometers and staff education, but this was discontinued. Residents and their families reported that the facility stopped heating up food items, including frozen meals and microwave popcorn, citing state regulations, staff workload, and concerns about food safety and potential burns. Residents expressed dissatisfaction, noting that the inability to heat up their preferred foods negatively impacted their meal enjoyment and choice. Staff interviews confirmed that management had directed them to stop heating food for residents, and staff expressed difficulty in denying these requests, acknowledging the impact on residents' quality of life. Administrative staff explained that the policy change was implemented due to an increase in outside food being brought in, lack of storage space, and concerns about staff capacity to safely heat food according to guidelines. The facility communicated this change to residents and families through a letter, stating that only small amounts of perishable food could be stored and that no food requiring heating would be accommodated. This resulted in residents losing the ability to choose their preferred meals and snacks, contrary to facility policy and resident rights.
Failure to Implement Policy for Outside Food Brought by Visitors
Penalty
Summary
The facility failed to implement its policy regarding the safe and sanitary storage, handling, and consumption of foods brought in by family and visitors for residents. The policy required that when food needed to be heated, staff should use a food thermometer and alcohol wipes to ensure proper heating, and that staff should be educated on required food temperatures and the use of thermometers. However, a letter from the Administrator to residents, staff, and family members stated that staff would no longer heat up food items for residents, including frozen foods, hot dogs, and microwave popcorn, and that only a small number of food items could be stored for residents due to limited space. In interviews, the Administrator and DON confirmed that residents were not allowed to have food heated up and cited concerns about staff being able to safely heat food and the burden it placed on staff. These actions were not in accordance with the facility's written policy.
Failure to Thoroughly Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to conduct a thorough investigation of an injury of unknown source for one resident with severely impaired cognition, memory, and decision-making abilities. The resident was found with a bruise and small abrasion on the forehead by an LPN, who documented that the resident denied abuse or neglect but was unable to recall the incident. The investigation consisted only of a statement from the LPN, notification of the provider and the resident's son, a skin check, and monitoring of the bruise. No neurological assessment was performed despite the unwitnessed head injury, and there was no follow-up with the son regarding the time frame or circumstances of the injury. Additionally, the investigation did not include statements from potential witnesses, other staff, or residents who may have had relevant information. Interviews with facility staff revealed that the process for investigating such incidents was not fully followed, as no additional data gathering or witness statements were obtained. The Director of Nursing acknowledged that the investigation was incomplete and lacked thorough data collection as required by facility policy.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure the timely completion and transmission of the required Minimum Data Set (MDS) discharge assessment for one resident. According to the report, a resident was admitted and later discharged, but review of the clinical record revealed that no discharge MDS assessment was completed or transmitted to CMS within the required 14-day period following discharge. The CMS system flagged the resident's file as lacking any type of assessment for over 120 days. During an interview, the MDS Coordinator stated that although daily audit reports and discussions occur during stand up meetings, this particular assessment was missed.
Failure to Provide and Document Splint Application for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate interventions to maintain or prevent decline in range of motion (ROM) for a resident with a history of stroke resulting in hemiplegia and hemiparesis. Physician orders specified that the resident was to wear a left wrist splint in the morning and remove it at bedtime, and a left ankle splint for six hours daily. Multiple observations over several days revealed that the resident was not wearing the prescribed splints, and the resident reported that splints were only applied during restorative therapy sessions, which occurred twice a week. The resident denied refusing the splints when offered. Interviews with nursing assistants, restorative aides, and nursing staff indicated confusion and lack of clarity regarding responsibility for applying the splints when restorative aides were reassigned to other duties. Documentation review showed that splint or brace assistance was recorded on only seven of the last thirty days, and there was no documentation of splint or brace application in the resident's Medication and Treatment Administration Records for several months. Facility leadership confirmed that nurses were supposed to apply the splints when restorative aides were unavailable, but there was no evidence of this being done or documented.
Failure to Accommodate Resident Food Allergies and Preferences
Penalty
Summary
The facility failed to ensure that a resident's menu and individual food plan met their documented nutritional needs and preferences. The resident, who had diagnoses including malnutrition and dysphagia and received extra calories via a PEG tube, was noted to have allergies and dislikes including gluten, eggs, mushrooms, mayonnaise, and tomato products. Despite this, observations showed that the resident was served a hamburger with mayonnaise and battered onion rings, which contained gluten, as well as gluten-free pasta with tomato sauce, which the resident disliked and refused to eat. The resident expressed dissatisfaction and concern about the presence of gluten and other disliked items in their meals. Interviews with staff revealed that meal tray cards listing allergies and dislikes were used to guide food preparation, but limitations in available gluten-free options from the food vendor resulted in the resident receiving inappropriate food items. The Food Services Director acknowledged that alternatives were not available for certain menu items, leading to the resident being served foods containing allergens or items they disliked. The facility's policy required accommodation of allergies and preferences, but this was not consistently implemented for the resident in question.
Failure to Maintain Sanitary Food Preparation and Storage Practices
Penalty
Summary
The facility failed to ensure that food was prepared and stored under sanitary conditions, as evidenced by multiple observations in the kitchen and nourishment areas. During an inspection of the nourishment refrigerator, an opened carton of thick and easy supplement was found with a manufacturer expiration date that had already passed, and the carton had been opened after its expiration. This indicates that expired food items were not consistently removed from storage, contrary to facility policy and food safety standards. Additionally, during meal preparation and tray line observation, a cook was seen engaging in unsanitary practices. The cook changed gloves multiple times without performing required hand hygiene between changes and was observed handling clean plates and food items with bare hands. Specifically, the cook touched a clean plate and a sandwich with bare hands and did not replace the contaminated plate. These actions were acknowledged by the staff involved and the food services manager, who noted that the staff member was working too quickly and that expired items should have been removed but were missed.
Noncompliance with Infection Control Precautions and PPE Use
Penalty
Summary
Staff failed to comply with infection prevention and control guidelines for multiple residents requiring different levels of precautions. For a resident with an indwelling Foley catheter on Enhanced Barrier Precautions (EBP), a nursing assistant emptied the catheter bag while wearing only gloves and not a gown, despite facility policy requiring both gown and gloves for high-contact activities involving indwelling devices. The staff member stated they did not believe a gown was necessary for this task, even though the EBP signage indicated otherwise. During personal care for another resident with hemiplegia and hemiparesis, a nursing assistant did not change gloves after providing pericare and continued to assist the resident with dressing and handling the resident's wheelchair with the same soiled gloves. The staff member later acknowledged that the gloves were dirty and should have been changed after pericare, but stated they typically only change gloves when visibly soiled. For a resident under investigation for Clostridium difficile (C. Diff), the room was posted with EBP signage instead of the required Contact Enteric precautions. Staff followed the posted EBP instructions, which did not require gown and glove use for all room entry or soap and water hand hygiene, as would be necessary for C. Diff. The error in signage led to staff not following the appropriate level of precautions until the signage was corrected.
Resource Mismanagement and Care Deficiencies
Penalty
Summary
The facility administration failed to effectively manage resources and maintain compliance with federal and state regulations, resulting in multiple deficiencies. These included inadequate administrative oversight and monitoring of personnel, systems, and policies related to care planning, resident environment, activities of daily living, range of motion services, respiratory care, nursing staff sufficiency, social services, pharmacy services, food service procedures, infection control, and tuberculosis testing. The administration's failure to ensure a homelike environment, proper maintenance, and timely comprehensive assessments after significant changes in residents' conditions contributed to these deficiencies. Specific incidents highlighted in the report include the failure to provide adequate care for dependent residents, such as bathing and toileting, leading to poor hygiene and unmet care needs. The facility also lacked a restorative program for residents needing range of motion and splint care, as acknowledged by the Director of Rehabilitation. Additionally, there were issues with respiratory care, where staff failed to administer oxygen as per the ordered dosage, and insufficient nursing staff led to delays in medication administration, affecting residents' pain management and overall care. One resident, admitted with chronic pain syndrome, experienced significant pain due to delayed administration of pain medications. Despite being scheduled for morning medication, the resident did not receive their pain relief until much later, resulting in severe discomfort. Interviews with staff revealed that the medication pass often extended beyond the scheduled time, affecting multiple residents. The administration also failed to ensure proper infection control practices and tuberculosis testing, further compromising resident safety and care quality.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to initiate a grievance process for concerns raised by the Resident Council, which included issues with call light wait times during nights and weekends. Despite residents voicing these concerns in meetings, the facility did not log or investigate these grievances, nor did they inform the residents of any findings or actions taken. This lack of action prevented the facility from identifying trends in grievances and addressing them effectively. Interviews revealed that staff directed residents to submit a concern or comment form, but did not assist in completing these forms, relying instead on residents to do so. The Activities Director provided resident council minutes to the administrator and director of nursing but did not ensure grievances were logged. The administrator expressed that grievances from the resident council were challenging to address if residents were not willing to participate in finding solutions, which limited the facility's ability to resolve the issues.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for six residents, leading to potential risks for these individuals. Resident 6, who had a history of amputations and used limb prosthetics, did not have these needs addressed in their care plan. Similarly, Resident 53, who was undergoing smoking cessation treatment, lacked a care plan that included their smoking history and current treatment. Staff interviews revealed that the Resident Care Managers (RCMs) were responsible for ensuring care plans were completed, but they felt overwhelmed due to staffing issues. Resident 5, who had severe cognitive impairment and required assistance for mobility, was observed multiple times without access to their call light, contrary to their care plan instructions. Resident 8, who had a nephrostomy, had a care plan that did not reflect the necessary care for this condition. Staff interviews indicated that the care plan was supposed to guide the care provided, but there was a lack of awareness and information regarding the specific needs of Resident 8's nephrostomy. Resident 49, who experienced pain in their left knee and lower back, did not have these issues documented in their care plan, which only mentioned pain related to hip surgery. Resident 168, who was prescribed antibiotics for presumed pneumonia, did not have this condition or treatment reflected in their care plan. The Director of Nursing Services (DNS) acknowledged that care plans should address all resident needs and that there were missing items in the care plans reviewed by the interdisciplinary team.
Care Plan Deficiencies in Resident Management
Penalty
Summary
The facility failed to ensure that care plans were accurately reviewed and revised to reflect the current status and needs of four residents. Resident 6, who was admitted with a history of stroke, diabetes, and bilateral below-knee amputations, had their skilled therapies discontinued and transitioned to restorative services. However, their care plan was not updated to reflect these changes. Resident 43, who elected hospice care, did not have their care plan updated to include hospice services and coordination with the hospice care team. Resident 53, with a diagnosis of tobacco use disorder and an order for nicotine patches, was found smoking outside the facility, yet their care plan did not reflect their smoking history, risk, or current treatment. Resident 2, admitted with a history of stroke, left hemiparesis, dysphagia, and Type 2 Diabetes Mellitus, was observed using a straw despite their care plan indicating they should not have one. Staff were unaware of this restriction, and no signs were posted in the resident's room to remind staff and visitors of the precaution. Interviews with staff revealed a lack of awareness and communication regarding the resident's care plan, leading to the resident being served drinks with a straw, contrary to their care plan instructions.
Deficiencies in ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, specifically in the areas of bathing and toileting. Resident 24, who was admitted with a fracture of the right femur, chronic heart failure, and kidney disease, was not provided with the necessary assistance for toileting. Despite being aware of their need to have a bowel movement, the resident was unable to be transferred to the bathroom due to the mechanical lift not fitting into the bathroom. The care plan for Resident 24 did not address their continence needs, and staff failed to offer alternative solutions such as a bedside commode. Residents 7, 8, 23, and 28, who were dependent on staff for bathing, did not receive showers or bathing assistance as per their preferences and needs. Resident 7, with moderate cognitive impairment, reported only being bathed every two or three weeks despite preferring weekly baths. Resident 28, who had a stroke and hemiplegia, was supposed to be bathed twice a week but experienced inconsistent bathing schedules due to staffing issues. Resident 8, with a history of stroke and muscle weakness, was observed with greasy, uncombed hair and reported receiving showers only once a week, although they preferred twice weekly showers. The facility's documentation and staff interviews revealed systemic issues in scheduling and providing showers. Staff members indicated that shower aides were responsible for bathing, and if they were unavailable, showers were often missed without proper documentation or follow-up. The Director of Nursing Services and the Administrator were unaware of the missed showers and the lack of adherence to residents' bathing preferences, highlighting a breakdown in communication and care planning within the facility.
Staffing Shortages Lead to Delayed Care and Unmet Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by multiple resident interviews and observations. Residents reported long wait times for assistance with activities of daily living, such as getting out of bed, attending activities, and receiving help with grooming and showers. Some residents expressed concerns about the lack of staff available to respond to call lights, particularly during nights and weekends, leading to delays in receiving necessary care. The report highlights specific instances where residents did not receive timely medication administration, which is critical for managing their health conditions. For example, Resident 16, who suffers from chronic pain syndrome, did not receive their morning pain medications on time, resulting in severe pain. The delay in medication administration was attributed to the heavy workload and insufficient staffing on the unit, as confirmed by staff interviews. Additionally, the facility's staffing issues affected the provision of showers and restorative services. Staff interviews revealed that shower aides were often pulled to cover floor duties due to staffing shortages, leading to missed showers for residents like Resident 28, who preferred twice-weekly showers. The facility's inability to maintain adequate staffing levels compromised the quality of care and residents' quality of life, as documented in the report.
Delayed Medication Administration
Penalty
Summary
The facility failed to ensure the timely administration of scheduled medications for four residents, resulting in significant delays in receiving essential medications. The scheduled AM Medication Pass was supposed to occur between 6:00 AM and 10:00 AM, but residents did not receive their medications until much later. Resident 16, who suffers from chronic pain syndrome, reported severe pain levels of 10/10 on two consecutive mornings due to not receiving their morning pain medications, including Gabapentin, Acetaminophen, and Suboxone, within the scheduled time. Interviews with staff revealed that the delay was due to the medication pass taking longer than expected. Other residents also experienced delays in receiving their medications. Resident 38 received seven morning medications, including pain and antipsychotic medications, over two hours after the scheduled time. Similarly, Resident 7 received their morning medications, including antidiabetic and anticoagulant medications, as late as 12:15 PM. These delays were documented in incident investigations, and the facility acknowledged the need for improvement in the efficiency of medication administration.
Failure to Ensure Sanitary Food Handling
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served under sanitary conditions in its kitchen, as observed by surveyors. Specifically, staff members were not wearing required hair and beard restraints while working in the kitchen, which is a violation of the facility's policy. On multiple occasions, staff members, including the Dietary Manager and Dietary Aides, were observed without hair or beard restraints. The Dietary Manager acknowledged that staff were supposed to wear these restraints upon entering the kitchen but noted that a new staff member was still in training. This lack of compliance with sanitary protocols placed residents at risk of receiving contaminated food.
Infection Control Deficiencies in Hand Hygiene and Precautions
Penalty
Summary
The facility failed to ensure compliance with infection prevention and control guidelines during meal service, peri-care, and transmission-based precautions. Specifically, Staff F, a Nursing Assistant Certified (NAC), did not perform hand hygiene before and after delivering meal trays to residents' rooms. This was observed multiple times as Staff F handled meal trays and residents' personal items without washing hands or using alcohol-based hand rub (ABHR). Staff F acknowledged the responsibility to perform hand hygiene but was unaware of the lapses during the breakfast meal tray pass. Additionally, Staff P, another NAC, was observed providing peri-care to a resident without changing gloves or performing hand hygiene afterward. Staff P used the same gloves to dress the resident and then moved the bedside commode and wheelchair without washing hands or using ABHR. This failure to adhere to hand hygiene protocols was noted despite recent training sessions on proper handwashing techniques. The facility also failed to implement appropriate transmission-based precautions for a resident with Clostridium difficile (c. diff) infection. The contact isolation sign outside the resident's room incorrectly instructed staff and visitors to use ABHR instead of washing hands with soap and water, which is necessary to remove c. diff spores. Staff H followed these incorrect instructions, and the Infection Preventionist and Director of Nursing Services were unaware of the signage error. The facility's policies require handwashing with soap and water for residents with c. diff, but this was not enforced, leading to potential infection risks.
Failure to Maintain Advance Directives Documentation
Penalty
Summary
The facility failed to obtain and maintain Advance Directives (AD) for Resident 24, who was admitted with diagnoses including a fracture of the right femur, chronic heart failure, and kidney disease. The care plan indicated that Resident 24 had a Power of Attorney (POA) for healthcare, with their daughter specified as the POA. However, a review of the electronic medical record revealed no documentation of the POA paperwork. This oversight was confirmed during an interview with Staff W, a Licensed Practical Nurse, who was unable to locate the POA documentation in the resident's chart. Further interviews revealed that Staff X, the Admissions Director, did not obtain the POA documents at the time of admission, despite the presence of Resident 24's daughter. Staff X was unsure of the process to follow up if the POA paperwork was not provided. Staff Z, the Medical Records Director, confirmed that if the POA document was not in the electronic medical record, it was not given to them. Staff AA, an RN-Staff Development Coordinator, also could not locate the document and noted that Resident 24's daughter had signed the Physician's Order for Life Sustaining Treatment (POLST) as the POA. The deficiency was identified as a failure to ensure the resident's healthcare preferences and decisions were documented and honored.
Failure to Maintain Homelike and Clean Environment
Penalty
Summary
The facility failed to ensure a homelike environment for three residents and maintain cleanliness in the facility's conference room. Resident 11, who had severe cognitive impairment, was observed to have a stark room lacking personal belongings or decor, with bare walls and minimal furnishings. Staff acknowledged the lack of homelike elements in the room. Resident 28, who had no cognitive impairment, expressed dissatisfaction with the cleanliness of their room windows, which had not been cleaned in over two years despite multiple requests. The maintenance staff confirmed that windows were cleaned quarterly and attributed wall damage to improper bed placement by nursing staff. Resident 17, who was hearing impaired but able to communicate, reported that their window and TV screen were dusty and streaked, which was confirmed by observation. Additionally, the conference room windows and screens were found to have extensive dirt and debris build-up. These deficiencies indicate a failure to provide a clean and homelike environment, as required by regulations, potentially impacting the residents' quality of life and the facility's overall environment.
Failure to Conduct Significant Change in Status Assessment for Hospice Election
Penalty
Summary
The facility failed to identify a Significant Change in Status for a resident who elected Hospice services, as required by the Resident Assessment Instrument (RAI) guidelines. The resident, who was not initially receiving Hospice services, elected their Hospice benefit on August 10, 2024. According to the RAI manual, a Significant Change in Status Assessment (SCSA) should have been conducted within 14 days of this election, by August 24, 2024. However, a review of the resident's Minimum Data Set (MDS) assessments on September 10, 2024, revealed that no SCSA had been completed. During an interview on September 11, 2024, the Licensed Practical Nurse/Minimum Data Set (MDS) Nurse, identified as Staff O, stated that the only change for the resident was the initiation of Hospice services and that the care plan had not been altered. Staff O was unaware that the election of Hospice services alone constituted a Significant Change requiring a SCSA, as per the RAI manual.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for a resident, identified as Resident 67, who was discharged to an assisted living facility. The discharge summary was missing a recapitulation of the resident's stay and a final summary of the resident's status, which are required components. The resident had been admitted with diagnoses including neutropenia, pulmonary fibrosis, and high blood pressure. The facility's policy on discharge summaries, dated May 6, 2019, requires participation from both social services and nursing staff in developing the summary, which should include a comprehensive overview of the resident's stay and status. Interviews with facility staff revealed gaps in the discharge process. Staff S, the Social Services Director, indicated that they were responsible for certain parts of the discharge summary but not for the recapitulation of the stay or physical assessment on discharge. Staff S also could not recall if any durable medical equipment or home health services were needed for Resident 67. Additionally, Staff A, the Administrator, and Staff B, the Director of Nursing Services, acknowledged that the discharge summary for Resident 67 was incomplete and should have been finalized on the day of discharge. This lack of a complete discharge summary placed residents at risk of post-discharge complications and delayed treatment.
Deficiency in ROM and Mobility Care for Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain or improve the range of motion (ROM) for three residents, leading to a deficiency in care. Resident 17, who had multiple diagnoses including rheumatoid arthritis and a history of shoulder issues, was observed wearing a sling without a corresponding order. Despite an order for occupational therapy to assess ROM, there was no follow-up, and the resident expressed interest in exercises that were not provided. The Director of Rehab acknowledged the oversight, indicating a lapse in the facility's process for monitoring and addressing potential declines in residents' activities of daily living. Resident 5, with severe cognitive impairment and limited mobility, was at risk for skin breakdown due to prolonged periods in a wheelchair without repositioning or a pressure-reducing cushion. Observations showed the resident remained in the same position for extended hours without staff intervention, contrary to the care plan that required repositioning every two hours. The lack of adherence to the care plan and absence of documentation of any refusals to reposition highlighted a significant gap in the facility's care practices. Resident 23, who had contractures and required a brace and splint for their right knee, was not consistently receiving the prescribed restorative nursing services. Documentation showed frequent refusals and incomplete application of the brace and splint, with significant gaps in the records. Staff interviews revealed that the restorative nursing program had been on hold, and there was confusion about who was responsible for overseeing the program. The lack of documentation and communication about the resident's refusals and the absence of the brace and splint during observations further underscored the facility's failure to implement and monitor necessary interventions for maintaining residents' mobility and function.
Failure to Implement Nutritional Interventions and Monitor Weight Loss
Penalty
Summary
The facility failed to develop and implement nutritional interventions and evaluate their effectiveness for a resident with nutritional needs. The resident, who was admitted with diagnoses including malnutrition, bipolar disorder, and cognitive communication deficit, experienced significant weight loss over several months. Despite the resident's care plan identifying a potential nutritional problem and risk for weight loss, the facility did not consistently obtain weights, notify appropriate parties, or implement the Registered Dietician's recommendations. The resident's medical records showed a decline in weight from 152.8 pounds to 135.6 pounds over a period of several months. The facility's policy required weekly reviews of residents at risk for nutritional issues, but there was no consistent method for weighing the resident or monitoring their weight loss. The resident frequently refused to be weighed, and there was no documentation of notification to the physician or power of attorney about these refusals or the weight loss. Interviews with staff revealed a lack of awareness and communication regarding the resident's weight loss and refusal to be weighed. Staff members indicated that they were not informed of the resident's weight loss and that the care plan was not updated to reflect the resident's refusal to be weighed. The facility's process for obtaining weights was not followed, and the care plan did not include updated interventions to address the resident's nutritional needs.
Deficiency in Enteral Tube Feeding Management
Penalty
Summary
The facility failed to ensure proper management of enteral tube feeding supplies for a resident with a PEG tube, leading to a risk of infection and complications. Resident 8, who was admitted with a history of stroke, dysphagia, and malnutrition, relied on a PEG tube for nutrition. Observations revealed that the tube feeding supplies, including bags and syringes, were not labeled or dated as required. The feeding bag was observed to be used beyond the recommended 24-hour period, and the water bag was unlabeled. These observations were made over several days, indicating a lack of adherence to proper protocols for tube feeding management. Interviews with facility staff, including a Registered Nurse, a Licensed Practical Nurse, and the Director of Nursing Services, confirmed that there were no physician orders or care plan directives for the replacement and labeling of tube feeding supplies. Staff members acknowledged that supplies should be replaced every 24 hours and properly labeled, but this was not being done. The care plan for Resident 8 was not updated to include the PEG tube until nearly a year after admission, and staff were unaware of the lack of orders for tube feeding supplies. This oversight in care planning and execution contributed to the deficiency identified by the surveyors.
Failure to Provide Ordered Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in care. Resident 24, who was admitted with diagnoses including a fracture of the right femur, chronic heart failure, and COPD, had physician orders for oxygen therapy and CPAP use. However, observations revealed that the resident was not using the prescribed nasal cannula or CPAP mask, and the oxygen concentrator was set to zero liters and not running. Staff interviews confirmed that the resident was not receiving the ordered respiratory support, which was inconsistent with the facility's policy and physician orders. Resident 17, admitted with COPD, Reynaud's Syndrome, gangrene in the fingers, and atrial fibrillation, was observed using an oxygen concentrator without a physician's order documented in their electronic chart. The resident stated they used oxygen at night for sleep apnea, but staff were unable to provide documentation of an order for oxygen use. This lack of documentation and adherence to physician orders for oxygen therapy represents a failure to meet professional standards of practice for respiratory care.
Failure to Administer Timely Pain Management
Penalty
Summary
The facility failed to provide necessary pain management for Resident 16, who was admitted with chronic pain syndrome and was dependent on opiate medication for pain relief. The resident's Minimum Data Set assessment indicated frequent pain affecting their sleep, and they reported a pain level of 8 out of 10. On multiple occasions, the resident expressed experiencing severe pain, with a pain level of 10 out of 10, and had not received their scheduled morning pain medications, which included Gabapentin, Acetaminophen, and Suboxone. Observations and interviews revealed that the facility's medication administration schedule was not adhered to, as the resident did not receive their morning medications within the scheduled time frame of 6:00 AM to 10:00 AM. Staff interviews confirmed delays in medication administration, with staff members acknowledging that the medication pass was taking longer than expected. This failure to administer pain medications as scheduled resulted in the resident experiencing avoidable pain and a diminished quality of life.
Failure to Conduct Care Planning Meetings for Resident
Penalty
Summary
The facility failed to provide medically-related social services to help Resident 13 achieve the highest possible quality of life. Resident 13, who has Parkinson's disease and moderate cognitive impairment, expressed dissatisfaction with their bathing schedule, stating they were only able to bathe once a week instead of their preferred twice a week. Additionally, an observation revealed that Resident 13 was sitting uncomfortably in their wheelchair, with no right legrest or footrest, causing their right leg to be suspended in the air. The facility did not conduct care planning meetings for Resident 13, as required, to address their care preferences and needs. Staff S, the Social Services Director, and Staff V, the Social Services Assistant, admitted to not holding quarterly care conferences for the resident, citing the power of attorney's declination. However, they were unable to provide any information on how the resident's care was assessed without these meetings. A review of the resident's progress notes over the past year showed no documentation of any care conferences, and Resident 13 confirmed that the facility never offered a care conference to discuss their care, bathing preferences, or wheelchair comfort.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) effectively for a resident, increasing the risk of developing multidrug-resistant organisms. The facility had a document titled 'Statement of Leadership Commitment for Antibiotic Stewardship in a Skilled Nursing Facility,' which was signed by key personnel, including the Medical Director and Director of Nursing Services. This document outlined the facility's commitment to the CDC's core elements of antibiotic stewardship, including leadership, accountability, and drug expertise. However, the facility did not adhere to these elements in the case of a resident who was admitted with a history of kidney stones, surgery to the urinary system, and an antibiotic-resistant bacteria infection. The resident's physician orders included an antibiotic with a note indicating a need for a stop date, but the medication was administered continuously without documented communication with the infectious disease provider regarding the stop date. Interviews with facility staff revealed a lack of awareness and follow-up regarding the resident's antibiotic use. The Director of Nursing Services was initially unaware of the status of the resident's antibiotic treatment and had to contact the infectious disease provider to obtain documentation, which was not part of the medical record until requested. The Infection Preventionist, who was responsible for overseeing the ASP, was also unaware of the lack of documentation and follow-up in the medical record. This oversight indicates a failure in the facility's ASP, as there was no proper tracking or communication regarding the antibiotic's usage and stop date, leading to potential adverse outcomes for the resident.
Failure to Monitor and Address Recurrent UTIs in Resident
Penalty
Summary
The facility failed to provide resident-focused care by not consistently monitoring, assessing, and evaluating the condition of a resident with a history of recurrent urinary tract infections (UTIs). The resident, who was readmitted to the facility with diagnoses including recurrent UTI, type two diabetes mellitus, and Parkinson's disease, did not have a care plan addressing their history of chronic UTIs or their candidacy for timed/scheduled voiding. Despite being incontinent of urine and having a history of chronic UTIs, the care plan only noted the resident's risk for skin breakdown and required assistance for peri care and brief changes. Throughout the period from 08/16/2024 to 08/19/2024, the resident exhibited symptoms indicative of a UTI, such as dark amber urine with odor, confusion, and discomfort with urination. However, there was a lack of documentation of vital signs and no notification to the resident's representative or provider about these findings. The resident's condition escalated to a UTI with sepsis, as confirmed by an emergency department encounter, where they presented with fever, tachycardia, and confusion. Interviews with facility staff revealed gaps in the care planning and monitoring processes. Staff acknowledged that the resident's recurrent UTIs were not included in their care plan or diagnosis list, and vital signs were not consistently checked during the alert status. The facility's protocol for placing a resident on alert did not necessitate provider notification, and there was a lack of communication regarding the resident's change in condition. These oversights contributed to the resident's decline and subsequent hospitalization for UTI with sepsis.
Failure to Provide Timely Pharmaceutical Services for New Admissions
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of three residents upon their admission. Resident 1, who was admitted with conditions including Bipolar Disorder and Seizure Disorder, did not receive prescribed medications such as Quetiapine, Benzatropine, and Lamotrigine on the day of admission. The Licensed Practical Nurse (LPN) documented the absence of these medications as 'new admit' without verifying their availability in the Omnicell or notifying the resident's provider. The Director of Nursing Services (DNS) confirmed that no medications were dispensed from the Omnicell for Resident 1 on the day of admission. Resident 2, admitted with conditions including a recent fall and cardiac issues, also did not receive several prescribed medications, including Memantine, Rosuvastatin, Symbicort, and Voltaren, due to pending delivery. Despite Memantine being available in the Omnicell, it was not administered. The resident expressed a need for pain ointment, which was not available until days after admission. There was no documentation indicating that the provider was notified about the unavailability of these medications. Resident 3, admitted with encephalopathy and psoriasis, did not receive Lactulose and Betamethasone as they were on order and not available in the Omnicell. Similar to the other cases, there was no documentation of provider notification regarding the unavailability of these medications. The DNS acknowledged the need to review the pharmacy delivery and admission process after receiving an updated list of medications available in the Omnicell.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure that three residents received proper nail care, leading to discomfort and potential injury. Resident 1, who had contractures, reported that their fingernails were so long they were digging into their palms, causing significant pain. Despite repeated requests, it took several days before the Activity Director filed the nails. Staff A confirmed that Resident 1's nails were long and causing discomfort, with reddened skin and callouses forming in their palms. Resident 2, who was dependent on staff for most activities of daily living, was observed to have long, jagged fingernails with dirty cuticles and debris under the nails. Resident 2 expressed a preference for having their nails cut, not just filed, but stated that staff did not comply with this request. Resident 3, who required maximum assistance for hygiene, also reported that staff had not been maintaining their fingernails properly. Their nails were long, with old polish and dirty cuticles, and the resident expressed a preference for having their nails cut rather than filed. Interviews with staff revealed inconsistencies in the understanding and execution of nail care responsibilities. Staff C, a Registered Nurse, stated that Nursing Assistants (NAs) were responsible for trimming nails unless the residents were diabetic or on blood thinners, in which case nurses were responsible. Staff B, a Licensed Practical Nurse, confirmed this protocol and added that nail care was usually documented in the resident's treatment administration record. However, Staff D, an NA, was unaware that NAs were responsible for trimming residents' fingernails. This lack of clarity and adherence to the facility's nail care policy resulted in inadequate care for the residents, leading to discomfort and potential injury.
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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