Life Care Center Of South Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Puyallup, Washington.
- Location
- 2508 7th St Southeast, Puyallup, Washington 98374
- CMS Provider Number
- 505526
- Inspections on file
- 24
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at Life Care Center Of South Hill during CMS and state inspections, most recent first.
A resident with a chronic Foley catheter and on anticoagulant therapy experienced significant bleeding and infection following a catheter change that was not performed or documented according to professional standards. The resident developed hematuria, a urethral tear, and acute blood loss anemia, ultimately requiring hospital transfer and transfusion. Staff and documentation did not consistently meet required protocols for catheter care and monitoring.
A resident with atrial fibrillation was not administered an ordered anticoagulant medication due to a transcription error in their EHR. This oversight led to the resident experiencing stroke-like symptoms and requiring an emergency hospital transfer. The facility's staff acknowledged the error as significant.
The facility failed to include necessary services in the care plans for three residents, leading to a risk of unmet needs. A resident with ankylosing spondylitis and pneumonia had a fluid restriction order not reflected in their care plan. Another resident with anemia, diabetes, hyperkalemia, and chronic kidney disease was on a fluid restriction, but this was not documented in their care plan. Additionally, a resident with arthritis, paroxysmal atrial fibrillation, and COPD had a deep tissue injury and a wound, but their care plan only addressed the risk for skin integrity issues, not the actual impairments.
The facility failed to monitor and document bowel movements and implement the bowel program for three residents, leading to a deficiency in care. Despite having provider orders for constipation treatment, residents experienced lapses in receiving necessary medication. Interviews with staff confirmed that LNs should have administered the medication when more than 72 hours had passed without a bowel movement.
The facility failed to monitor fluid intake and transcribe dietary orders for two residents, leading to potential health risks. One resident with CHF had untracked dietary fluids and no system to total intake, while another resident with anemia and diabetes had conflicting fluid restriction orders and inadequate documentation. Staff interviews revealed deficiencies in monitoring and documentation practices.
The facility failed to implement non-pharmacological interventions (NPI) before administering pain medications to five residents, leading to the risk of unnecessary medication use. Residents with conditions such as fractures, amputations, and osteomyelitis received pain medications like oxycodone and acetaminophen without documented NPI attempts, as required by their care plans. Staff interviews confirmed that NPI should have been documented and attempted prior to administering narcotic pain medications.
The facility failed to timely monitor adverse side effects and target behaviors for three residents prescribed psychotropic medications for depression. Monitoring for one resident was delayed by over a month, while another resident's monitoring was delayed by several days. Additionally, incomplete documentation and delayed monitoring for side effects were noted for a third resident. Staff interviews revealed a lack of awareness and oversight regarding timely implementation of behavior monitoring protocols.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with chronic wounds and indwelling devices, as well as to track infectious organisms in their logs for two months. A resident with a chronic wound and another with a urinary catheter did not have EBP signs or PPE supplies, and infections like disseminated shingles and a UTI were not logged.
A facility failed to implement an effective Antibiotic Stewardship Program, leading to inappropriate antibiotic use for a resident with a UTI. The resident was prescribed cefdinir, but culture results showed resistance, necessitating a change to ciprofloxacin. The Infection Preventionist did not review lab results, relying on the provider's judgment, contrary to facility policy. The DON expected the Infection Preventionist to review infections and lab results, highlighting a gap in the facility's antibiotic stewardship efforts.
A facility failed to provide timely information on formulating an advanced directive for a resident. The resident was admitted, and the social services department contacted the resident's representative 20 days later. The Social Service Assessment had the advanced directive section blank, and the care plan lacked this information. The Social Service Director admitted that the information was provided 13 days after admission, not meeting expectations. The Administrator confirmed that residents should be asked about their advanced directive status within 48 hours of admission.
A resident with COPD and chronic respiratory failure was inaccurately assessed in the MDS as not receiving oxygen therapy, despite continuous use of oxygen at two liters per minute via nasal cannula since admission. Observations, interviews, and EHR documentation confirmed the resident's oxygen use, and staff acknowledged the coding error, which required modification.
A resident's care plan development was delayed as the initial care conference was held 20 days after admission, contrary to the facility's expectation of conducting it within 72 hours. Interviews with the Social Service Director and Administrator confirmed the delay.
A facility failed to administer enteral nutrition according to orders for a resident with dysphagia, leading to a lack of documentation and potential inadequate nutrition. The resident's weight declined, and staff did not document the total tube feed in the EHR. The RD's recommendation to adjust the feeding schedule was not implemented timely.
A facility failed to provide proper respiratory care for a resident with COPD and chronic respiratory failure. The resident was receiving oxygen therapy without documented physician orders or a care plan, and the oxygen tubing was not dated. Staff interviews confirmed the lack of proper documentation and maintenance, which did not meet facility expectations.
The facility did not update nursing staff postings daily to reflect actual hours worked, as observed during a survey. Staff interviews revealed that postings were not updated each shift, contrary to expectations, leading to incomplete information about available nursing staff.
The facility failed to notify the SLTCO of transfers for two residents, one with shingles and another with anemia and diabetes, compromising their access to advocacy and rights information. The administrator confirmed the lack of documentation for these notifications.
The facility failed to provide written bed hold notices to residents during hospital transfers, affecting four residents. Despite expectations to offer and document bed holds, staff interviews and EHR reviews confirmed the absence of such documentation. This deficiency involved residents transferred for various medical reasons, including shingles and an infected surgical implant.
Two residents experienced significant delays in receiving pain medication, with one waiting up to three hours and another reporting multiple instances of delays. Despite these documented concerns, the facility failed to report the alleged violations to the State Agency as required by their policy.
The facility failed to investigate alleged violations of delayed pain medication administration for two residents. One resident experienced a four-hour delay, while another reported a three-hour delay and poor customer service from a staff member. The facility did not document or investigate these incidents, as confirmed by the DON.
A resident did not receive their ordered bedtime medications due to issues with order entry timing, and there was no documentation of medication removal or issues in progress notes. Later, the resident's discharge was delayed, and they requested to hold routine medications after taking a reversal medication. The nurse did not administer the medications at the requested time, and there was no documentation of physician notification or consultation. Staff acknowledged the need for proper documentation and communication with the physician.
A facility failed to implement a personalized discharge plan for a resident with a pelvic fracture, who was discharged without home health services or a primary care provider (PCP) follow-up. Despite plans for community service referrals, including home health therapy and PCP appointments, the resident was discharged without these services. Interviews revealed that the home health agency had no record of receiving a referral, and the Social Services Director admitted the resident fell through the cracks due to staffing issues.
Failure to Follow Professional Standards During Indwelling Catheter Care Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that a resident with a chronic indwelling urinary catheter received care and treatment in accordance with professional standards of practice. The facility's policy required staff to document specific details after catheter insertion, including the date and time, catheter size and type, amount of sterile water used, urine characteristics, any complications, practitioner notifications, prescribed interventions, and patient teaching. However, documentation and care practices did not consistently meet these standards during the resident's stay. The resident, who had a history of bladder cancer, chronic catheter use, and was on anticoagulant therapy, experienced multiple episodes of hematuria and bleeding associated with catheter changes. After a catheter change, the resident developed significant bleeding from the penis, which continued despite removal and reinsertion of the catheter. The provider noted that the bleeding was most likely due to trauma from incorrect catheter insertion. The resident subsequently developed symptoms of infection, including fever, flank pain, and low oxygen saturation, and was diagnosed with a urinary tract infection and likely pyelonephritis. Despite ongoing monitoring and interventions, the resident's condition worsened, with continued bleeding, pain, and the development of acute blood loss anemia. The resident was eventually transferred to the hospital, where a urethral tear and laceration were confirmed, and a blood transfusion was required. Staff interviews confirmed awareness of the bleeding and complications following the catheter change, and documentation did not consistently reflect adherence to professional standards for catheter care and monitoring.
Failure to Administer Anticoagulant Medication
Penalty
Summary
The facility failed to provide an ordered anticoagulant medication to a resident, identified as Resident 27, which was significant to their health. Resident 27 was admitted with diagnoses including atrial fibrillation, a condition that increases the risk of blood clots, and was supposed to continue taking an anticoagulant medication as per hospital discharge orders. However, from the time of admission until the resident's transfer to the hospital, the facility did not transcribe the anticoagulant medication into the resident's electronic health record (EHR), resulting in the resident not receiving the medication. As a result of not receiving the anticoagulant, Resident 27 experienced stroke-like symptoms, including face drooping, left-sided weakness, and left eye dilation, which necessitated an emergent transfer to the hospital. The hospital's emergency department contacted the facility multiple times to inquire about the anticoagulant medication, revealing that the resident had not been administered the medication as ordered. This oversight was identified as a significant medication error by the facility's staff, including the Administrator and the Director of Nursing Services.
Removal Plan
- Audits of all newly admitted residents for hospital order transcription
- In-servicing of staff on transcribing hospital orders
- Ongoing audits of all newly admitted residents for hospital order transcription
- Referral to the Quality Assurance and Performance Improvement program for ongoing monitoring
Deficiencies in Resident Care Plans
Penalty
Summary
The facility failed to include necessary services in the care plans for three residents, leading to a risk of unmet needs and diminished quality of life. Resident 40, admitted with ankylosing spondylitis and pneumonia, had a provider's order for a fluid restriction, but this was not reflected in their care plan. Both a Licensed Practical Nurse and the Director of Nursing Services confirmed the absence of this critical information in the care plan, acknowledging it did not meet expectations. Similarly, Resident 42, who was readmitted with conditions including anemia, diabetes, hyperkalemia, and chronic kidney disease, was on a fluid restriction as per provider orders. However, their care plan lacked documentation of this restriction. A Registered Nurse confirmed that the fluid restriction should have been included in the care plan. Additionally, Resident 226, with arthritis, paroxysmal atrial fibrillation, and COPD, had a deep tissue injury and a wound on the buttock, but their care plan only addressed the risk for skin integrity issues, not the actual impairments. A Registered Nurse/Unit Care Coordinator noted the absence of a care plan for the existing skin integrity issues.
Failure to Implement Bowel Program and Document Bowel Movements
Penalty
Summary
The facility failed to consistently monitor and document bowel movements and implement the bowel program as needed for three residents, leading to a deficiency in care. Resident 177, who had a history of heart and kidney disease, diabetes, depression, and anxiety, reported issues with constipation since admission. Despite having provider orders for constipation treatment, there was a nine-day period where no medication was administered. Similarly, Resident 176, with heart disease and depression, had multiple days where no constipation treatment was provided, despite orders and a care plan that included monitoring for constipation as a side effect of antidepressant medication. Resident 40, who had kidney disease, stroke with hemiplegia, and depression, also experienced a lapse in constipation treatment. The resident reported constipation for several days without receiving medication, despite having provider orders for treatment. The facility's policy required documentation of bowel movements and implementation of standing orders for constipation, which was not followed. Interviews with staff confirmed that the licensed nurses should have administered the necessary medication when more than 72 hours had passed without a bowel movement.
Failure to Monitor Fluid Intake and Transcribe Orders
Penalty
Summary
The facility failed to accurately monitor fluid intake and ensure dietary and supplement orders were properly obtained and transcribed for two residents, leading to potential health risks. Resident 40, who was admitted with chronic heart failure, ankylosing spondylitis, and pneumonia, had a fluid restriction order of 2000 ml due to CHF. However, the facility did not track dietary-provided liquids, and there was no system in place to total the resident's fluid intake. Interviews with staff revealed that the monitoring of Resident 40's fluid restriction did not meet expectations, as nursing staff were not totaling or monitoring the total fluid intake, and dietary fluids were not being tracked. Resident 42, who was readmitted with anemia, diabetes, hyperkalemia, and chronic kidney disease, was also on a fluid restriction. The resident's dietary order conflicted with the provider's order, and there was no care plan or interventions documented for fluid restrictions. Staff interviews indicated that fluid intake was not properly documented or monitored, and there was confusion regarding the prescribed fluid restriction amounts. The lack of documentation and monitoring did not meet expectations, and the care plan failed to include necessary fluid restriction orders.
Failure to Implement Non-Pharmacological Interventions Before Pain Medication
Penalty
Summary
The facility failed to implement non-pharmacological interventions (NPI) before administering pain medications to five residents, leading to the risk of unnecessary medication use. Resident 6, with a diagnosis of a left forearm fracture, had orders for oxycodone with a requirement to attempt NPI first, yet the medication administration record (MAR) showed multiple instances marked as NA for NPI. Similarly, Resident 24, who had a left lower leg amputation, received oxycodone without documented NPI attempts, as indicated by numerous NA entries in the MAR. Staff interviews confirmed that NPI should have been documented and attempted prior to administering narcotic pain medications. Resident 32, diagnosed with respiratory failure, was given acetaminophen without NPI on a specific date, contrary to the provider's orders. Resident 41, with osteomyelitis, had 18 instances of oxycodone administration without NPI documentation. Lastly, Resident 226, suffering from arthritis and spinal stenosis, received both acetaminophen and hydrocodone-acetaminophen without NPI documentation on multiple occasions. Staff interviews revealed that the expectation was for NPI to be offered and documented before administering as-needed pain medications, which was not met, as evidenced by the MAR entries.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to timely initiate monitoring of adverse side effects and target behaviors for three residents who were prescribed psychotropic medications for depression. Resident 24 was admitted with a diagnosis of depression and was prescribed nortriptyline. However, the monitoring for targeted behaviors related to the antidepressant was not initiated until over a month later. Similarly, Resident 276 was prescribed multiple antidepressants, including amitriptyline, trazadone, and sertraline, but the monitoring for targeted behaviors was delayed by several days. Staff interviews revealed a lack of awareness and oversight regarding the timely implementation of behavior monitoring protocols. Resident 226 was also affected by the facility's failure to monitor side effects and target behaviors promptly. This resident was prescribed duloxetine for depression, but the monitoring for side effects was not initiated until eight days after the medication was administered. Additionally, there was incomplete documentation for monitoring target behaviors, with missing entries for the evening shift and a lack of documentation on whether behaviors were exhibited or interventions were offered. Staff acknowledged the errors in documentation and the delay in initiating monitoring, which did not meet the facility's expectations.
Failure to Implement Infection Control Program and Track Infections
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically in the application of Enhanced Barrier Precautions (EBP) for two residents. Resident 5, who had a chronic wound on their left ankle, did not have an EBP sign on their door, and staff were not using gowns and gloves for high-contact care activities. Similarly, Resident 226, who had an indwelling urinary catheter, also lacked an EBP sign and appropriate personal protective equipment (PPE) supplies at their doorway. Interviews with staff, including the Infection Preventionist and the Administrator, confirmed that these residents should have had EBP in place, but it was not implemented. Additionally, the facility failed to track infectious organisms effectively in their infection control logs for August and September 2024. The logs did not include any identified organisms or multidrug-resistant organisms (MDROs) for tracking. Notably, Resident 177, who had disseminated shingles, and Resident 278, who was treated for a urinary tract infection, were not included in the infection control logs. Staff interviews revealed that it was the practice to track all infections and update the logs, but this was not done for the mentioned months.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program, which is designed to promote appropriate use of antibiotics and reduce the risk of unnecessary antibiotic use. This deficiency was identified during a review of the facility's practices concerning a resident who was admitted with sepsis, obstructive uropathy, and a urinary tract infection (UTI). The facility's policy required an antibiotic time-out at 72 hours after initiation to reassess the need for antibiotics based on lab results and the resident's condition. However, the facility did not adhere to this policy, as evidenced by the case of Resident 26, who was prescribed cefdinir for a UTI. A culture result, which was not reviewed by the facility, indicated the presence of pseudomonas, a multidrug-resistant organism resistant to cefdinir, necessitating a change to ciprofloxacin. The deficiency was further highlighted by the interviews conducted with facility staff. The Infection Preventionist, Staff M, admitted to not reviewing lab or culture results for all UTIs, relying instead on the provider's judgment. This oversight led to the inappropriate continuation of cefdinir, despite the culture results indicating resistance. The Director of Nursing Services, Staff B, expressed that it was their expectation for the Infection Preventionist to review infections and associated laboratory culture results as part of the antibiotic stewardship efforts. This lack of adherence to the facility's policy and failure to review critical lab results placed residents at risk for adverse outcomes associated with inappropriate antibiotic use.
Failure to Timely Address Advanced Directive for a Resident
Penalty
Summary
The facility failed to provide information on formulating an advanced directive for one of the sampled residents, identified as Resident 36. Upon review, it was found that Resident 36 was admitted to the facility, and the social services department contacted the resident's representative to schedule a care conference 20 days after admission. The Social Service Assessment conducted shortly after admission had the advanced directive section left blank, and the care plan also lacked information regarding the resident's advanced directive status. During interviews, the Social Service Director acknowledged that information regarding advanced directives was provided 13 days after admission, which did not meet the facility's expectations. The Administrator confirmed that residents should be asked about their advanced directive status within 48 hours of admission, and the delay in addressing this for Resident 36 did not meet expectations.
Inaccurate MDS Assessment for Oxygen Therapy
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for Resident 226, which did not accurately reflect the resident's status regarding oxygen therapy. Resident 226 was admitted with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. Despite the resident receiving continuous oxygen therapy at two liters per minute via nasal cannula since admission, the admission MDS inaccurately indicated that the resident was not receiving oxygen therapy. Observations and interviews confirmed that Resident 226 was receiving oxygen therapy, and the electronic health record (EHR) documented the use of oxygen on multiple dates. Staff H, an LPN/MDS Nurse, and Staff B, the Director of Nursing Services, acknowledged the error in coding the MDS and stated that it needed modification. This inaccuracy in the MDS placed the resident at risk for unmet care needs and a diminished quality of life.
Failure to Conduct Timely Care Conference
Penalty
Summary
The facility failed to include a resident's input and preferences in the development of their care plan, which was identified during a review of care conferences. Specifically, the facility did not conduct an initial care conference for the resident within the expected timeframe. The resident was admitted to the facility, and the social services department contacted the resident's representative to schedule a care conference, which was held 20 days after admission. This delay did not meet the facility's expectation of holding an initial care conference within 72 hours of admission. Interviews with the Social Service Director and the Administrator confirmed that the care conference for the resident did not meet the expected timeline.
Failure to Administer Enteral Nutrition as Ordered
Penalty
Summary
The facility failed to administer enteral nutrition according to the provider's orders and professional standards for a resident with dysphagia, who required a feeding tube for nutrition. The resident, who had a history of stroke, kidney disease, aphasia, and muscle weakness, was dependent on staff for all activities of daily living. The care plan indicated that the resident was at risk for weight fluctuations and malnutrition, and the registered dietitian was to evaluate and recommend changes to the tube feed as needed. However, the facility did not have a system to ensure the amount of enteral formula received matched the ordered amount, and the licensed nurses did not document the total amount of tube feed administered every shift in the resident's electronic health record. Observations and interviews revealed that the tube feed was temporarily turned off during wound care, and staff were unclear about where to document the total tube feed in the medication administration record. The resident's weight had declined over several weeks, indicating potential inadequate nutrition. The registered dietitian had recommended a change in the tube feed order to prevent continuous feeding for 24 hours, but this change was not implemented within the expected timeframe. The Director of Nursing Services expected the dietitian's recommendations to be followed within 72 hours and for the licensed nurses to document the total tube feed every shift.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident diagnosed with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. The resident was admitted to the facility with hospital discharge orders indicating the need for oxygen therapy at two liters per minute via nasal cannula. However, the facility did not transcribe or obtain physician orders for this oxygen therapy, nor did they include it in the resident's care plan. Observations showed that the resident was receiving oxygen therapy, but the tubing was not dated, indicating a lack of maintenance and regular change. Interviews with facility staff revealed that there were no orders for the resident's oxygen therapy, and it had not been care planned as required. The Director of Nursing Services acknowledged that the orders for oxygen therapy should have been initiated and care planned upon the resident's admission. This oversight placed the resident at risk for unmet needs and potential negative outcomes due to the lack of proper documentation and maintenance of the oxygen therapy equipment.
Failure to Update Nursing Staff Postings
Penalty
Summary
The facility failed to ensure that the nursing staff posting was updated daily to reflect the actual nursing staff hours worked during the survey period. Observations on multiple occasions revealed that the nursing staff postings did not include the actual hours worked, with the forms left blank. On one occasion, the posting was dated with the previous day's date and did not show the actual nursing staff hours. This lack of accurate and timely information prevented residents, family members, and visitors from knowing the facility's actual number of available nursing staff. Interviews with staff members revealed inconsistencies in the process of updating the nursing staff postings. The Staffing Coordinator admitted to not updating the forms to reflect actual hours worked until the next morning if there were no call-offs, rather than updating them each shift. The Administrator confirmed that the expectation was for the postings to be updated at the beginning of every shift to include actual worked hours. However, this expectation was not met, as evidenced by the incomplete postings for several days during the survey period.
Failure to Notify SLTCO of Resident Transfers
Penalty
Summary
The facility failed to properly notify the Office of State Long-Term Care Ombudsman (SLTCO) of discharges for two residents, which is a requirement to ensure residents have access to advocacy and are informed of their rights. Resident 177 was transferred to a local medical center for treatment of shingles, a condition associated with a compromised immune system, but the SLTCO was not notified of this transfer. The resident's electronic health records confirmed the transfer date, and during an interview, the facility's administrator acknowledged the lack of documentation regarding the notification to the SLTCO. Similarly, Resident 42 was transferred to a hospital for treatment of anemia and diabetes but was readmitted to the facility without the SLTCO being informed of the initial transfer. The discharge and entry tracking records confirmed the transfer and readmission dates. The facility's administrator also confirmed the absence of documentation for notifying the SLTCO about Resident 42's transfer. These oversights in communication with the SLTCO were identified during interviews and record reviews, highlighting a deficiency in the facility's discharge notification process.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their representatives at the time of transfer to a hospital, as required by regulations. This deficiency was identified for four residents who were transferred to hospitals for various medical reasons, including treatment for shingles, an infected surgical implant, and other health issues. The absence of bed hold notices was confirmed through interviews with the residents and staff, as well as a review of the residents' electronic health records (EHRs), which showed no documentation of bed hold offers or discussions. Resident 177, who was transferred for shingles treatment, reported not receiving a bed hold notice, and staff interviews confirmed the lack of documentation in the EHR. Similarly, Resident 27 was transferred to a hospital without a bed hold notice, as confirmed by the Medical Records Director. Resident 42 and Resident 47 also did not receive bed hold notices during their hospital transfers, with staff unable to locate any documentation in their EHRs. The facility's staff, including the Business Office Manager, LPN/Unit Care Coordinator, and Director of Nursing Services, acknowledged the expectation to offer and document bed holds, but this was not met in these cases.
Failure to Report Delayed Pain Medication Administration
Penalty
Summary
The facility failed to implement its abuse prohibition policy for two residents, leading to a deficiency in reporting alleged violations to the State Agency (SA). Resident 10, who had multiple fractures and an anxiety disorder, experienced a significant delay in receiving pain medication. Despite requesting pain relief at 1:30 AM, the medication was not administered until 4:29 AM, three hours later. This delay was documented by Resident 10's collateral contact, but the facility did not report this alleged violation of delayed care to the SA as required by their policy. Similarly, Resident 11 reported a pattern of poor customer service and delays in pain medication administration by the same staff member, Staff L. Resident 11 experienced wait times of up to three to four hours for pain medication on multiple occasions. Despite these concerns being documented, the facility again failed to report the alleged violation to the SA. The Director of Nursing acknowledged that the facility should have reported these concerns but did not, resulting in a failure to comply with state regulations.
Failure to Investigate Alleged Violations of Delayed Pain Medication
Penalty
Summary
The facility failed to implement its abuse prohibition policies and procedures for two residents who were reviewed for abuse. Specifically, the facility did not conduct a thorough investigation or maintain documentation of alleged violations involving delayed administration of pain medication. Resident 10 experienced a four-hour delay in receiving pain medication after requesting it from a registered nurse, which was documented by a collateral contact. The facility's reporting log did not show that this alleged violation was reported or investigated. Similarly, Resident 11 reported concerns about a staff member's poor customer service and a three-hour delay in receiving pain medication. Again, the facility's reporting log lacked documentation to indicate that this alleged violation was recognized or investigated. Interviews with the Director of Nursing confirmed that the facility did not conduct or document thorough investigations of these alleged violations, as required by their policies and state guidelines.
Medication Administration Deficiency for a Resident
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for Resident 3, particularly in the area of medication administration. On the day of admission, Resident 3 did not receive their ordered bedtime medications, including those for chronic pain, due to issues with the timing of order entry into the computer system. The Medication Administration Record (MAR) indicated that some medications were documented as administered, but there was no evidence of them being removed from the Omnicell or any documentation of issues in the progress notes. The Director of Nursing confirmed that the medications should have been removed for Resident 3 but were not. On another occasion, Resident 3's discharge was delayed due to an abnormal lab result, and a reversal medication was ordered. Resident 3 decided to follow online recommendations to hold routine medications for six hours after taking the reversal medication. However, the nurse did not administer the routine medications at the requested time, and there was no documentation of the physician being notified of Resident 3's request or refusal to take medications at the scheduled time. The MAR did not reflect any orders to hold the routine medications, and the nurse progress notes lacked documentation of the physician's consultation regarding the medication timing. The facility's staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing, acknowledged that the physician should have been notified of Resident 3's medication timing requests and that it was inappropriate to document the medication as refused if the resident was willing to take it at a different time. The lack of proper documentation and communication with the physician contributed to the deficiency in medication administration for Resident 3.
Failure to Implement Personalized Discharge Plan
Penalty
Summary
The facility failed to implement a personalized discharge plan for Resident 2, who was reviewed for discharge planning. Resident 2, who had no cognitive problems and was diagnosed with a fracture of the pelvis, planned to discharge back to the community and move in with a family member. The discharge care plan included interventions for social services to make community service referrals, including home health services, primary care provider (PCP) follow-up appointments, and ordering durable medical equipment needed for discharge. However, a psychosocial progress note indicated that Resident 2 did not have a PCP, and a referral was sent to a named home health agency (HHA-1) for home health therapy and a GAP provider to assist with obtaining a PCP. Despite these plans, a state agency referral showed that Resident 2 was discharged home without home health services. Interviews revealed that HHA-1 had no record of receiving a referral for Resident 2, and the Social Services Director acknowledged that Resident 2 fell through the cracks due to being short-staffed at the time. The Director of Nursing confirmed that the referral for home health and PCP services was not received by HHA-1, indicating that Resident 2 likely did not have timely PCP follow-up care or home health therapy services, which did not meet the facility's expectations.
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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