Linden Grove Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Puyallup, Washington.
- Location
- 400 - 29th Street Northeast, Puyallup, Washington 98373
- CMS Provider Number
- 505485
- Inspections on file
- 43
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 45 (1 serious)
Citation history
Health deficiencies cited at Linden Grove Health Care Center during CMS and state inspections, most recent first.
A resident with a Foley catheter did not receive necessary care or monitoring, as there were no documented orders, care plans, or staff tasks addressing catheter care or securement. The resident developed severe pain and a mucosal membrane pressure injury at the catheter site, requiring hospital transfer and intervention. Facility staff confirmed that expected protocols for catheter care were not implemented.
A resident with cognitive impairment and a history of stroke and dementia, who required staff assistance for daily living, was able to leave the facility unsupervised due to failures in risk assessment, monitoring, and staff communication. The resident was later found by bystanders on a freeway ramp after a fall and was transported to the hospital, with facility staff unaware of the resident's absence until notified by the hospital. The facility's investigation revealed deficiencies in elopement risk evaluation, delayed response in searching for the resident, and lack of familiarity among reception staff with residents.
The facility failed to obtain informed consent for psychotropic medications for three residents. A resident received Zolpidem Tartrate and Escitalopram Oxalate without proper consent documentation, another was given risperidone without consent, and a third received Trazodone without verbal or written consent. Staff interviews confirmed the lack of documentation and the failure to meet expected procedures.
The facility failed to obtain necessary consent, assessment, and physician orders for the use of low beds, considered a form of physical restraint, for three residents. These residents, who were assessed as fall risks and required staff assistance, were observed in low beds without the required documentation. The Director of Nursing acknowledged this did not meet expectations, and this issue was previously cited.
The facility failed to investigate multiple allegations of abuse and neglect, including a resident left in a wheelchair for three nights, another resident's electric wheelchair removed without proper documentation, and unaddressed medication issues. Staff interviews revealed a lack of communication and failure to recognize these situations as neglect, leading to potential risks for continued abuse and diminished quality of life.
The facility failed to monitor and correctly set Low Air Loss Mattresses (LALM) for three residents, leading to a deficiency in pressure ulcer care. A resident with multiple health issues had an LALM incorrectly set at 200 lbs, despite weighing 126.8 lbs. Similar issues were found with two other residents, whose LALM settings did not match their weights. Maintenance staff set up the LALM based on estimated weight ranges, and licensed nurses were responsible for monitoring, which was not documented.
The facility did not maintain the required minimum RN coverage of eight hours daily for 60 out of 92 days. Nursing schedules for July, August, and September 2024 revealed significant gaps in RN coverage. The Staffing Coordinator admitted to the shortage of available RNs, and the DON confirmed that the facility's expectations were not met.
The facility failed to provide non-pharmacological interventions (NPI) before administering PRN pain medications to several residents, despite orders to do so. Residents with various medical conditions received pain medications without prior NPI, as documented in their medication administration records. Interviews with staff confirmed that the facility's expectations for documenting NPI were not met.
The facility's QAPI program failed to identify and address deficiencies, leading to repeated issues. Key deficiencies included failure to report abuse allegations, improper use of pressure ulcer prevention interventions, and lack of psychotropic medication consents. The QAPI committee was often unaware of these issues, resulting in unresolved deficiencies.
A facility failed to review and update the AD for a resident with dementia, missing required reviews and lacking documentation of court-appointed guardianship. Staff interviews revealed a lack of follow-up and documentation efforts, placing the resident at risk of not having an established decision maker.
A resident's personal wheelchair had armrests in disrepair, with cracked vinyl exposing uncleanable surfaces. The resident, diagnosed with cancer and depression, reported the issue, and staff confirmed the need for repair or replacement. The condition did not meet the facility's expectations.
A resident with palliative care needs was left in a power wheelchair for three nights due to missing transfer equipment, preventing proper wound care and causing distress. Despite staff being informed, the issue was not promptly addressed, leading to an allegation of neglect.
The facility failed to provide written transfer notifications to two residents or their representatives, as well as the Ombudsman program. One resident with encephalopathy and diabetes and another with heart failure and COPD were transferred to the hospital without receiving the required written notices. Staff acknowledged the oversight, admitting that only verbal notifications were given.
The facility failed to provide written bed hold notices for two residents transferred to the hospital, as required by regulations. Resident 81, with encephalopathy and diabetes, and Resident 13, with heart failure and COPD, were both transferred and readmitted without proper bed hold documentation. Staff acknowledged the oversight, citing procedural lapses.
A resident with multiple diagnoses, including anxiety and depression, was inaccurately assessed in the facility's records. The PASARR indicated a level 2 evaluation requiring special interventions, but the MDS was incorrectly coded, failing to reflect this status. Staff interviews confirmed the error in the assessment coding.
The facility failed to complete timely and accurate PASARR assessments for two residents, leading to potential risks for unidentified mental health needs. One resident's PASARR was delayed and initially inaccurate, missing serious mental illness indicators, while another resident's PASARR was completed late, not meeting the required timeline. Staff interviews confirmed these deficiencies.
The facility failed to develop comprehensive care plans for two residents, one with impaired vision and another who smoked. Despite assessments indicating these needs, the care plans lacked specific measures to address them, as confirmed by staff interviews. This oversight placed the residents at risk of unmet care needs.
The facility failed to conduct timely care planning meetings for two residents, one with multiple diagnoses including quadriplegia and another with dementia. Both residents did not recall recent care conferences, and the Social Service Director confirmed the lapse, while the Administrator was unaware of the missed meetings.
A resident was prescribed quetiapine for schizophrenia without proper documentation or diagnosis in their medical records. Despite being admitted with other conditions, there was no evidence supporting the schizophrenia diagnosis, as required by CMS and DSM-5 criteria. Facility staff were unable to provide justification for the diagnosis, highlighting a failure to meet professional standards of practice.
A resident was confined to bed due to the lack of a suitable wheelchair, preventing them from leaving their room. Additionally, two residents did not receive prescribed bowel management medications, despite not having bowel movements for several days. Staff interviews revealed that the facility's alert system for bowel protocols was not effectively utilized.
A facility failed to administer a nutritional supplement, Med Pass 2.0, as ordered for a resident at nutritional risk. Despite orders to provide the supplement when intake was less than 50%, records showed no documentation of it being given, and the resident's intake remained poor. Interviews revealed a lack of communication and follow-through among staff, leading to unmet nutritional needs.
A facility failed to provide oxygen therapy as ordered for a resident with dementia and asthma. Despite orders for oxygen at 1-2 liters per minute, observations showed the oxygen concentrator was unused, and the resident was not using oxygen. Staff inaccurately documented that the resident was receiving oxygen, with a nurse stating this was due to the resident's O2 saturation levels being above 92%. The DON confirmed that provider orders were not followed.
A resident with multiple diagnoses, including chronic pain and paraplegia, did not receive pain management as per provider's orders, affecting their participation in therapy. Despite having orders for pain medications, the facility failed to administer them consistently, and non-pharmacological interventions were not offered. Staff interviews indicated awareness of the resident's pain, but appropriate actions were not taken, leading to a deficiency in care.
A facility failed to act on a pharmacist's recommendations for a resident's medication regimen, specifically regarding Clonazepam and Zolpidem Tartrate. The pharmacist suggested reducing Clonazepam to lower fall risk and discontinuing or documenting the extended use of Zolpidem as per CMS guidelines. However, the provider declined the Clonazepam recommendation without clear rationale, and documentation for Zolpidem was incomplete. Interviews revealed no documentation of a gradual dose reduction for Zolpidem, and the Director of Nursing acknowledged the oversight.
The facility failed to conduct gradual dose reductions (GDR) and monitor side effects for psychotropic medications in several residents. A resident with multiple diagnoses did not receive a GDR or psychiatrist evaluation as required. Another resident on Risperidone did not have documented orthostatic blood pressure readings. Additionally, a resident on Zolpidem Tartrate had incomplete documentation of side effects, hours of sleep, and non-drug interventions. Staff acknowledged these documentation failures.
Two residents in an LTC facility were at risk due to inadequate monitoring and care planning. A resident with cognitive impairment and a history of elopement had a non-functional wanderguard, leading to multiple elopement incidents. Another resident with a history of falls did not have a new intervention included in their care plan, resulting in repeated falls. These deficiencies in monitoring and care planning placed the residents at risk for injury.
A facility failed to ensure proper labeling and storage of medications, as observed in one medication cart. An RN, due to a dead laptop battery, prepared medications ahead of time, labeling them with only residents' first names. Additionally, a bag with tablets was improperly labeled. The DON confirmed the practice did not meet safety standards.
A resident with multiple diagnoses, including a stroke and paralysis, did not receive dressing changes as ordered, with eight missed changes documented in December. The facility's Assistant DON confirmed that the lack of documentation indicated the changes were not completed, placing the resident at risk of unmet needs and decreased quality of life.
The facility failed to obtain necessary consents and physician orders for physical restraints and monitoring devices for several residents. Two residents had beds placed against the wall and perimeter mattresses without documented orders or consents, while two others wore Wanderguard devices without documented consents. Staff interviews revealed no formal consent form for these devices, and the Director of Nursing acknowledged recent charting system changes that may have contributed to the oversight.
The facility failed to provide eight consecutive hours of direct care supervision by an RN for 9 of 29 days reviewed and did not meet the State RN staffing requirement of 24-hour RN coverage for 29 of 29 days reviewed. The DNS acknowledged the lack of 24-hour RN coverage and mentioned that only LPNs were available to work the floor. The facility had recently hired two RNs and started using agency staff to cover LN and NAC positions, along with increasing their pay scale and revamping employee retention tactics to address the staffing issues.
Failure to Provide Foley Catheter Care and Monitoring Resulting in Pressure Injury
Penalty
Summary
The facility failed to provide necessary care and monitoring for a Foley catheter, resulting in an avoidable pressure injury at the catheter insertion site for one resident. Upon readmission, the resident had a Foley catheter in place due to obstructive uropathy and was cognitively intact. Throughout the resident's stay, there were no documented physician orders, care plans, eTAR entries, Point of Care tasks, or Kardex guidance related to Foley catheter care, monitoring, or securement. Progress notes and assessments also lacked documentation of catheter care or monitoring. The resident experienced severe, unrelieved pain at the catheter site, which was not alleviated by prescribed interventions, and exhibited signs of distress such as anxiousness, restlessness, and verbalizing discomfort. The resident was eventually transferred to the hospital, where it was noted that the catheter and surrounding area were unclean, and a significant meatal erosion was identified at the insertion site. Hospital records indicated that exchanging the Foley catheter resolved the resident's pain, and a mucosal membrane pressure injury (MMPI) was diagnosed. Interviews with facility staff confirmed that expected protocols for Foley catheter care and monitoring were not in place or followed for this resident.
Failure to Prevent Elopement and Provide Adequate Supervision for Cognitively Impaired Resident
Penalty
Summary
The facility failed to accurately assess, identify, monitor, and supervise a resident at risk for elopement, resulting in the resident leaving the facility unsupervised and sustaining harm. The resident, who had a history of stroke, dementia, and encephalopathy, was documented as requiring staff assistance for activities of daily living and was noted in the care plan to be at risk for falls and injury due to cognitive loss and lack of safety awareness. Despite these documented risks, the resident was able to exit the facility without staff knowledge or intervention. On the day of the incident, nursing notes indicated that the resident had previously expressed a desire to leave and had shown signs of confusion and attempts to leave the facility. The resident was last checked on in their room in the early afternoon, and when staff later noticed the resident was missing, there was a delay in initiating a search. Staff were unclear about which residents were allowed to leave and did not immediately begin looking for the missing resident. Additionally, staff in the reception area did not notice the resident leaving the building. The resident was subsequently found by bystanders on a freeway ramp after having fallen and sustained injuries, including abrasions and bruising. Emergency services were called, and the resident was transported to the hospital, where it was determined that facility staff were not aware the resident was missing until contacted by the hospital. The facility's own investigation identified issues with the accuracy of the elopement risk assessment, delays in searching for the resident, and lack of familiarity among reception staff with the residents.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent for the administration of psychotropic medications for three residents, which is a requirement to ensure residents or their legal representatives are fully informed about their treatment. Resident 92 was prescribed Zolpidem Tartrate for insomnia and Escitalopram Oxalate for depression, but the consent for Zolpidem Tartrate lacked documentation of the medication's frequency, and no consent was found for Escitalopram Oxalate. Staff interviews confirmed the absence of proper documentation and acknowledged that the expected procedures were not followed. Resident 87 was prescribed risperidone, an antipsychotic medication, without any consent documentation on file. Similarly, Resident 2 was administered Trazodone for insomnia without obtaining verbal or written consent. Staff interviews revealed that the necessary consents were not located, and the expectation was that consents should be obtained prior to medication administration. These oversights placed residents at risk of not being fully informed about their medication use, potential side effects, and the ability to make informed decisions about their care.
Failure to Obtain Consent and Orders for Low Bed Use
Penalty
Summary
The facility failed to obtain a provider's order, assessment, and consent for the use of low beds for three residents, which is considered a form of physical restraint. The facility's policy requires that physical restraints, including low beds, should only be used upon the written order of a physician and after obtaining consent from the resident or their representative. However, for Residents 86, 74, and 89, there was no documentation of consent, order, or assessment for the use of low beds, which were observed during the survey. Resident 86, who was admitted with conditions such as intracranial hemorrhage, anxiety, depression, and aphasia, was assessed as a fall risk and required staff assistance for mobility. Despite this, there was no documentation supporting the use of a low bed. Similarly, Resident 74, diagnosed with dementia, depression, and osteopenia, and Resident 89, diagnosed with dementia, anxiety, and receiving palliative care, were also observed in low beds without the necessary documentation. The Director of Nursing Services acknowledged that the lack of consent, assessment, and order did not meet the facility's expectations. This deficiency was previously cited in a Statement of Deficiencies.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and investigate allegations of abuse and neglect for several residents, leading to potential risks for continued abuse and diminished quality of life. Resident 78, who was dependent on staff for transfers, reported being left in a power wheelchair for three nights due to missing equipment. Despite the resident's grievance and staff awareness, no investigation was initiated, and the incident was not logged in the facility's records. Staff interviews revealed a lack of communication and failure to recognize the situation as neglect. Resident 48 experienced a safety incident involving their electric wheelchair, which was removed after being seen in the roadway. Although staff were aware of the incident, it was not documented in the incident log, and no investigation was conducted. Similarly, Resident 77 reported a resident-to-resident altercation that was not logged or investigated, despite staff acknowledging the need for such actions. The lack of documentation and follow-up on these incidents highlights a systemic issue in addressing and investigating potential neglect and abuse. Other residents, such as Resident 360 and Resident 66, also reported issues with medication administration and being left uncovered, respectively. These incidents were not logged or investigated, indicating a broader failure to adhere to facility policies and state regulations. The facility's inaction in these cases demonstrates a significant deficiency in ensuring resident safety and addressing grievances appropriately.
Failure to Monitor and Set Low Air Loss Mattress Correctly
Penalty
Summary
The facility failed to ensure that the ordered intervention of a Low Air Loss Mattress (LALM) was properly monitored and used as directed for three residents, leading to a deficiency in pressure ulcer care. Resident 73, who had diagnoses including heart and lung disease, dementia, and malnutrition, was dependent on staff for all activities of daily living and had pressure ulcers on the buttocks and heels. Despite the care plan specifying the use of an air mattress for pressure reduction, the LALM was incorrectly set at 200 lbs, while the resident's actual weight was 126.8 lbs. Staff interviews revealed that the maintenance department set up the LALM based on an estimated weight range, and licensed nurses were responsible for monitoring the settings, which were not documented in the electronic health record. Further investigation showed similar issues with Residents 83 and 18, whose LALM settings were also incorrect based on their documented weights. Resident 83, weighing 83 lbs, had the LALM set at 200 lbs, and Resident 18, weighing 90 lbs, had the LALM set at 400 lbs. The Assistant Director of Nursing stated that the expectation was for maintenance staff to set up the LALM based on residents' weights and for licensed nurses to ensure the settings were correct. This failure to implement the care plan as ordered prevented the facility from promoting wound healing and preventing further decline in the residents' conditions.
Failure to Maintain Minimum RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for a minimum of eight hours each day, as required, for 60 out of 92 days reviewed for staffing. Specifically, the nursing schedules for July, August, and September 2024 showed that there was no RN scheduled for 23, 19, and 18 days, respectively. This deficiency was identified through observation, interviews, and record reviews. During interviews, the Staffing Coordinator acknowledged the shortage of available RNs and the Director of Nursing Services confirmed that the lack of daily RN coverage did not meet the facility's expectations.
Failure to Provide Non-Pharmacological Interventions Before PRN Pain Medications
Penalty
Summary
The facility failed to provide non-pharmacological interventions (NPI) prior to administering as-needed (PRN) pain medications for six of eight sampled residents. This deficiency was identified through interviews and record reviews, revealing that residents were at risk of taking unnecessary medications, experiencing avoidable side effects, and having a diminished quality of life. The residents involved had various medical conditions, including palliative care, osteomyelitis, diabetes, heart and lung disease, fibromyalgia, quadriplegia, radiculopathy, anxiety, depression, dementia, atrial fibrillation, insomnia, kidney disease, and Crohn's disease. For Resident 78, the electronic health record showed nearly daily administration of PRN narcotic pain medication without prior NPI in December 2024 and January 2025. Similarly, Resident 48's medication administration record (MAR) for January 2025 lacked consistent documentation of NPI despite orders to attempt such interventions before administering oxycodone and acetaminophen. Resident 94's MAR also showed multiple entries of administered pain medications without consistent documentation of NPI, despite orders to document such interventions and their effectiveness. Resident 92 received narcotic pain medication 77 times in January 2025 without documented NPI, contrary to the provider's orders. Resident 360's MAR showed no order for NPI, yet the resident received acetaminophen and narcotic medications multiple times. Lastly, Resident 87's December 2024 MAR showed no documented NPI before administering acetaminophen. Interviews with staff, including the Director of Nursing Services and Assistant Director of Nursing, confirmed that the facility's expectations for documenting NPI prior to PRN medication administration were not met.
Repeated Deficiencies Due to Ineffective QAPI Program
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) program effectively identified and addressed deficiencies, leading to repeated issues and a pattern of deficiencies. During the Long Term Care survey conducted on January 29, 2025, it was found that the facility did not identify or address several areas of concern, including the failure to report and investigate allegations of abuse or neglect for six out of seven sampled residents. Additionally, the facility did not ensure the proper use and monitoring of ordered interventions, such as the Low Air Loss Mattress, for the prevention of pressure ulcers in three out of seven residents. The facility also demonstrated ineffective plans of correction for sustaining compliance in various areas, resulting in repeated deficiencies. For instance, the facility failed to complete and maintain psychotropic medication consents before administering these medications to three out of five sampled residents. Furthermore, the facility did not periodically review residents' advanced directives or maintain court-appointed guardianship documentation, affecting one out of two sampled residents. These issues were not brought to the attention of the QAPI committee, indicating a lack of awareness and oversight. Additional deficiencies included the failure to provide a safe, sanitary, and homelike environment, obtain necessary consents for the use of physical restraints, and provide written notifications for transfers or bed hold policies. The facility also failed to accurately assess residents' conditions, develop comprehensive care plans, and ensure professional standards of practice were met. Despite some awareness of certain issues, such as staffing shortages, the QAPI committee was generally unaware of many concerns, leading to repeated citations and unresolved deficiencies.
Failure to Review Advanced Directive and Obtain Guardianship Documentation
Penalty
Summary
The facility failed to periodically review and update the advanced directive (AD) for Resident 77, who was admitted with diagnoses including dementia, depression, and osteoarthritis. Despite being unable to sign AD documentation due to cognitive issues, the facility did not conduct the required reviews in August and November 2024. This oversight was acknowledged by Staff F, who confirmed that the reviews were missed. Additionally, there was a lack of documentation regarding the court-appointed guardianship, which was supposed to be obtained and maintained in the resident's medical records. Interviews with facility staff revealed that there was a breakdown in communication and follow-up regarding the guardianship documentation. Staff D, the Business Office Manager, admitted that they did not follow up with the resident's family to obtain the necessary paperwork, nor did they document attempts to do so. The Administrator confirmed that ADs should be reviewed upon admission, quarterly, and as needed, and that Social Services were responsible for obtaining the AD. This failure placed Resident 77 at risk of not having an established decision maker and a diminished quality of life.
Deficient Wheelchair Maintenance for Resident
Penalty
Summary
The facility failed to provide a safe, sanitary, and homelike environment for Resident 62, who was reviewed for environmental conditions. Resident 62, who had diagnoses including cancer and depression, was observed using a personal wheelchair with both armrests in disrepair. The armrests had multiple cracked areas in the vinyl, exposing beige material underneath, creating an uncleanable surface. During interviews, Resident 62 expressed that the armrests were rough to the touch and that staff should have noticed the need for repair or replacement. Staff E, an LPN, confirmed the poor condition of the armrests and acknowledged the need for maintenance and physical therapy intervention. Staff B, the Director of Nursing Services, also stated that the condition of the wheelchair armrests did not meet expectations.
Neglect Due to Missing Transfer Equipment
Penalty
Summary
The facility failed to ensure a resident was free from neglect, as evidenced by the incident involving Resident 78. The resident, who was admitted with diagnoses including palliative care, osteomyelitis, and diabetes, was dependent on staff for transfers in and out of bed using a mechanical lift. However, due to the facility's inability to locate a necessary piece of equipment, Resident 78 was left in their power wheelchair for three consecutive nights, preventing proper transfer and wound care. This situation caused distress to the resident, who subsequently took measures to prevent a recurrence by keeping the equipment with them in bed. Interviews with staff revealed a breakdown in communication and response to the resident's needs. Staff P, a CNA, reported the missing equipment to Staff N, an LPN, who was on vacation at the time. Upon return, Staff N checked the resident's wounds and located the missing equipment. Despite being informed of the situation, Staff B, the DNS, was unaware that the resident had slept in their wheelchair for three nights. Additionally, the resident filed a grievance form alleging neglect, which was reported to the DNS by Staff F from Social Services. The facility's policy requires all allegations of neglect to be reported and investigated, but this was not adequately followed in this case.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written notification of the reason for hospital transfer to two residents, Resident 81 and Resident 13, or their representatives, as well as the Washington State Long-Term Care Ombudsman program. Resident 81, who was admitted with encephalopathy and diabetes, was hospitalized and readmitted without receiving a written notice of transfer. Staff C, the Assistant Director of Nursing, acknowledged that the resident or their representative did not receive the required written notice, which should have been provided upon transfer or sent via certified mail. Similarly, Resident 13, who had diagnoses including heart failure and chronic obstructive pulmonary disease, was transferred to the hospital and readmitted without receiving a written notification of the transfer. Staff E, an LPN, admitted to providing only verbal notification, while Staff B, the Director of Nursing Services, could not confirm if a written notification was sent. Additionally, Staff F from Social Services confirmed that the Ombudsman program was not notified in writing about Resident 13's transfer, which was a requirement.
Failure to Provide Bed Hold Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide written bed hold notices at the time of transfer to the hospital for two residents, which is a requirement under WAC 388-97-0120 (4). Resident 81, who had diagnoses including encephalopathy and diabetes, was hospitalized and readmitted without any documentation or progress notes related to a bed hold for the hospitalization. Staff D, the Business Office Manager, acknowledged the oversight, attributing it to the transfer occurring over the weekend. Staff C, the Assistant Director of Nursing, confirmed that a bed hold packet should have been offered to Resident 81, who was alert and oriented. Similarly, Resident 13, with diagnoses including heart failure and chronic obstructive pulmonary disease, was transferred to the hospital and later readmitted without a bed hold form documented in their electronic health record. Staff D confirmed the absence of the necessary documentation, and Staff B, the Director of Nursing Services, stated that bed holds should be offered to all residents upon hospital transfer. The lack of bed hold documentation for both residents indicates a failure in the facility's process to ensure residents are informed of their rights regarding bed holds during hospitalizations.
Inaccurate PASARR Assessment for a Resident
Penalty
Summary
The facility failed to accurately assess the status of a resident, identified as Resident 41, in relation to the Pre-Admission Screening and Resident Review (PASARR), a mental health screening tool. Resident 41 was admitted with diagnoses including anxiety, chronic obstructive pulmonary disease, depression, and a personality disorder, and was capable of communicating needs. The PASARR, dated May 7, 2020, indicated that Resident 41 had a level 2 evaluation and required special interventions and follow-up by a provider. However, the minimum data set assessment (MDS) dated December 2, 2024, incorrectly coded Resident 41 as not having a level 2 PASRR and not having a serious mental illness. During interviews, both the Social Service Director and the Administrator acknowledged the coding error in the MDS, confirming that it should have reflected a level 2 PASARR.
Failure to Timely and Accurately Complete PASARR Assessments
Penalty
Summary
The facility failed to ensure timely and accurate completion of Pre-Admission Screening and Resident Review (PASARR) assessments for two residents, which placed them at risk for unidentified mental health care needs. Resident 92 was admitted with diagnoses of depression and insomnia and was receiving antianxiety, antidepressant, and hypnotic medications. However, the initial PASARR completed by the hospital case manager did not indicate any serious mental illness (SMI) indicators, and a level 2 evaluation was not conducted. A subsequent PASARR completed by the facility's Social Services Director later identified SMI indicators, but the referral for a level 2 evaluation was delayed. Staff interviews confirmed the inaccuracies and untimeliness of the PASARR process for Resident 92. Similarly, Resident 360 was admitted with a broken left upper thigh bone and kidney disease, and the PASARR was completed one day after admission, failing to meet the requirement for completion prior to or upon admission. The PASARR did not indicate any SMI indicators, and no level 1 PASARR was completed at the appropriate time. Staff interviews acknowledged the delay in completing the PASARR for Resident 360, which did not meet the facility's expectations for timely assessments.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their specific care needs. Resident 39, who was admitted with diagnoses including heart failure, diabetes, and anxiety disorder, was identified as having impaired vision without corrective lenses according to the annual minimum data set assessment. Despite this, the resident's care plan did not include any measures to address the impaired vision, as confirmed by both the MDS Nurse and the Director of Nursing Services during interviews. Similarly, Resident 84, admitted with anemia and anxiety disorder, was found to be a smoker according to the facility's Resident Smoker List and a smoking evaluation. However, the resident's care plan did not include any provisions for smoking, such as monitoring for ashes or burn holes, which was acknowledged as an oversight by a Licensed Practical Nurse and the Director of Nursing Services. These omissions in care planning placed the residents at risk of unmet care needs and potential negative outcomes.
Failure to Conduct Timely Care Planning Meetings
Penalty
Summary
The facility failed to conduct timely care planning meetings for two residents, which is a requirement to ensure that care is provided according to the residents' needs. Resident 48, who was readmitted with multiple diagnoses including heart and lung disease, fibromyalgia, quadriplegia, and depression, did not have a care conference since May 10, 2023, despite the expectation for quarterly meetings. The resident was dependent on staff for activities of daily living and was able to communicate their needs, yet they did not recall having a recent care conference. Similarly, Resident 77, who was admitted with diagnoses including dementia, depression, and osteoarthritis, also did not have a care conference since February 12, 2024. This resident was also able to communicate their needs but did not recall attending a care conference. The Social Service Director confirmed the lapse in care conferences for both residents, and the Administrator was unaware of the missed or late conferences, despite the facility's expectation for quarterly meetings.
Inappropriate Diagnosis and Medication Use for a Resident
Penalty
Summary
The facility failed to meet professional standards of practice in diagnosing a resident with mental health disorders, specifically regarding the use of unnecessary medications. Resident 2, who was admitted with diagnoses including diabetes, heart failure, depression, and suicidal ideation, was prescribed quetiapine for schizophrenia. However, there was no documentation or diagnosis of schizophrenia in Resident 2's medical records. The admitting physician's note mentioned schizophrenia, but this was not supported by any evidence or assessment in accordance with DSM-5 criteria, as required by CMS and the State Operations Manual. Interviews with facility staff revealed a lack of supporting documentation for the schizophrenia diagnosis. Staff R, the Resident Care Manager, and Staff B, the Director of Nursing Services, were unable to provide evidence or documentation to justify the diagnosis. The pharmacy consultation report highlighted the requirement for a qualified practitioner to diagnose schizophrenia using evidence-based criteria, which was not adhered to in this case. This oversight placed Resident 2 at risk for unmet needs and complications due to the inappropriate use of psychoactive medication.
Deficiencies in Mobility and Bowel Management
Penalty
Summary
The facility failed to provide a suitable mobility device for Resident 4, who was admitted with diagnoses including malignant melanoma, malnutrition, depression, and diabetes. Observations revealed that Resident 4 was confined to bed without a wheelchair that matched their height, preventing them from leaving their room and interacting with other residents. Interviews with Resident 4 and staff confirmed the absence of an appropriate wheelchair, which did not meet the facility's expectations for resident mobility. Additionally, the facility did not implement a bowel program for Residents 24 and 108, both of whom had orders for constipation management. Resident 24 experienced multiple days without a bowel movement, and the prescribed bowel medications were not administered according to the provider's orders. Similarly, Resident 108 did not receive the necessary bowel medications despite not having a bowel movement for several days. Interviews with staff indicated that the facility's system was supposed to alert nurses to initiate the bowel protocol, but this was not effectively carried out, leading to unmet needs for these residents.
Failure to Administer Nutritional Supplement as Ordered
Penalty
Summary
The facility failed to administer the Registered Dietician's (RD) recommendations for Resident 73, who was at nutritional risk due to poor food and fluid intake. Despite having an order for Med Pass 2.0, a fortified nutritional shake, to be administered when the resident's intake was less than 50%, the medication administration records for December 2024 and January 2025 showed no documentation of the supplement being given. The resident's electronic health record (EHR) indicated multiple instances of eating less than 25-50% of meals, yet there was no documentation of Med Pass 2.0 being offered or refused. Interviews with facility staff revealed a lack of communication and follow-through on the dietary plan. The Licensed Practical Nurse (LPN) and Assistant Director of Nursing (ADON) stated that the expectation was for the Certified Nurse Aide (CNA) to inform the LPN of poor intake, who would then administer the supplement. However, this process was not followed, as evidenced by the lack of documentation and continued poor dietary intake. The RD reiterated the expectation for the LPN to administer and document the supplement as ordered, highlighting a breakdown in the facility's protocol for addressing the resident's nutritional needs.
Failure to Administer Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with provider orders for Resident 59, who was admitted with diagnoses including dementia and asthma. The provider orders specified that Resident 59 should receive oxygen therapy at 1-2 liters per minute via nasal cannula during both day and night shifts. However, observations on two consecutive days revealed that the oxygen concentrator was unused, and Resident 59 was not wearing a nasal cannula or using oxygen. Despite this, the Medication Administration Record indicated that staff had signed off daily, confirming that Resident 59 was utilizing oxygen as ordered. During interviews, Resident 59 stated they had not used oxygen since admission, and a registered nurse admitted to signing off on the oxygen administration because the resident's O2 saturation levels were consistently above 92%. The Director of Nursing acknowledged that the expectation was for provider orders to be followed, and staff should not have signed off if the resident was not using the oxygen.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide pain management as per the provider's orders for a resident, identified as Resident 24, which affected their ability to participate in physical therapy services. Resident 24, who was admitted with multiple diagnoses including multiple sclerosis, chronic pain, and paraplegia, had orders for various pain medications such as a fentanyl patch, oxycodone, and morphine sulfate. Despite these orders, the facility did not administer pain medication for 12 out of 14 instances where the resident refused restorative services due to pain. Additionally, non-pharmacological interventions were not offered during these refusals. The resident's electronic health record showed the last pain assessment was conducted several months prior, and the medication administration records indicated a lack of pain management for numerous occurrences of moderate to severe pain. Interviews with staff revealed that while they were aware of the resident's pain, appropriate measures were not consistently taken to address it. The resident expressed that their pain medications were not effective enough, and they often had to endure pain during therapy sessions. This deficiency in pain management placed the resident at risk of decreased mobility and a diminished quality of life.
Failure to Act on Pharmacist's Recommendations for Medication Management
Penalty
Summary
The facility failed to act on the consultant pharmacist's medication regimen review (MRR) recommendations for Resident 92, who was reviewed for unnecessary medication use. Resident 92 had diagnoses of depression, anxiety disorder, and insomnia and was prescribed Clonazepam for anxiety and Zolpidem Tartrate for insomnia. The pharmacist recommended reducing Clonazepam to minimize fall risk, but the provider declined without a clear rationale. Additionally, the pharmacist suggested discontinuing or documenting the extended use of Zolpidem, as required by CMS guidelines, but the documentation was incomplete and lacked clarity. Interviews with facility staff revealed that there was no documentation of a gradual dose reduction (GDR) for Zolpidem, and the provider's notes did not address the pharmacy's recommendations for Clonazepam. The Director of Nursing Services acknowledged the lack of documentation and the failure to clarify the rationale for not following the pharmacist's recommendations. This oversight placed Resident 92 at risk for adverse side effects and did not meet the facility's expectations for medication management.
Failure to Conduct GDR and Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to conduct gradual dose reductions (GDR) and monitor for side effects related to the use of psychotropic medications for several residents. Resident 94, who was admitted with multiple diagnoses including heart disease, stroke, dementia, anxiety, and depression, was prescribed Clonazepam and Duloxetine. Despite the care plan indicating the need for GDR and a psychiatrist evaluation, no GDR was conducted, and no evaluation was performed since the resident's admission. The Assistant Director of Nursing acknowledged that behavioral health services were not resumed after the resident graduated from hospice care, which should have included GDRs. For Resident 87, who was admitted with dementia and required moderate assistance, the facility failed to document orthostatic blood pressure readings as required for residents receiving antipsychotic medication, specifically Risperidone. The Director of Nursing Services confirmed that the expectation was for staff to obtain and document these readings, which was not done. Resident 92, who had diagnoses including atrial fibrillation, high blood pressure, and insomnia, was prescribed Zolpidem Tartrate for severe intermittent insomnia. The facility failed to document side effects, hours of sleep, and non-drug interventions as required. The Licensed Practical Nurse and Director of Nursing Services both acknowledged that the documentation did not meet expectations, as side effects were not specified, and non-pharmacological interventions were not properly recorded.
Failure to Monitor Wanderguard and Update Care Plan Leads to Resident Risks
Penalty
Summary
The facility failed to ensure that risk factors were consistently monitored and addressed to minimize the risk for accident hazards for two residents. Resident 94, who had significant cognitive impairment and a history of elopement, was not adequately monitored with a functional wanderguard device. Despite having a care plan that required the wanderguard to be checked every shift, there were multiple instances where the checks were not documented, and the device was found to be non-functional during testing. This lack of consistent monitoring and testing led to three separate elopement incidents, where the resident was able to leave the facility without staff knowledge. Resident 86, who had a history of falls and was unable to communicate their needs, experienced multiple falls within the facility. After a fall on December 22, 2024, a new intervention was identified to assist the resident to bed after evening medications. However, this intervention was not included in the resident's care plan, and the resident experienced another fall in the dining room. The failure to update the care plan with the new intervention contributed to the repeated fall incident. The deficiencies in monitoring and updating care plans for these residents placed them at risk for potential injury and negative outcomes. The facility's policies and procedures were not consistently followed, leading to lapses in care and supervision for residents with known risks for elopement and falls.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure medications were properly labeled and stored in accordance with accepted professional standards, as observed in one of the four medication carts reviewed. During an observation, a Registered Nurse (RN), identified as Staff C, was seen with multiple clear plastic medication cups containing various pills on top of a medication cart. Each cup had a second plastic cup on top and was labeled with handwritten first names of residents, without any other identifiers. Staff C admitted to preparing the medications ahead of time due to a dead laptop battery, which was not in line with their training or safe medication administration practices. Additionally, a small clear plastic bag containing two white tablets was found in the top drawer of the medication cart, labeled with a single resident's first name. Staff C explained that the medication was meant for a resident who was supposed to take it during dialysis but did not eat, so it was returned. The Director of Nurses, Staff B, confirmed that Staff C was aware of the improper practice and acknowledged that it did not meet nursing expectations for safe medication administration, representing a significant safety risk to residents.
Failure to Complete Dressing Changes as Ordered
Penalty
Summary
The facility failed to ensure that dressing changes were completed as ordered for a resident with multiple diagnoses, including high blood pressure, a stroke, and one-sided paralysis. The resident was alert, non-verbal, and required substantial assistance with activities of daily living. An order dated 12/20/2024 specified that wound care and dressing changes to one of the resident's feet were to be done twice daily at 7:00 AM and 5:00 PM. However, the Treatment Administration Record for December 2024 showed that there were eight missed dressing changes out of 23 opportunities, with blanks or spaces without documentation for several 5:00 PM and 7:00 AM dressing changes. Staff D, a Registered Nurse and the Assistant Director of Nursing, confirmed that if a dressing change was not done, nursing staff should document the reason, such as the resident being unavailable or refusing the care. Upon reviewing the Treatment Administration Record, Staff D acknowledged that the lack of documentation indicated the dressings were not changed on the dates with blanks, and there should have been additional documentation. This failure placed residents at risk of unmet needs, decline in status, and decreased quality of life.
Lack of Consents and Orders for Restraints and Monitoring Devices
Penalty
Summary
The facility failed to obtain necessary consents and physician orders for the use of physical restraints and monitoring devices for several residents. Specifically, two residents were observed with beds placed against the wall and perimeter mattresses without documented physician orders or consents. These residents were cognitively impaired and required substantial assistance with activities of daily living, indicating a high level of dependency on staff for their care. The absence of documented consents and physician orders for these interventions suggests a lack of adherence to the facility's policy on the use of restraints, which mandates written orders and consents. Additionally, two other residents were found to be wearing Wanderguard devices without documented consents in their electronic health records. Staff interviews revealed that there was no formal consent form for such devices, and attempts to locate documentation of consent in progress notes were unsuccessful. The Director of Nursing Services acknowledged the absence of a formal consent form and mentioned recent changes to the facility's charting system, which may have contributed to the oversight. This lack of documentation and formal consent process placed residents at risk for injury and diminished quality of life.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide eight consecutive hours of direct care supervision by a Registered Nurse (RN) for 9 of 29 days reviewed and did not meet the State RN staffing requirement of 24-hour RN coverage for 29 of 29 days reviewed. This deficiency was identified through interviews and record reviews. The daily nursing staff forms for May 2024 showed no RN coverage on specific dates and only 8-hour RN coverage on the remaining days. The Director of Nursing Services (DNS) acknowledged the lack of 24-hour RN coverage and mentioned that only Licensed Practical Nurses (LPNs) were available to work the floor. The facility had recently hired two RNs and started using agency staff to cover Licensed Nurse (LN) and Nursing Assistant Certified (NAC) positions, along with increasing their pay scale and revamping employee retention tactics to address the staffing issues.
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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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