Madison Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Everett, Washington.
- Location
- 2520 Madison, Everett, Washington 98203
- CMS Provider Number
- 505463
- Inspections on file
- 26
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 47
Citation history
Health deficiencies cited at Madison Post Acute during CMS and state inspections, most recent first.
The facility did not complete required PASRR Level 2 evaluations for a resident with anxiety and depression prior to admission, and failed to update or conduct Level 2 evaluations for two residents with serious mental illness who remained beyond their 30-day exemption period. Staff interviews confirmed a lack of awareness and follow-through on PASRR requirements.
The facility assigned an unqualified individual as the Director of Food and Nutrition Services, who was not a certified Dietary Manager and was only enrolled in a certification program. The facility used the certification of the previous manager in place of the current director's required credentials, as confirmed by staff interviews and record review.
Surveyors identified unsanitary conditions in the kitchen and food storage areas, including a leaking handwashing sink, food debris, improper dishwashing temperatures, ice buildup in the freezer, poor hand hygiene, and unlabeled or undated food items. Staff were aware of these issues, but proper cleaning and maintenance had not been completed.
The facility did not have an effective system to document, track, or resolve grievances raised by residents during Resident Council meetings, including repeated complaints about loud TV noise, staff disturbances at night, and cold food. Staff responsible for grievance resolution were not informed of these concerns, and no formal grievance forms or follow-up actions were documented, resulting in unresolved issues affecting residents' quality of life.
The facility did not provide updated or complete Notification of Medicare Non-Coverage (NOMNC) forms to four residents, using outdated forms that lacked the required appeal organization contact information and failing to document that residents or their representatives received an explanation of the form or appeal process. The Social Service Director was unaware of the need to update the forms or include the necessary information.
The facility did not consistently provide or document required written notices of bed hold, transfer, and discharge to residents, their representatives, and the State Ombudsman during hospitalizations and discharges. Staff interviews revealed confusion about notification responsibilities, and EMR reviews showed missing documentation for several residents who were hospitalized or discharged.
The facility did not ensure that required PASRR Level II evaluations were completed or that recommendations from completed evaluations were incorporated into care plans for several residents with mental health diagnoses. Staff failed to refer residents for further review, did not document communication with the state PASRR evaluator, and were unaware of specific care recommendations, resulting in incomplete care planning.
Two residents requiring hemodialysis did not have consistent pre- and post-dialysis assessments completed, and there was a lack of ongoing communication and documentation from the dialysis center. Staff interviews confirmed missing documentation, incomplete communication packets, and absent after-visit summaries, with no contracts in place between the facility and the dialysis providers.
Several residents reported and were observed receiving meals that were lukewarm, overcooked, or unappetizing, with some meals lacking proper temperature control and palatability. Test trays confirmed issues such as dry and bland food, and a grievance documented a foreign object in a meal. The administrator was unaware of these ongoing food quality concerns.
A resident's trust account balance was not reimbursed to the state Office of Financial Recovery within the required 30 days after the resident's death. The Business Office Manager confirmed the delay, resulting in the account not being reconciled as mandated.
Two residents did not have individualized, comprehensive care plans implemented as required. One resident with severe dementia and Dutch as a primary language lacked the Dutch-to-English signage intervention specified in their care plan, and staff were unaware of this intervention. Another resident with a urinary catheter had a care plan that did not document the clinical reason for the catheter or necessary follow-up, and staff could not explain the rationale for its continued use.
Two residents did not receive care in accordance with professional standards: one did not have required blood pressure monitoring or bowel protocol interventions documented when receiving antihypertensive medication and experiencing constipation, and another did not have provider notification documented when blood glucose readings exceeded ordered parameters. Staff interviews confirmed that these protocols were not followed or documented as required.
Two residents did not receive respiratory care in accordance with physician orders and professional standards. One resident's oxygen was consistently set below the prescribed rate, and staff were unaware of the discrepancy. Another resident's CPAP machine lacked active orders for use and maintenance, and the mask was observed to be unclean, with staff unable to confirm cleaning or proper care.
Staff did not follow infection prevention protocols, including failing to use PPE for a resident on Enhanced Barrier Precautions during toileting, neglecting hand hygiene during perineal care for another resident, and not using barriers or proper disinfection when handling medical equipment and medications. These lapses were confirmed by staff and the facility's infection preventionist.
Seven rooms were found to house two residents each despite not meeting the minimum square footage requirement of 80 square feet per resident. Each room measured between 142 and 154 square feet, and staff confirmed that an exemption request was pending but not approved.
A resident's grievances regarding a noisy roommate, missing personal items, and dissatisfaction with a nursing assistant's care were not properly documented or addressed by the facility. Despite the resident's complaints, only one grievance was logged, and the facility failed to ensure the resident's concerns were resolved, as evidenced by continued care from the nursing assistant in question. Staff interviews revealed a lack of awareness and communication regarding the resident's grievances, indicating a failure to adhere to the facility's grievance policy.
A resident with swallowing difficulties was unable to receive daily recreational meals due to staffing limitations, as the facility only provided 1:1 supervision for meals on weekdays. Despite the resident's preference for daily meals, the scheduling practices did not accommodate their needs on weekends, leading to a deficiency in honoring resident choice.
A registered nurse administered medications to a resident with dementia during their meal in the dining room, contrary to facility policy requiring privacy for medication administration. The resident had cognitive impairments and did not request this practice. The Director of Nursing acknowledged the need for further education.
A facility failed to conduct a comprehensive Resident Assessment Instrument (RAI) for a resident with a leg fracture and on hospice care. The Care Area Assessment (CAA) lacked a thorough analysis, missing the resident's goals, preferences, and input. The contracted RN responsible for the MDS and care plans did not complete the necessary comprehensive analysis, risking inadequate service provision.
A facility failed to implement care plan interventions for a resident at high risk for falls, leading to a deficiency. The resident, with a history of falls and poor trunk control, was observed using a positioning wedge improperly without the required strap. Staff interviews revealed a lack of awareness about the wedge's purpose, and the care plan did not address the resident's trunk control issues. This was a repeat citation.
The facility failed to update care plans for two residents, one with discharge planning issues and another with dental care needs. A resident's care plan was not revised despite changes in their discharge situation, while another's dental care plan did not reflect the absence of their upper partial dentures, affecting their ability to chew properly.
The facility failed to implement professional standards of practice for two residents, leading to potential risks. A resident with swallowing difficulties did not receive proper cues during meals, as recommended by the SLP. Another resident's blood pressure was not monitored as required before administering medication, and a lab test was delayed due to errors in the electronic health record system. These deficiencies highlight the facility's failure to adhere to professional standards.
Two residents in an LTC facility did not receive adequate assistance with activities of daily living, including meal assistance and oral hygiene. One resident, with a leg fracture and dementia, was left unattended with meal trays untouched and no oral care provided. Another resident, with a history of stroke and a gastrostomy tube, had dry, coated lips and tongue due to infrequent oral care. Staff interviews revealed inconsistencies in understanding and executing care plans.
The facility failed to provide care according to professional standards for two residents. One resident's alternating air mattress was not set to the prescribed settings, risking skin breakdown. Another resident, admitted to hospice with a leg fracture, was not repositioned as required, lacking a specific schedule in their care plan. Staff interviews revealed a lack of adherence to care interventions, increasing the risk of unmet care needs.
The facility did not complete annual performance reviews for NAC staff, specifically for one NAC whose file was reviewed. Staff K, hired in July 2023, lacked a current evaluation. A change in ownership on May 1 led to confusion about hire dates, contributing to the oversight.
The facility failed to maintain sanitary conditions in food storage, preparation, and service, with undated and expired items found in the kitchen and unit refrigerators. The dishwasher did not reach the required temperature, and meal trays were delivered with uncovered desserts. Staff interviews revealed a lack of adherence to food labeling and temperature monitoring protocols, placing residents at risk of consuming contaminated or spoiled food.
The facility failed to adhere to infection control practices, including improper PPE use for a resident on COVID-19 precautions and inadequate storage of O2 tubing for another resident. Staff entered a resident's room without proper PPE and disposed of it incorrectly. Additionally, clean linens were transported uncovered, increasing infection risk.
The facility failed to ensure that a NAC received the required 12 hours of training per year, with only 6.3 hours documented. The Staff Development Coordinator acknowledged the shortfall and was unable to provide evidence of the required training for the NAC, highlighting a lapse in maintaining comprehensive training records.
The facility failed to meet regulatory requirements for room size in six resident rooms, with multiple rooms not providing the required 80 square feet per resident. Despite this, surveyors found no compromise to resident health or safety. This was a repeat citation.
Failure to Complete Required PASRR Evaluations for Residents with Mental Health Needs
Penalty
Summary
The facility failed to ensure that required Pre-Admission Screening and Resident Review (PASRR) processes were completed for three out of five residents reviewed. For one resident with diagnoses of anxiety and depression, the PASRR Level 1 screen indicated the need for a Level 2 evaluation prior to admission, but there was no evidence in the electronic health record that this evaluation was completed. Staff interviews revealed a lack of awareness regarding the requirement for a Level 2 evaluation before admission when indicated by a positive Level 1 screen. For two other residents, the PASRR Level 1 screens documented indicators of serious mental illness and granted a 30-day exemption from Level 2 evaluation, contingent on discharge within that period. However, when these residents remained beyond 30 days, there was no evidence that updated PASRR Level 1 screens or required Level 2 evaluations were completed. Staff confirmed that no requests for Level 2 evaluations were submitted for these residents, despite the extended stays.
Unqualified Dietary Manager Serving as Director of Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the individual designated as the Director of Food and Nutrition Services possessed the required qualifications. The person serving in this role, identified as the Dietary Manager, confirmed during interview that they were not a certified Dietary Manager and were only enrolled in an educational program to obtain certification. The facility was using the certification of the Assistant Dietary Manager, who previously held the position, in place of the current director's required certification. Review of the staff roster and facility assessment documented the current director as the certified dietary manager, despite the lack of certification. The facility administrator acknowledged that the previous manager's certification was being used until the current director became certified.
Deficient Sanitary Practices in Food Storage, Preparation, and Service
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen and food storage areas regarding sanitary food storage, preparation, and service. The dishwashing area had a large hole in the wall, a rusty can supporting a pipe, and a pool of discolored liquid beneath a leaking handwashing sink. Food debris and cracker wrappers were present on the floor. Staff interviews confirmed awareness of these issues, including reports of cockroaches and ongoing pest control measures. The dishwashing temperature log had missing entries, and recorded temperatures were below the required level for proper sanitation. Staff operating the dishwasher indicated that the machine was a low-temperature chemical model and described running it empty to reach the correct temperature, but logs showed temperatures as low as 116-127 degrees Fahrenheit. The freezer had significant ice buildup due to missing door seals, which staff acknowledged were pending replacement. Hand hygiene practices were not followed, as staff were observed changing gloves without performing hand hygiene between tasks. The nourishment refrigerator contained opened and undated beverage items, and the dry storage area had multiple opened and unlabeled food items, including cereals and pasta. Staff interviews confirmed awareness of the need for deep cleaning and equipment replacement, but these actions had not yet been completed at the time of the survey. No specific residents were identified as being directly affected in the report.
Failure to Address and Resolve Resident Grievances from Resident Council Meetings
Penalty
Summary
The facility failed to implement a system to ensure that grievances voiced by residents, particularly through Resident Council meetings, were properly documented, tracked, investigated, and resolved. Residents repeatedly reported issues such as loud TV noise, staff being boisterous at night, and cold food during meals. These concerns were consistently brought up in Resident Council meetings over several months, but there was no documentation of resolutions or evidence that grievance forms were completed or logged. The facility's grievance log did not reflect these ongoing concerns, and there was no follow-up or investigation into the issues raised. Interviews with staff revealed a lack of clarity and communication regarding the grievance process. The Activity Director, who assisted with Resident Council meetings, did not consider concerns raised in these meetings as formal grievances and therefore did not complete grievance forms or track the issues. The Social Service Director, designated as the Grievance Officer, was not notified of any concerns from the Resident Council meetings and had not received any related grievance forms. The Administrator expected that grievances from Resident Council meetings would be documented and processed, but acknowledged that this was not occurring and that there was no established process for handling these concerns. Specific residents reported ongoing disturbances at night due to loud TVs and staff noise, which affected their ability to sleep. Observations confirmed that noise levels were high, including loud communication from staff devices. Despite these repeated complaints and direct observations, there was no evidence that the facility took appropriate steps to address or resolve the grievances, and staff members responsible for resolving such issues were unaware of the ongoing concerns.
Failure to Provide Updated and Complete NOMNC Forms
Penalty
Summary
The facility failed to provide complete and updated Notification of Medicare Non-Coverage (NOMNC) forms to four sampled residents. For each resident, the NOMNC form used was outdated, having last been approved by CMS in 2011 rather than the most recent version. Additionally, the forms lacked required information, specifically the name and telephone contact of the appeal organization. There was also no documentation in the residents' electronic health records indicating that the residents or their representatives were given an explanation of the NOMNC form or the appeal process. Interviews with the Social Service Director revealed a lack of awareness regarding the need to update the NOMNC form and include the appeal organization's contact information. The Social Service Director stated they were responsible for issuing and explaining the NOMNC form but was unaware that the forms in use were outdated and missing required information. This deficiency was identified through both record review and staff interviews.
Failure to Provide Required Bed Hold and Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required written notices of bed hold, transfer, and discharge to residents, their representatives, and the State Ombudsman in cases of hospitalization and discharge. For three residents reviewed, documentation was missing regarding the issuance of bed hold policies and transfer/discharge notifications during hospital transfers or discharges. Specifically, one resident was hospitalized and re-admitted without any progress notes or EMR documentation indicating that a bed hold or transfer/discharge notice was offered or provided. Staff interviews revealed confusion and inconsistent practices regarding who was responsible for completing and sending these notifications, with some staff unaware of the requirement to notify the State Ombudsman for hospital transfers or unplanned discharges. Additionally, for another resident who was sent to the emergency room, there was no evidence in the EMR that the State Ombudsman was notified. In the case of a resident discharged to an adult family home, the EMR lacked documentation of notification to the State Ombudsman. Staff reported that notifications for planned discharges were sent monthly, but could not provide documentation that notifications were sent for each individual discharge as required. The facility's own policy required timely notification and documentation, but these procedures were not consistently followed.
Failure to Complete and Implement PASRR Evaluations and Recommendations
Penalty
Summary
The facility failed to ensure proper coordination and completion of the Preadmission Screening and Resident Review (PASRR) process for four out of six residents reviewed. Specifically, residents with diagnoses including depression, major depressive disorder, anxiety disorder, dementia, and borderline personality disorder were either not referred for required Level II PASRR evaluations or had recommendations from completed Level II evaluations omitted from their care plans. Documentation showed that Level I PASRR screenings indicated the need for Level II evaluations for several residents, but there was no evidence that these evaluations were completed or that the state PASRR evaluator was contacted as required. For one resident with a diagnosis of depression, the Level I PASRR indicated a need for a Level II evaluation, but no such evaluation was found in the electronic health record, and the state PASRR evaluator confirmed no referral was received. Another resident with major depressive disorder also required a Level II evaluation, but staff could not locate documentation of its completion. A third resident with dementia, anxiety disorder, and depression had an invalidated Level II PASRR and, after a repeat Level I PASRR, again required a Level II evaluation, but there was no documentation of follow-up or communication with the state evaluator. A fourth resident with depression and borderline personality disorder had a completed Level II PASRR evaluation with specific recommendations for care, including environmental modifications and trauma-informed approaches. However, none of these recommendations were incorporated into the resident's care plan, and staff were unaware of the evaluation's findings or the resident's trauma history. Interviews with staff revealed a lack of awareness and follow-through regarding PASRR requirements and care plan updates, and management was unaware of the deficiencies until informed during the survey.
Failure to Ensure Communication and Documentation for Dialysis Services
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the hemodialysis center and did not consistently complete pre- and post-dialysis assessments for two residents requiring hemodialysis services. For one resident with end stage kidney disease and diabetes, the care plan required monitoring for complications and regular dialysis attendance, but documentation revealed missing post-dialysis assessments on multiple dates and a lack of after-visit summaries from the dialysis center. Staff interviews confirmed that communication packets were inconsistently managed, and necessary documentation from the dialysis center was often not received or completed. For another resident with similar diagnoses, the care plan also required monitoring and regular dialysis, but there were no completed pre- or post-dialysis assessments for an extended period, and specific assessments were missing on additional dates. Progress notes indicated that the resident was sent to the hospital from dialysis without timely communication. Staff acknowledged gaps in documentation and communication with the dialysis center, including missing run sheets that contained critical clinical information. The facility did not have contracts with the dialysis centers providing care to these residents, and no additional documentation was provided regarding their dialysis care.
Failure to Provide Palatable and Properly Tempered Food
Penalty
Summary
Surveyors identified that the facility failed to provide appetizing and palatable food at safe and appetizing temperatures to several residents. Multiple residents reported that their meals were served lukewarm or only warm, rather than hot, and observations confirmed that plates were cool to the touch and lacked heated plate warmers. Residents described the food as overcooked, dry, or difficult to chew, with specific complaints about sausage patties, salmon, and macaroni salad. Test tray observations further revealed issues such as dry salmon, bland soup, overcooked and lukewarm asparagus, and macaroni salad with an unappealing taste. Additionally, a grievance was documented regarding a foreign object (bread tie) found in a sandwich. Resident council meeting minutes indicated that the kitchen was aware of temperature issues and was working on acquiring temperature-controlled carts, but at the time of the survey, these issues persisted. The facility administrator was unaware of the food concerns raised by residents and the lack of palatable meals. The findings were based on interviews, direct observations, and review of resident council minutes and grievances, demonstrating a pattern of inadequate food quality and temperature control for multiple residents.
Delayed Reimbursement of Resident Trust Funds After Death
Penalty
Summary
The facility failed to reimburse funds from a resident's trust account to the appropriate party within 30 days following the resident's death, as required by regulation. Record review showed that a resident who had passed away had a remaining trust account balance of $378.67, which had not been submitted to the state Office of Financial Recovery (OFR) within the required timeframe. During an interview, the Business Office Manager confirmed that the funds had not yet been submitted as required. This delay resulted in the resident's account not being reconciled within the mandated 30-day period.
Failure to Develop and Implement Individualized Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for two residents, one with dementia and one with a urinary catheter. For the resident with dementia, the care plan noted severe cognitive impairment, depression, and anxiety, and included interventions such as asking yes/no questions, cueing, and monitoring cognitive changes. A separate care plan addressed the resident's primary language, Dutch, and called for the use of Dutch-to-English signage provided by the family. However, during observation, no such signage was present in the resident's room, and staff were unaware of this intervention, indicating the care plan was not fully implemented. For the resident with a urinary catheter, the care plan documented the presence of the catheter but did not specify the clinical reason for its use, whether it was unavoidable, or the required follow-up care. Interviews with staff revealed a lack of awareness regarding the rationale for the catheter and acknowledged that the care plan was vague and incomplete. The absence of individualized and comprehensive care planning for both residents was confirmed through observation, interviews, and record review.
Failure to Follow Medication and Monitoring Protocols for Two Residents
Penalty
Summary
The facility failed to ensure that professional standards were met for two residents in relation to medication administration and monitoring. For one resident with heart failure, the facility did not document blood pressure readings as required when administering antihypertensive medication, despite provider orders specifying to hold the medication if blood pressure readings were below certain parameters. There were also periods where no blood pressure readings were documented at all, and staff interviews confirmed that the expectation was to follow the provider's orders and document the necessary parameters. Additionally, the same resident experienced constipation, and the facility did not follow its own bowel protocol. The resident went several days without a bowel movement, but the prescribed sequence of interventions—such as administering Milk of Magnesia, a glycerin suppository, and an enema—was not followed or documented. Staff interviews indicated that nurses were expected to monitor bowel movements and administer medications according to the protocol, but this did not occur. For another resident with diabetes, the facility failed to notify the medical provider when the resident's blood sugar levels exceeded the ordered parameters on multiple occasions. The resident's orders required provider notification for blood sugar levels above 400, but there was no documentation of such notifications in the medical record. Staff confirmed that they were educated to follow these parameters and document provider notifications, but this was not done in these instances.
Failure to Provide Respiratory Care per Physician Orders and Standards
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with physician's orders and accepted professional standards for two residents requiring respiratory support. For one resident with an order for oxygen at 2 liters per minute (lpm) via nasal cannula to maintain oxygen saturation above 90%, observations showed the oxygen concentrator was set at 1.5 lpm on multiple occasions. The resident reported that the prescribed setting was 2 lpm and expressed reluctance to request an adjustment. Documentation confirmed the order for 2 lpm, and the care plan reflected this intervention, but staff were unaware of the discrepancy and could not explain how oxygen saturation was being maintained as ordered. For another resident using a CPAP machine, there were no active orders in the medication administration record regarding the CPAP, including settings, maintenance, or cleaning instructions. The resident reported that staff had never cleaned the CPAP mask, and repeated observations revealed visible debris and oily substances on the mask. Staff interviews confirmed a lack of knowledge and responsibility for CPAP care, and the Director of Nursing was unable to locate any active orders or confirm proper maintenance. These findings demonstrate a failure to ensure respiratory care was provided as ordered and according to facility policy.
Failure to Follow Infection Control Protocols During Resident Care and Medication Administration
Penalty
Summary
Staff failed to comply with infection prevention and control guidelines in several instances involving residents on transmission-based precautions, during perineal care, and while administering medications. For one resident with a right lower leg fracture and ankle wound, who was on Enhanced Barrier Precautions (EBP), a nursing assistant entered and exited the resident's room without donning any personal protective equipment (PPE) despite a posted EBP sign and available PPE cart. The nursing assistant later confirmed assisting the resident with toileting without PPE, and another staff member was unclear about the PPE requirements for this resident. During perineal care for another resident, a nursing assistant did not perform hand hygiene after removing gloves and before donning new ones, instead placing contaminated hands into the glove box and continuing care. The staff member acknowledged the lapse, and the facility's infection preventionist confirmed that hand hygiene should be performed each time gloves are removed during perineal care. In medication administration, a nurse used a glucometer in a resident's room and then placed the contaminated device and supplies on the medication cart without a barrier, disinfected the glucometer but not the cart, and repeated similar actions with an insulin pen. The nurse admitted that used equipment should be considered contaminated until disinfected and that barriers should have been used under the equipment both in the resident's room and on the medication cart. The infection preventionist confirmed that these steps were required by facility policy.
Resident Rooms Below Required Square Footage Standards
Penalty
Summary
The facility failed to ensure that seven resident rooms (107, 108, 110, 302, 305, 306, and 307) met the required minimum square footage per resident, as specified by regulatory standards. Observations and record reviews confirmed that each of these rooms contained two beds, but the measured square footage for each room ranged from 142 to 154 square feet, which is below the required 160 square feet for double occupancy rooms (80 square feet per resident). The facility census confirmed that these rooms were occupied by two residents each during the survey period. Staff interviews revealed that an exemption had been requested from the state for these rooms, but it had not been granted at the time of the survey.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly filed and addressed, as evidenced by the case of a resident who experienced multiple unresolved issues. The resident, who was alert and oriented, had previously stayed at the facility and reported several grievances during their stay. These included a noisy roommate, missing personal property, and dissatisfaction with a particular nursing assistant's care. Despite the resident's complaints, these grievances were not documented in the facility's grievance logs, except for one related to handwashing. The resident expressed concerns about a roommate's loud television and encroachment on personal space, which were verbally communicated to staff but not formally recorded as grievances. Additionally, the resident reported missing a pair of plaid lounge pants, which the laundry manager acknowledged but did not document as a grievance. Furthermore, the resident requested not to have a specific nursing assistant, Staff K, provide care due to unsanitary practices. However, Staff K continued to care for the resident on two occasions after the grievance was reported, and the grievance form lacked follow-up documentation to confirm the resident's satisfaction with the resolution. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's grievances. The Director of Nursing Services was unaware of the missing item and noisy roommate issues, and the scheduler admitted to not properly reassigning Staff K despite knowing the resident's preference. The infection preventionist failed to document the resident's dissatisfaction with the resolution of their grievance. These oversights highlight the facility's failure to adhere to its grievance policy, which requires prompt resolution and follow-up with residents to ensure their concerns are addressed satisfactorily.
Failure to Honor Resident's Meal Preferences Due to Staffing
Penalty
Summary
The facility failed to honor the preferences of a resident, identified as Resident 26, regarding their Activities of Daily Living, specifically related to recreational meal intake. Resident 26, who was admitted with a stroke affecting their ability to swallow and maintain adequate nutrition, had physician orders for tube feeding to meet 100% of their nutritional needs. Despite being assessed as able to safely tolerate some oral intake with 1:1 supervision, the facility only provided this support for lunch from Monday through Friday, due to staffing limitations on weekends. This restriction was not aligned with the resident's preference to have a recreational meal every day, as they enjoyed the social aspect of the meals. Interviews with staff revealed that the scheduling practices did not account for the resident's needs on weekends. Staff G, the primary caregiver for Resident 26's meals, confirmed that the resident only received assistance during weekdays because they did not work on weekends, and no other staff were scheduled to provide this support. Staff I, responsible for scheduling, was unaware of any limitations affecting Resident 26's meal assistance. The Director of Nursing Services acknowledged the scheduling practices but did not provide further information on why the resident's meals were limited to weekdays. This oversight placed Resident 26 at risk for decreased quality of life, as their preference for daily social interaction during meals was not met.
Medication Administration During Meals
Penalty
Summary
The facility failed to ensure a homelike dining environment by allowing a registered nurse to administer medications to a resident during their meal in the dining room. This action was observed during a dining observation where Staff C, a registered nurse, gave a spoonful of crushed medications to Resident 5 while they were eating. The facility's policy stated that medications should be administered in the privacy of the resident's room or another private area, unless the resident requested otherwise. However, there was no indication that Resident 5 had requested to receive medications in the dining room. Resident 5, who was admitted with a diagnosis of dementia, had cognitive impairments and was unable to complete interview questions related to cognition. The staff assessment confirmed memory impairment and impaired decision-making. Despite this, Staff C stated that administering medications during meals was their usual practice for cognitively impaired residents, as they were more likely to take them at that time. This practice was acknowledged by Staff B, the Director of Nursing Services, who recognized the need for further education on the matter.
Deficiency in Comprehensive Resident Assessment
Penalty
Summary
The facility failed to ensure that the Resident Assessment Instrument (RAI) for a resident was comprehensive and included thorough summaries of the Care Area Assessments (CAA). Specifically, for one resident who was admitted with a fracture of the right upper leg and later admitted to hospice services, the CAA assessment did not contain a comprehensive analysis of findings. The assessment lacked the resident's goals, preferences, strengths, needs, or input from the resident or their representative. Instead, the CAA contained a brief narrative that suggested continuing to care plan to slow or minimize decline in Activities of Daily Living (ADLs). The contracted Registered Nurse responsible for completing the Minimum Data Set (MDS), including the CAA and care plans, stated that the process involved reviewing gathered information and providing a shorter description to proceed to the care plan. Despite daily telephonic meetings with the facility's Resident Care Manager and Director of Nursing Services to discuss residents, the comprehensive analysis required for the CAA was not completed. This oversight placed the resident at risk of not receiving appropriate services based on their individualized needs.
Failure to Implement Care Plan Interventions for Fall Prevention
Penalty
Summary
The facility failed to implement care plan interventions for a resident who was at high risk for falls, which placed them at risk for injury and decreased quality of life. The resident, who had a history of falls and poor trunk control, was readmitted to the facility with diagnoses including a fall, high blood pressure, and a fracture of the right upper leg. An incident report from January 2024 indicated that the resident fell out of bed due to poor trunk control, and therapy recommended using a positioning wedge with a secure strap to prevent further falls. However, during observations in July and August 2024, the resident was seen using the wedge improperly, without the strap, and stated they did not use it the previous night. The care plan for the resident, updated in January and revised in June 2024, directed staff to ensure the wedge was secured with a strap for safety. However, the treatment administration record for July 2024 did not document the use of the wedge, and staff interviews revealed a lack of awareness and understanding of the wedge's purpose and the need for the strap. The Director of Nursing Services was unaware of the resident's refusal to use the strap, and the care plan did not address the resident's poor trunk control. This deficiency was a repeat citation from October 2023.
Failure to Revise Care Plans for Discharge and Dental Services
Penalty
Summary
The facility failed to revise comprehensive care plans for two residents, leading to potential risks for unmet care needs. Resident 20, who was admitted with conditions including an above-the-knee amputation, diabetes, and high blood pressure, had a care plan that was not updated to reflect changes in their discharge planning. Despite being over-resourced and unable to move to an Assisted Living Facility as initially planned, the care plan was not revised to address these changes, although progress notes were documented in the medical record. Resident 3, admitted with diagnoses such as congestive heart failure and sleep apnea, experienced issues with their dental care plan. The resident's care plan did not reflect the absence of their upper partial dentures, which had been sent for repair before the COVID pandemic and not returned. Despite staff acknowledging the issue and working to resolve it, the care plan remained outdated, failing to address the resident's current needs for dental care and assistance with oral hygiene.
Failure to Implement Professional Standards of Practice
Penalty
Summary
The facility failed to implement professional standards of practice for two residents, leading to potential risks for adverse outcomes. Resident 26, who had a stroke affecting their ability to swallow, was prescribed a tube feeding to meet their nutritional needs and was assessed to tolerate some oral intake with specific swallow strategies. However, the care plan and Kardex did not include these strategies, and staff failed to consistently cue the resident during meals, as observed on multiple occasions. This lack of adherence to the Speech Language Pathologist's recommendations placed Resident 26 at risk for swallowing difficulties. Resident 21, diagnosed with Diabetes Mellitus Type 2, chronic pain, and high blood pressure, was prescribed Amlodipine Besylate with specific parameters to hold the medication if their systolic blood pressure was below 100 mm Hg. The Medication Administration Record (MAR) for July and August 2024 showed no documented blood pressures, indicating a failure to follow the physician's orders. Additionally, an A1C lab test ordered on 07/18/2024 was not completed until 15 days later, due to the order being placed in the wrong section of the electronic health record, which was not processed by the nursing staff. Interviews with the Director of Nursing Services and a facility consultant revealed that the transition to an electronic medical record system contributed to these errors. The blood pressure monitor was inadvertently left off the MAR, and the provider's notes were not fully integrated into the system, causing delays in processing orders. These deficiencies highlight the facility's failure to ensure professional standards of practice, as required by regulations.
Deficiency in Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living for two dependent residents, leading to a deficiency in care. Resident 30, who was admitted with a fracture of the right upper leg, required supervision or touching assistance with eating and partial/moderate assistance for oral hygiene. Despite these needs, observations revealed that Resident 30 was left unattended for extended periods, with meal trays left untouched and no assistance provided for oral hygiene. Interviews with staff indicated a lack of clarity and consistency in the care provided, with some staff believing the resident required only setup assistance, while others noted the resident's increasing dementia and need for more supervision. Resident 26, who had a history of stroke, impaired swallowing, and required a gastrostomy tube for nutrition, also did not receive adequate oral care. The care plan indicated the need for one-person assistance with oral care using glycerin swabs, but observations showed the resident's mouth was dry and coated with white matter, and the resident reported infrequent assistance with mouth swabbing. Staff interviews revealed inconsistencies in the understanding and execution of the resident's oral care needs, with some staff unaware of the specific requirements for glycerin swabs and the frequency of care needed. The facility's failure to provide necessary assistance with activities of daily living for these residents, particularly in terms of meal assistance and oral hygiene, placed them at risk for diminished quality of life. The lack of clear communication and adherence to care plans among staff contributed to the deficiency, as evidenced by the observations and interviews conducted during the survey.
Deficiencies in Resident Care and Repositioning
Penalty
Summary
The facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, specifically for two residents. Resident 21, who was at risk for pressure ulcer development due to immobility and other comorbidities, had an alternating air mattress that was not set to the prescribed settings. Despite the mattress being ordered for wound prevention, the settings were incorrectly set at 450/25 instead of the required 300/15, as indicated on the pump's sticker. This discrepancy was not identified by the staff responsible for monitoring the mattress settings, leading to a potential risk of skin breakdown. Resident 30, who was admitted to hospice services and had a fracture of the right upper leg, was not repositioned according to the facility's policy. Observations showed that Resident 30 spent extended periods in bed without assistance from staff for repositioning or care, despite requiring extensive assistance for repositioning due to impaired balance and pain. The care plan for Resident 30 did not include a specific repositioning schedule or address the positioning of the resident's heels, which could contribute to pressure-related issues. Interviews with staff revealed a lack of awareness and adherence to the required care interventions for both residents. Staff responsible for Resident 21's care were unaware of the incorrect mattress settings, and staff caring for Resident 30 did not consistently follow a repositioning schedule. These failures in care delivery placed both residents at increased risk of unmet care needs and potential skin breakdown.
Failure to Complete Annual NAC Performance Reviews
Penalty
Summary
The facility failed to ensure that annual performance reviews for Nurse Aide Certified (NAC) staff were completed, specifically for one of the four NACs whose files were reviewed. Staff K, who was hired on July 6, 2023, did not have a current employee evaluation in their file, and there was no evidence that an evaluation was completed or discussed with them. During interviews, it was revealed that the facility underwent a change in ownership on May 1, 2024, and all staff completed new hire paperwork on that date. However, there was confusion regarding whether staff should retain their original hire dates or adopt the new May 1st date, which contributed to the oversight in completing performance evaluations.
Sanitation Deficiencies in Food Handling and Storage
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and service, as observed in the kitchen, snack/nourishment refrigerators, and during meal delivery. In the kitchen, undated and expired food items were found, including a sandwich, a thickened dairy beverage, and pitchers of lemonade and iced tea. Temperature logs for the kitchen refrigerator were incomplete, and the dishwasher was not reaching the required temperature of 120 degrees Fahrenheit, initially recorded at only 100 degrees Fahrenheit. Staff interviews revealed a lack of awareness and adherence to proper food labeling and temperature monitoring protocols. In the unit nourishment refrigerator, several items were found without labels or dates, including cheese slices, oats, and muffins, along with expired ketchup and Capri Sun drinks. Staff interviews indicated confusion about responsibility for checking and discarding expired or unlabeled items. During meal delivery, desserts such as Jello were observed uncovered on trays, contrary to sanitary serving practices. These deficiencies in food handling and storage practices placed residents at risk of consuming contaminated or spoiled food.
Infection Control Deficiencies in PPE Use and Linen Handling
Penalty
Summary
The facility failed to adhere to infection prevention and control practices, specifically in the use of personal protective equipment (PPE) and the handling of oxygen (O2) tubing. For Resident 23, who was on aerosol contact precautions due to COVID-19, staff did not properly don and doff PPE. Staff S entered the resident's room wearing only an N95 respirator, unaware of the need for additional PPE such as a gown and gloves. Staff P also failed to wear the appropriate mask and improperly doffed the gown and gloves outside the resident's room, disposing of them down the hallway. Resident 3, who used oxygen therapy at night due to obstructive sleep apnea, had their O2 tubing improperly stored. The tubing was observed lying on the floor and later rolled and placed on top of the concentrator, contrary to good practice. Staff interviews revealed that the tubing should be stored in a plastic bag when not in use, but this was not consistently done, as the bags often disappeared. Additionally, the facility did not cover clean linens during transport, as observed with Staff D and Staff U carrying uncovered clothing protectors and towels through the hallways. Interviews with staff confirmed that clean linens should be covered when transported, but this practice was not followed, contributing to the risk of infection spread within the facility.
Deficiency in Nurse Aide Training Hours
Penalty
Summary
The facility failed to develop, implement, and maintain an in-service training program to ensure that Nursing Assistants Certified (NACs) received the required 12 hours of training per year. This deficiency was identified during a review of the employee file for one of the NACs, referred to as Staff K, who had only completed 6.3 hours of training instead of the mandated 12 hours. The facility's assessment indicated that training topics included communication, resident rights, abuse prevention, infection control, and culture change, but there was no documented evidence of the required training duration or start times for Staff K. During an interview, the Staff Development Coordinator acknowledged the shortfall in training hours for Staff K and mentioned efforts to ensure compliance with the 12-hour training requirement. Although the facility was able to locate the necessary training documentation for other NACs, they could not provide evidence for Staff K, indicating a lapse in maintaining comprehensive training records. This failure placed residents at risk for potential unmet care needs due to insufficiently trained staff.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that six resident rooms met the regulatory requirements for square footage, with multiple resident rooms needing at least 80 square feet per resident and single resident rooms requiring at least 100 square feet. Specifically, rooms 107, 108, 302, 305, 306, and 307 did not meet these standards. Observations and record reviews revealed that rooms 107, 302, 305, and 307 each had two beds but did not provide the required space per resident, with room sizes ranging from 142 to 154 square feet for two beds. Despite these deficiencies, surveyor observations determined that the health and safety of the residents residing in these rooms were not compromised due to the size of the rooms. This issue was noted as a repeat citation from a previous survey conducted on October 16, 2023.
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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