Martha And Mary Health Service
Inspection history, citations, penalties and survey trends for this long-term care facility in Poulsbo, Washington.
- Location
- 19160 Front Street Northeast, Poulsbo, Washington 98370
- CMS Provider Number
- 505474
- Inspections on file
- 21
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Martha And Mary Health Service during CMS and state inspections, most recent first.
A resident who underwent spinal surgery was discharged without removal of surgical staples as ordered by the physician, and staff did not document staple removal or communicate the need for removal to the receiving facility. Staff interviews confirmed the oversight and lack of communication regarding the surgical wound care.
A resident who was dependent on staff for toileting and bed mobility was left on a bedpan overnight due to a lack of communication between shifts. The resident, who had pressure ulcers and required frequent repositioning, was not turned or assisted for an extended period, resulting in a possible deep tissue injury. Staff interviews confirmed the resident needed help to turn due to pain and weakness, and that regular repositioning was expected.
The facility failed to implement proper Enhanced Barrier Precautions (EBP) for residents with wounds and urinary catheters, as required signage was missing. Infection control practices were inconsistent, with staff not wearing gowns during high-contact activities and missing hand hygiene opportunities. Equipment like the Hoyer lift was not cleaned between uses. The facility's infection surveillance and Legionella Water Management Program were incomplete, and CPAP machines were not stored or cleaned properly, indicating significant gaps in infection prevention measures.
The facility failed to assess and document the use of bed rails for four residents, leading to potential safety risks. Despite policy requirements for assessments and informed consent, the facility did not conduct necessary evaluations for bed rail use, leaving residents unable to independently manage the rails. Staff interviews confirmed the lack of documentation and assessments, highlighting a significant oversight in resident safety and regulatory compliance.
The facility failed to use non-pharmacological interventions (NPIs) before administering PRN pain medications for four residents, leading to potential unnecessary medication use. A resident with dementia and chronic pain received oxycodone and acetaminophen without documented NPIs. Another resident with osteoporosis received Tramadol without side effect or NPI documentation. A third resident received morphine and acetaminophen without NPIs or pain scores, and a fourth resident with chronic pain had PRN oxycodone without NPIs. Staff interviews confirmed the lack of documentation and the expectation for NPI use.
The facility failed to ensure residents were free from unnecessary psychotropic medications by not completing AIMS assessments, monitoring target behaviors, or documenting non-pharmacological interventions. For example, a resident's AIMS assessments were incomplete, and there was no follow-up documentation for observed behaviors. Staff interviews revealed expectations for monitoring and documentation were not met, leading to deficiencies in managing psychotropic medication use.
The facility failed to update and accurately reflect care plans for several residents, leading to discrepancies in medication use, diagnoses, and care needs. For instance, a resident's care plan inaccurately identified medication diagnoses, while another's care plan was outdated regarding a removed PEG tube. Additionally, care plans for residents no longer requiring specific precautions or medications were not revised, as confirmed by staff.
The facility failed to meet professional standards for three residents, including incomplete documentation of oxygen administration, delayed lab tests, and unsecured medications. A resident's oxygen flow rate was not documented for six weeks, another had incomplete CPAP orders and delayed lab tests, and a medication cart was left unlocked. Additionally, a resident had medication at their bedside without a self-administration assessment.
A resident with severe cognitive impairment did not receive adequate bathing assistance, receiving only three showers over a 30-day period. The care plan required offering a bed bath if a shower was not possible, but this was not consistently done due to staff shortages and reassignments, as confirmed by the Unit Manager and DON.
The facility failed to follow professional standards for bowel management and hospice services for three residents. A resident did not receive documented non-pharmacological interventions for constipation, while another did not have bowel movements for several days without appropriate interventions. Additionally, a resident receiving hospice care lacked a current plan of care, leaving staff uncertain about the services to be provided.
A resident with pressure ulcers was found with a pressure relieving mattress set incorrectly at level 5 instead of the prescribed level 3, as per their care plan. The resident's weight had not been updated since late November, and staff interviews confirmed that mattress settings should be based on weight and checked each shift.
The facility failed to provide proper respiratory care for three residents, including inadequate documentation of oxygen administration, incomplete CPAP orders, and lack of nebulizer equipment maintenance. These deficiencies placed residents at risk for ineffective respiratory support.
The facility failed to provide accurate drug information to two residents, impacting their informed consent. One resident received Abilify, an antipsychotic, but the consent form incorrectly listed it as an antidepressant. Another resident was prescribed Nuedexta, inaccurately identified as an antipsychotic and mood stabilizer, with incorrect indications for use. Staff acknowledged these errors in drug classification and information.
A facility failed to document and assess the use of body pillows as potential restraints for a resident who was dependent on mobility and had impaired decision-making abilities. Observations showed pillows placed under the fitted sheet without proper assessment, consent, or care plan. Staff acknowledged the oversight, and the DON confirmed the lack of necessary documentation.
The facility failed to ensure accurate MDS assessments for two residents, one with a suprapubic catheter and another with mental health needs. A resident with a catheter was incorrectly documented as incontinent, while another's MDS omitted a Level 2 PASRR, crucial for identifying mental health conditions. These inaccuracies were acknowledged by the DNS and MDS staff.
A facility failed to ensure accurate PASRR assessments and timely Level II evaluations for a resident with severe cognitive impairment and multiple mental health diagnoses. The resident's Level I PASRR assessment omitted key diagnoses, and no documentation was found for a required Level II evaluation, risking inappropriate placement and delayed mental health services.
The facility failed to implement comprehensive care plans for several residents, leading to deficiencies in individualized care. A resident with sleep apnea lacked a care plan for CPAP concerns and AGP procedures. Another resident with chronic pain did not have non-pharmacological interventions in their care plan. A resident with dysphagia had an incorrect diet documented, and a resident with depression and PTSD had incomplete pain management and psychotropic medication care plans.
A facility failed to promptly notify the provider of lab results outside clinical reference ranges for a resident with severe cognitive impairment, diabetes, and heart failure. The resident's A1C test was delayed by 41 days, and the elevated result was not communicated to the provider until 34 days after it was available. Other required lab tests were also not conducted as ordered. Staff confirmed the delays and acknowledged the failure to meet the facility's policy for prompt notification.
Three staff members failed to follow CDC guidelines for PPE use when caring for COVID-19 positive residents. A CNA did not wear eye protection and did not discard their N95 respirator after care. Another CNA did not perform hand hygiene before donning a new N95 respirator. An LPN also failed to discard their N95 respirator after care. The Infection Preventionist confirmed the expectation to remove and discard PPE after each encounter.
Failure to Follow Physician Orders for Surgical Wound Care
Penalty
Summary
Facility staff failed to follow physician orders regarding the removal of surgical staples for a resident who had undergone a C2-T10 posterior spinal fusion and T4 corpectomy. The hospital's transfer orders specified that the staples should be removed three weeks postoperatively unless there were concerns about the incision, in which case the surgeon should be contacted. Review of the resident's electronic medical record showed no documentation that the staples were removed or that the surgeon was contacted regarding the incision. Additionally, when the resident was discharged to their prior living facility, there was no documentation sent regarding the presence of staples in the incision or instructions for their removal. Staff interviews confirmed that the order for staple removal was missed and that this information was not communicated to the receiving facility. This lapse was identified during record review and staff interviews, with no evidence that the required care was provided or communicated.
Failure to Provide Timely Assistance with Toileting and Bed Mobility
Penalty
Summary
The facility failed to provide necessary assistance with toileting and bed mobility for a resident who was admitted with cancer and pressure ulcers. The resident was cognitively intact but required staff assistance for bed mobility and was totally dependent for toileting. According to the care plan, the resident needed one-person assistance for bed mobility and maximum assistance with a bedpan for bowel movements. On the evening of 04/08/2025, staff placed the resident on a bedpan but did not inform the night shift that the resident was still on the bedpan. The night shift staff provided medication and assessment but were unaware of the bedpan and did not reposition the resident during their shift. The resident remained on the bedpan from approximately 9:15 PM until 7:15 AM the following morning, when staff discovered the bedpan during a wound assessment. As a result, the resident sustained a possible deep tissue injury on the left gluteal fold. Staff interviews confirmed that residents with pressure ulcers or at risk for them should be repositioned at least every two hours, and that this resident required assistance to turn due to pain and weakness. The failure to communicate and provide necessary assistance led to the resident remaining on the bedpan for an extended period, resulting in injury.
Inadequate Infection Control and Surveillance in LTC Facility
Penalty
Summary
The facility failed to implement proper Enhanced Barrier Precautions (EBP) for several residents, as evidenced by the absence of required signage indicating EBP status. Residents with conditions such as wounds and urinary catheters, who were supposed to be on EBP, did not have the necessary signage outside their rooms. This oversight was acknowledged by staff, including the Infection Preventionist and the Director of Nursing Services, who confirmed that the lack of signage did not meet facility expectations. Additionally, there was a mix-up in signage for residents who no longer required EBP, leading to further confusion. Infection control practices were not consistently followed, as observed in the care of residents with catheters. Staff failed to wear gowns during high-contact activities and missed multiple opportunities for hand hygiene. Furthermore, equipment such as the Hoyer lift was not cleaned between uses, contrary to standard precautions. Staff interviews revealed a lack of understanding and adherence to infection control protocols, indicating a need for further education and training. The facility's infection surveillance and Legionella Water Management Program were also found lacking. The antibiotic surveillance records were incomplete, missing critical information such as symptom onset dates and culture results. The Legionella program failed to identify internal areas of risk and did not have a comprehensive monitoring plan. Additionally, CPAP machines were not stored or cleaned according to policy, increasing the risk of contamination. These deficiencies highlight significant gaps in the facility's infection prevention and control measures.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to comprehensively assess residents for the use of bed rails or mobility bars, which are considered physical restraints, for four out of five residents reviewed. This deficiency was identified through observations, interviews, and record reviews. The facility's policy, revised in September 2024, mandates a full assessment and informed consent before authorizing the use of side rails. However, the facility did not adhere to this policy, as evidenced by the lack of documented assessments and informed consent for the residents involved. Resident 11, who was cognitively intact but had documented delusions, was found to have bilateral side rails for bed mobility without a comprehensive assessment or informed consent. The resident experienced a fall and hallucinations, yet no reevaluation of the necessity and safety of the bed rails was conducted. Similarly, Residents 91, 40, and 51 had bed rails installed without documented assessments or evaluations for safety, entrapment risks, or less restrictive alternatives. These residents were unable to independently release the bed rails, indicating a lack of proper assessment and consideration of their individual needs and conditions. Interviews with staff, including the Unit Manager and Director of Nursing Services, revealed that the expected documentation and assessments were not completed. Staff acknowledged the absence of necessary evaluations and the failure to meet the facility's expectations for assessing the appropriateness and safety of bed rails. Despite requests for documentation, the facility was unable to provide evidence of completed assessments for the residents involved, highlighting a significant oversight in ensuring resident safety and compliance with regulatory requirements.
Failure to Implement Non-Pharmacological Interventions Before PRN Pain Medications
Penalty
Summary
The facility failed to implement non-pharmacological interventions (NPIs) before administering as-needed (PRN) pain medications for four residents, leading to potential unnecessary medication use. Resident 78, diagnosed with dementia and chronic pain, received PRN oxycodone and acetaminophen multiple times in November and December without documentation of NPIs being attempted. The Director of Nursing Services acknowledged the lack of documentation and expressed the expectation for nursing staff to document NPIs when a resident complains of pain. Resident 355, with age-related osteoporosis and a pathological fracture, received Tramadol for pain without documentation of side effects or NPIs. The Assistant Director of Nursing Services confirmed the expectation for side effect monitoring and NPI documentation on the Treatment Administration Record. Similarly, Resident 11, who was cognitively intact, received morphine and acetaminophen without documented NPIs or pain scores, despite expressing interest in alternative pain management options. Staff interviews revealed a lack of reevaluation of pain management following the resident's discharge from hospice. Resident 24, with chronic pain and moderate cognitive impairment, had an order for PRN oxycodone without documented NPIs. Staff confirmed that NPIs should be part of pain medication orders and documented on the Medication Administration Record. The report highlights the facility's failure to document and implement NPIs, potentially leading to unnecessary medication use and inadequate pain management for the residents involved.
Deficiencies in Psychotropic Medication Management and Monitoring
Penalty
Summary
The facility failed to ensure that seven sampled residents were free from unnecessary psychotropic medications. The staff did not complete the Abnormal Involuntary Movement Scale (AIMS) assessments fully for residents using antipsychotic medications, which are crucial for determining the severity of abnormal movements. For instance, Resident 11's AIMS assessments were incomplete, missing sections where the resident was supposed to perform specific tasks. Interviews with staff revealed that the expectation was to complete the AIMS assessments fully, documenting any tasks the resident could or could not perform. Additionally, the facility did not adequately monitor and document observed target behaviors and non-pharmacological interventions for residents receiving psychotropic medications. For example, Resident 11 had documented behaviors, but there was no follow-up documentation or progress notes to address these behaviors. Staff interviews indicated that CNAs were expected to report behaviors to nurses, who would then provide interventions and document them. However, this process was not consistently followed, leading to a lack of documentation and monitoring. Furthermore, the facility failed to implement non-pharmacological interventions before administering psychotropic medications. Resident 11's records showed no documentation of such interventions, despite receiving psychotropic medication and having documented behaviors. Staff interviews confirmed that non-pharmacological interventions should have been documented, but this was not done. Similar issues were found with other residents, where target behaviors were not identified, monitored, or documented, and non-pharmacological interventions were not implemented or recorded.
Inaccurate and Outdated Care Plans in LTC Facility
Penalty
Summary
The facility failed to ensure that resident care plans were reviewed, revised, and accurately reflected the residents' care needs for six of the 25 sampled residents. Resident 73's care plan inaccurately identified the diagnosis for the use of Seroquel and did not include the specific target behaviors for the medications prescribed. Additionally, the care plan did not address the use of mirtazapine for depression, and the diagnosis for Nuedexta was incorrectly documented. Staff acknowledged these inaccuracies and omissions. Resident 99's behavior care plan was incomplete, lacking details about the psychotropic medication in use, the supporting diagnosis, and the resident-specific target behaviors. Resident 81's care plan was outdated, as it still mentioned a PEG tube that had been removed, and staff confirmed that care plans should be updated with significant changes. Resident 11's care plan was not revised after being discharged from hospice, and it still included a discontinued medication, which staff acknowledged should have been updated. Resident 91's care plan incorrectly indicated the need for enhanced barrier precautions, which was not required, and Resident 8's care plan still included aerosol contact isolation that was no longer necessary. Staff interviews confirmed that these care plans did not meet expectations and needed to be updated to reflect the current care needs and conditions of the residents.
Deficiencies in Documentation, Order Clarification, and Medication Security
Penalty
Summary
The facility failed to ensure services met professional standards of practice for three residents. For Resident 73, the facility did not document the flow rate of oxygen administered over a six-week period, despite having an order for oxygen to maintain saturation levels. The Unit Manager acknowledged that the nurses failed to document the oxygen dose and did not clarify or correct the incomplete order. Resident 51's care was compromised due to incomplete CPAP orders that lacked specific pressure settings and instructions for humidifier maintenance. Additionally, there was a delay in carrying out laboratory orders for Resident 51, as labs ordered on December 2 were not drawn until December 11. The Assistant Director of Nursing Services admitted that the delay was not in line with expectations, especially given the medication changes. The facility also failed to secure medications properly. A medication cart was left unlocked and unattended for 13 minutes, and Resident 40 had a bottle of anti-itch lotion at their bedside without a self-administration assessment. The Unit Manager and Director of Nursing Services confirmed that medications should not be left at the bedside and should be stored securely.
Failure to Provide Adequate Bathing Assistance
Penalty
Summary
The facility failed to provide adequate assistance with bathing for Resident 90, who was admitted with severe cognitive impairment and required supervision for activities of daily living (ADLs). According to the Quarterly Minimum Data Set dated 09/04/2024, Resident 90 needed assistance with ADLs. However, a review of the Point of Care documentation, the 'Shower Book,' and the 'Marina Daily Shower' sheets revealed that Resident 90 only received showers on three occasions: 11/17/2024, 12/02/2024, and 12/08/2024, over a 30-day period. The care plan for Resident 90, dated 11/29/2023, indicated an ADL self-care performance deficit and included an intervention to offer a bed bath if a shower could not be performed. Staff E, the Unit Manager/LPN, confirmed that Resident 90 did not receive a shower during the week of November 24th because the shower aide was reassigned to other duties. Staff B, the Director of Nursing Services, acknowledged that staff call-outs contributed to the issue and confirmed that a bed bath should have been offered in the absence of a shower aide.
Deficiencies in Bowel Management and Hospice Coordination
Penalty
Summary
The facility failed to implement care and services in accordance with accepted professional standards for three residents, specifically in the areas of bowel management and hospice services. For Resident 82, the facility did not document non-pharmacological interventions despite the resident not having a bowel movement for several days, as required by the facility's bowel management policy. The Assistant Director of Nursing Services (ADNS) confirmed that the expectation was for nurses to document both pharmacological and non-pharmacological interventions, which was not done in this case. Resident 11, who was dependent on staff for care and receiving opioid pain medication, did not have bowel movements for multiple days without documentation of non-pharmacological interventions or administration of as-needed medications. The Unit Manager confirmed that the bowel protocol was not followed, and there was no documentation of attempts at non-pharmacological interventions. Additionally, Resident 99, who was receiving hospice services, did not have a current hospice plan of care in their electronic health record, and staff were unsure of the hospice services the resident was to receive.
Improper Pressure Relieving Device Settings for Resident
Penalty
Summary
The facility failed to ensure that a pressure relieving device was functioning correctly for a resident with pressure ulcers. Resident 81, who was admitted with Guillain-Barre Syndrome and malnutrition, was observed multiple times lying in bed with a pressure relieving mattress set at level 5, contrary to the care plan which specified a setting of level 3 due to the resident's weight of 107 pounds. The care plan, revised in October 2023, directed that the air mattress should be set at level 3 and checked for proper functioning each shift. Staff interviews revealed that the air mattress settings were based on the resident's weight and should be monitored for accuracy each shift. However, the resident's weight had not been updated since November 29, 2024, and the mattress was incorrectly set at level 5. The Assistant Director of Nursing Services confirmed that the mattress should have been set at level 3 for maximum effectiveness and noted that the setting should be recorded on the Treatment Administration Record for monitoring by nurses each shift.
Deficiencies in Respiratory Care Documentation and Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory care in accordance with accepted professional standards for three residents. Resident 73, who had severe cognitive impairment and heart failure, was observed receiving oxygen via nasal cannula. However, the facility did not document the amount of oxygen administered, nor did they include instructions to check and replace the humidifier bottle or clean the oxygen concentrator's external filter weekly, as per facility policy. This lack of documentation and adherence to policy placed the resident at risk for ineffective assisted ventilation. Resident 51, with severe cognitive impairment and obstructive sleep apnea, required CPAP therapy. The facility's orders for CPAP did not include the prescribed pressure settings, nor did they instruct staff to check and refill the humidifier chamber with distilled water or disinfect it weekly. This omission in the CPAP orders could lead to improper use of the device and inadequate respiratory support for the resident. Resident 81, who was moderately cognitively impaired and had respiratory failure, was observed with a nebulizer machine. The care plan did not include treatments via the nebulizer or care of the associated equipment. The MARs lacked documentation for lung sounds or cleaning of the equipment, and there were no directions on how to clean, replace, or store the equipment. This oversight in documentation and care planning could compromise the resident's respiratory health.
Inaccurate Drug Information Provided to Residents
Penalty
Summary
The facility failed to provide accurate information regarding the risks and benefits of proposed drug therapies for two residents, impacting their ability to make informed decisions. Resident 11, who was diagnosed with depression and PTSD, was receiving Abilify, an antipsychotic medication. However, the consent form incorrectly listed Abilify as an antidepressant. Interviews with staff revealed that the consent process did not accurately reflect the drug class and associated risks, which should have been communicated as antipsychotic rather than antidepressant. Resident 73, who was cognitively impaired and diagnosed with anxiety, depression, and agitation, was prescribed Nuedexta for pseudobulbar affect. The consent form inaccurately identified Nuedexta as an antipsychotic and mood stabilizer, with incorrect indications for use such as calling out, yelling, and dementia with behaviors. Staff acknowledged that the resident was provided with inaccurate drug information, including the drug class, indications for use, and potential adverse side effects.
Failure to Document and Assess Use of Potential Restraints
Penalty
Summary
The facility failed to obtain an assessment, orders, consent, and develop a care plan for the use of potential restraints for Resident 91, who was reviewed for physical restraints. Resident 91 was readmitted to the facility and was noted to be dependent on mobility, rarely/never understood, and moderately impaired for daily decision-making. Observations revealed that body pillows were placed on both sides of Resident 91's bed under the fitted sheet, without any documentation in the Electronic Health Record regarding an assessment, consent, orders, or care plan for the use of these pillows. Staff interviews indicated that the pillows were placed to prevent Resident 91 from falling out of bed, as the resident moved back and forth and could turn themselves. Staff acknowledged that the pillows should not have been placed under the fitted sheet and that necessary documentation and assessments were lacking. The Unit Manager and Director of Nursing Services confirmed that an assessment, consent, orders, and a care plan should have been completed for the use of body pillows, but these steps were not taken.
Inaccurate MDS Assessments for Residents with Catheter and Mental Health Needs
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, which placed them at risk for unmet care needs. Resident 54, who had a suprapubic catheter due to urinary retention and neuromuscular dysfunction of the bladder, was inaccurately documented as always incontinent on their Annual MDS. The correct option, indicating the presence of a catheter, was not selected. This discrepancy was acknowledged by the Director of Nursing Services (DNS) and the MDS nurse, who confirmed that continence should be coded as 'not rated' when a resident has a urinary catheter for the entire assessment period. Resident 11, diagnosed with depression, anxiety, and post-traumatic stress disorder, was also affected by an inaccurate MDS assessment. The Significant Change MDS failed to document the resident's Level 2 Preadmission Screening and Resident Review (PASRR), which is crucial for identifying serious mental illness or intellectual disability. The MDS Manager acknowledged the error, noting that the Level 2 PASRR should have been included. The DNS confirmed that the omission did not meet the facility's expectations.
Inaccurate PASRR Assessment and Lack of Level II Evaluation
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening and Resident Review (PASRR) assessment accurately reflected a resident's mental health diagnoses and that Level II PASRR evaluations were timely referred and completed. Specifically, for one resident, the Level I PASRR assessment documented only an anxiety disorder and did not include the resident's depressive disorder or dementia with behaviors/agitation diagnoses. This oversight necessitated a referral for a Level II PASRR evaluation, which was not documented as completed in the resident's electronic health record. The resident in question was admitted to the facility with severe cognitive impairment and had diagnoses of non-Alzheimer's dementia with agitation, anxiety, and depressive disorders. A mental health evaluation confirmed these active diagnoses. However, the Level I PASRR assessment was inaccurate, and no documentation was provided to show that a Level II PASRR evaluation referral was made or completed. This failure placed the resident at risk for inappropriate placement and not receiving timely and necessary mental health services.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to review, revise, and implement comprehensive care plans for five residents, leading to deficiencies in individualized care. Resident 59, who was admitted with sleep apnea, had a care plan that did not include information on how to contact the vendor or pulmonologist for CPAP concerns. Additionally, the care plan lacked details about aerosol-generating procedures (AGP) related to CPAP use. Resident 51, also on CPAP, did not have an AGP care plan. Resident 78, admitted with chronic pain, had a care plan that did not include non-pharmacological interventions tailored to the resident's needs. Resident 91, who had dysphagia and protein-calorie malnutrition, had a care plan that did not reflect the correct diet and lacked specific information for social and sensory stimulation activities. The care plan inaccurately documented the resident's diet as general, regular texture thin fluids, which did not align with the physician's orders for a dysphagia ground texture diet. Resident 11, diagnosed with depression and PTSD, had a pain management care plan that did not include narcotic usage or non-pharmacological interventions. The psychotropic medication care plan also lacked non-pharmacological interventions. These omissions in the care plans resulted in a failure to provide appropriate and individualized care for the residents, as the plans did not accurately reflect their assessed needs or provide clear direction to staff.
Failure to Promptly Notify Provider of Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering provider of laboratory results that fell outside of clinical reference ranges for Resident 73, who was reviewed for unnecessary medications. Resident 73, who had severe cognitive impairment and diagnoses of diabetes and heart failure, was on medications including metformin and spironolactone. A provider note indicated that Resident 73 had elevated blood glucose levels and required an A1C test, among other lab tests, to be conducted as part of a three-month blood draw. However, the A1C test was delayed by 41 days, and the elevated result was not communicated to the provider until 34 days after it was available. Additionally, other lab tests that were ordered to be drawn every three months, such as TSH, B12, vitamin D, BNP, CBC, and CMP, had not been conducted as of the date of the report. Staff members, including the Unit Manager and Assistant Director of Nursing Services, confirmed the delays and acknowledged that the notification of the provider did not meet the facility's policy for prompt notification. This failure placed residents at risk for delayed treatment and potential negative outcomes.
Failure to Adhere to PPE Protocols for COVID-19 Positive Residents
Penalty
Summary
The facility failed to ensure that three staff members adhered to CDC guidelines for using personal protective equipment (PPE) when caring for residents with confirmed COVID-19 infections. Staff A, a Certified Nursing Assistant (CNA), entered the room of a COVID-19 positive resident wearing a N95 respirator, gown, and gloves but without eye protection. After providing care, Staff A removed their gown and gloves, performed hand hygiene, but did not remove or discard the N95 respirator before exiting the room and continued to interact with other residents. Similarly, Staff B, another CNA, entered the same resident's room with appropriate PPE, but after exiting, they failed to perform hand hygiene before donning a new N95 respirator. Staff C, a Licensed Practical Nurse (LPN), also failed to remove and discard their N95 respirator after caring for a different COVID-19 positive resident, exiting the room and proceeding down the hallway. The Infection Preventionist confirmed that both residents were on isolation due to their COVID-19 positive status and that staff were expected to remove and discard PPE, including N95 respirators, after each care encounter. The failure to follow these protocols placed both residents and staff at risk of contracting and spreading COVID-19.
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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