Marysville Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Marysville, Washington.
- Location
- 1821 Grove Street, Marysville, Washington 98270
- CMS Provider Number
- 505386
- Inspections on file
- 41
- Latest survey
- September 29, 2025
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Marysville Care Center during CMS and state inspections, most recent first.
A resident was not protected from a significant medication error, as required, due to a failure in the medication administration process.
A resident with a prosthetic heart valve and on long-term Warfarin therapy did not have a comprehensive care plan addressing anticoagulant use, including monitoring for side effects. Staff interviews confirmed the lack of a formal care plan for this medication, despite expectations that such care should be documented.
A resident's legal guardian was not provided timely access to the resident's medical records after multiple requests, due to lack of communication about required forms and fees, and confusion regarding electronic delivery. The guardian was not informed of the process or costs, resulting in delayed access to important clinical information.
A resident with multiple neurological and psychiatric diagnoses was started on Risperidone without documented consent or notification of the legal guardian. The guardian was not informed of the medication's risks and benefits, and the medication was not discontinued until several days after the guardian requested its removal. Staff and DON confirmed that the required consent process was not followed.
The facility did not conduct thorough investigations for two residents following a resident-to-resident altercation and a medication error. The investigations lacked documentation of alert charting for monitoring, staff statements, and root cause analysis, resulting in incomplete reviews of the incidents as required by state guidelines.
A facility failed to thoroughly investigate abuse allegations involving a resident with Alzheimer's, missing key elements like staff statements and root cause analysis. The investigation into a bruise and abuse allegation lacked interviews with the resident's roommate and documentation from direct care staff, social services, or law enforcement, leaving the resident at risk for unidentified abuse or neglect.
The facility failed to maintain complete and accurate medical records for several residents, including incomplete dialysis communication forms for two residents, missing consultation reports for a resident's dental visit, and inadequate documentation of oxygen orders for two residents. Staff interviews confirmed the lack of follow-up actions to obtain missing information and inconsistencies in oxygen administration documentation.
The facility failed to implement its compliance and ethics program, resulting in inaccurate documentation of therapy missed visits for several residents. Missed visit notes were falsely signed by a COTA/DOR on behalf of other staff who were not present, linked to understaffing issues. Residents affected had conditions requiring therapy, and the falsification of documentation was against facility policy.
The facility failed to address grievances for two residents, one with unresolved mattress concerns and another with missing dentures. Despite requests and discussions, issues remained unresolved due to communication breakdowns and funding difficulties, with no grievances logged.
A facility failed to comply with PASRR requirements for a resident with major depressive disorder and unspecified psychosis. Despite signs of serious mental illness and hallucinations, the resident's PASRR did not indicate a need for a level two evaluation. The Social Services Director was unaware of the resident's hallucinations, and the Director of Nursing Services acknowledged issues with inaccurate PASRRs from the hospital.
The facility failed to complete required PASRR evaluations for three residents with mental health conditions. One resident with dementia and anxiety had no Level 2 evaluation despite a positive Level 1 PASRR. Another resident with depression and panic disorder was admitted without a necessary Level 2 evaluation. A third resident with bipolar disorder and anxiety was not referred for Level 2 evaluation despite SMI indicators. Staff misunderstood the requirements, leading to non-compliance with federal guidelines.
A resident with a Stage 2 pressure ulcer, diabetes, and respiratory failure did not have a comprehensive care plan addressing their needs. The care plan lacked interventions for oxygen therapy, wound care, and diabetes management. Staff were unaware of the wound type, and the Kardex did not provide guidance on care. The Resident Care Manager was responsible for updates, but the care plan was not current, risking the resident's quality of life.
The facility failed to update care plans for three residents, leading to deficiencies in care. A resident on comfort care had an outdated care plan not reflecting their current condition. Another resident's care plan inaccurately stated they wore dentures, despite not wearing lower dentures for a year. A third resident's care plan did not reflect their current mobility status, as they could move their affected side without resistance. The facility did not meet the expectation of updating care plans quarterly and with any change of condition.
A resident with severe cognitive impairment and functional limitations was not provided with dentures before meals, as required by their care plan. The resident was observed eating without dentures, leading to difficulty chewing. Staff interviews revealed a lack of communication and oversight, resulting in the dentures not being provided in the morning as needed.
A resident with intact cognitive function reported difficulty hearing and a desire for hearing aids, but the facility failed to assist in accessing hearing services or making referrals. Despite assessments indicating hearing impairment, care plans lacked specific interventions, and staff did not facilitate access to audiology services. This oversight risked the resident's quality of life due to unaddressed hearing issues.
A facility failed to create a comprehensive dementia care plan for a resident with dementia, anxiety, and depression. The care plan lacked personalized goals and interventions, relying solely on psychotropic medications. The resident exhibited frequent agitation and yelling, which were not addressed in the care plan, leading to unmet needs and increased distress.
The facility failed to ensure two residents were free from unnecessary psychotropic medications. One resident was prescribed Divalproex Sodium for seizures without a valid diagnosis, while another was given Quetiapine without proper documentation or evaluation. The facility did not monitor for adverse effects or implement non-pharmacological interventions, and care plans lacked specific behavioral management strategies.
A resident with missing and broken teeth experienced delays in receiving dental care due to inadequate coordination and communication within the facility. Despite multiple requests and referrals, there was a lack of follow-up, leading to a delay in dental services. Staff interviews revealed issues in scheduling and documenting appointments, with the DON noting challenges in finding dentists for residents with limited mobility.
The facility failed to ensure an orderly discharge for two residents, leading to potential unmet care needs. One resident was discharged without follow-up physician care documentation, and another was discharged without proper instructions for ongoing skin care and follow-up appointments.
The facility failed to provide recommended nutritional supplements for two residents, leading to a risk of delayed wound healing. One resident with protein-calorie malnutrition and a Stage 3 pressure injury did not receive the prescribed Prosource and House Shakes. Another resident with an unstageable pressure injury and end-stage renal disease received Prosource only once daily instead of the recommended twice daily. Staff interviews revealed communication breakdowns and discrepancies in the Nutrition Assessment Recommendations.
The facility failed to ensure accurate clinical records for two residents with pressure injuries. One resident's dressing change frequency did not match the Physician Assistant's recommendation, and another resident's wound was packed with a different material than recommended. These discrepancies were acknowledged by the nursing staff but not properly documented.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Develop Comprehensive Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident who was admitted with multiple diagnoses, including a prosthetic heart valve and long-term use of anticoagulants such as Warfarin. Upon review of the resident's medication orders, it was found that there was no care plan addressing the use of Warfarin, specifically regarding potential adverse side effects or necessary monitoring associated with the medication. Interviews with facility staff revealed that while Certified Nursing Assistants relied on the Kardex to identify residents on blood thinners and monitor for signs of bleeding or bruising, there was no formal care plan in place for this resident's anticoagulant therapy. The Nurse Manager confirmed the absence of a care plan for Warfarin use, and the Director of Nursing stated that such medications should be care planned, but this was not reflected in the resident's documentation at the time of review.
Failure to Timely Provide Medical Records to Legal Representative
Penalty
Summary
The facility failed to provide a resident's medical record to the legal representative in a timely manner, as required by facility policy and federal regulation. The legal guardian of a resident with multiple complex diagnoses, including intracranial hemorrhage, cerebral infarction, hemiplegia, bipolar disorder, depression, and anxiety, requested a copy of the resident's medical record during a care conference and through subsequent emails. Despite these requests, the guardian was not informed at the time of the initial request that a specific form needed to be completed, nor were they notified of any associated fees. The guardian made multiple attempts to obtain the records, both in person and via email, but did not receive the requested information within the required timeframe. Facility staff interviews confirmed that the process for requesting records required a form, but this was not communicated to the guardian at the time of the request. Additionally, staff did not inform the guardian of the potential fees for obtaining the records, and there was confusion regarding the ability to send records electronically. The medical records director acknowledged responsibility for processing such requests but did not provide the necessary information about fees or electronic delivery options. As a result, the legal representative was unable to access the resident's clinical information in a timely manner.
Failure to Obtain Guardian Consent for Psychotropic Medication
Penalty
Summary
The facility failed to review the risks and benefits of a newly prescribed psychotropic medication with the legal representative of a resident who had a legal guardian. The resident, who had a history of intracranial hemorrhage, cerebral infarction, hemiplegia, hemiparesis, bipolar disorder, depression, and anxiety, was started on Risperidone without documented consent or evidence that the guardian was informed of the medication's risks and benefits. The guardian reported not being notified of the new medication order and did not provide consent for its use. During a care conference, the guardian requested discontinuation of the medication, but it was not stopped until eleven days later. Record review confirmed that there was no documentation of the guardian being notified or consenting to the use of Risperidone. Staff interviews revealed that the facility's expectation was to obtain consent from the resident's legal representative prior to administering psychotropic medications, but this process was not followed in this case. The Director of Nursing acknowledged that the required consent form was not signed by the guardian and that the medication was not discontinued promptly after the guardian's request.
Failure to Conduct Thorough Investigations of Incidents and Medication Error
Penalty
Summary
The facility failed to conduct thorough investigations for two residents involved in separate incidents, including a resident-to-resident altercation and a medication error. For the altercation, the investigation did not document that both residents were placed on alert charting for monitoring after the incident, despite facility protocol and staff statements indicating this should have occurred. Additionally, the investigation lacked comprehensive details regarding the circumstances and actions taken immediately following the event. In the case of the medication error, the investigation for one resident did not include staff statements or a root cause analysis to determine how abuse or neglect was ruled out. The resident involved had significant medical conditions, including intracranial hemorrhage, cerebral infarction, hemiplegia, and a legal guardian responsible for their care. The investigation also failed to document the process for discontinuing a medication as requested by the responsible party, and the medication was not discontinued in a timely manner. These omissions resulted in incomplete investigations that did not meet the requirements outlined in state guidelines.
Incomplete Investigation of Abuse Allegations
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse and neglect concerning a resident with severe cognitive impairment, diagnosed with Alzheimer's Disease. The investigation into an abuse allegation dated 01/29/2025 and a bruise found on 02/02/2025 was incomplete, lacking essential information such as staff statements, a root cause analysis, and interviews with the resident's roommate. The facility's investigation did not adequately determine how abuse or neglect was ruled out, and there was no documentation of staff in-service or statements from direct care staff, social services, or law enforcement. During interviews, facility staff acknowledged the shortcomings in the investigation process. Staff A, the Administrator, admitted to not interviewing the resident's roommate and failing to retain staff statements or in-service documentation. Staff B, the Director of Nursing, noted that the bruise was unwitnessed and not considered significant, which led to a less extensive investigation. The facility's failure to follow the Washington State Reporting Guidelines for Nursing Homes resulted in an incomplete investigation, leaving the resident at risk for unidentified abuse or neglect.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, leading to deficiencies in documentation. For Resident 50 and Resident 64, both of whom were undergoing dialysis, the facility did not ensure that the pre/post dialysis communication forms were fully completed. The sections that were supposed to be filled out by the dialysis staff were left incomplete, and there was no documentation of attempts to obtain the missing information. This lack of documentation was confirmed by interviews with staff members, who acknowledged the incomplete records and the absence of follow-up actions to retrieve the necessary information. Resident 17's medical records were also found to be incomplete. After a dental appointment, there was no consultation report in the resident's records, despite the resident being started on antibiotics for a dental infection. Staff interviews revealed that there was no established process for following up with outside providers to obtain records from appointments, leading to a gap in the resident's medical documentation. For Residents 10 and 60, the facility failed to document specific oxygen orders accurately. Observations showed inconsistencies in the administration of oxygen, with no specific documentation of the liters per minute being provided. Staff interviews indicated that the oxygen orders were incomplete, lacking parameters for when to administer oxygen. The facility's policy did not require nurses to document the specific flow of oxygen given, resulting in incomplete records for these residents.
Inaccurate Documentation of Therapy Missed Visits
Penalty
Summary
The facility failed to properly implement its compliance and ethics program, leading to the submission of inaccurate and unethical documentation for therapy missed visits for eight out of ten residents reviewed. This deficiency was identified through interviews and record reviews, revealing that missed visit notes were falsely signed by Staff Z, a Certified Occupational Therapy Assistant and Director of Rehab, on behalf of other staff members who were not present or had not worked at the facility during the documented times. This practice was linked to understaffing issues within the therapy department, as noted by a Licensed Physical Therapist Assistant who expressed concern over the falsification of documentation. The residents affected by this deficiency had various medical conditions requiring therapy services, including hemiplegia, Parkinson's disease, multiple sclerosis, and muscle weakness. The missed visit documentation falsely indicated that residents were unavailable for therapy on specific dates, with notes being signed by Staff Z on behalf of other therapists who were either not scheduled to work or had not been employed at the facility for some time. Interviews with the involved staff members, including a Physical Therapist and a Licensed Physical Therapist Assistant, confirmed that they were unaware of the missed visit notes being signed in their names and had not authorized such actions. Staff Z admitted to completing the missed visit notes under the direction of corporate, citing reasons such as resident unavailability and staffing concerns. However, the reasons listed were not resident-specific, and there was no documented communication with the staff members whose names were used. The facility's policy on compliance and ethics explicitly prohibits falsification of documentation, highlighting the severity of the deficiency. The Regional Support to the Director of Rehab acknowledged the inappropriate signing of notes on behalf of other staff and indicated that education for Staff Z would be necessary moving forward.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to maintain a system to ensure resident grievances were identified, logged, and resolved in a timely manner for two residents. For Resident 1, who was admitted with diagnoses including lung cancer, malnutrition, and spinal stenosis, there was a grievance regarding the need for an air mattress to alleviate back pain. Despite multiple discussions and referrals to hospice, the issue remained unresolved, and there was no documentation of the request in the resident's progress notes. Staff members, including the Director of Nursing Services, were unaware of the ongoing concern, indicating a breakdown in communication and grievance handling. For Resident 2, who had been in the facility since 2018, there was an issue with missing lower dentures, which were reported to not fit properly, causing difficulty in chewing food. Despite a request for a dental appointment being made months earlier, the issue remained unresolved due to funding difficulties, and there was no grievance filed for the missing dentures. Staff members, including the Social Services Director, were unaware of the missing dentures, highlighting a failure in the facility's grievance process and communication system.
Failure to Comply with PASRR Requirements for Resident with Mental Health Needs
Penalty
Summary
The facility failed to ensure compliance with the Preadmission Screening and Resident Review (PASRR) requirements for a resident with a history of major depressive disorder and unspecified psychosis. The resident, identified as Resident 17, was admitted with these diagnoses, yet the PASRR dated June 17, 2020, indicated no need for a level two evaluation despite signs of serious mental illness (SMI) and management with psychotropic medication. A subsequent review of the resident's medication administration record for October 2024 showed no psychotropic medications were prescribed, and a provider note dated October 5, 2024, documented the resident experiencing hallucinations. The Social Services Director, Staff G, stated that changes in a resident's condition, such as behaviors, mood, hallucinations, and mental health status, would prompt a review of the PASRR. However, Staff G was unaware of Resident 17's hallucinations, indicating a lapse in communication and monitoring. The Director of Nursing Services, Staff B, acknowledged awareness of PASRR concerns, particularly regarding inaccurate PASRRs received from the hospital, which contributed to the oversight in Resident 17's case.
Failure to Complete PASRR Evaluations for Residents
Penalty
Summary
The facility failed to ensure the completion of the Pre-Admission Screening and Resident Review (PASRR) forms according to federal guidelines for three residents. Resident 48 was admitted with diagnoses including dementia, anxiety, and depression, and had a positive Level 1 PASRR indicating a severe, chronic disability. However, there was no documentation of an intellectual disability or a Level 2 evaluation prior to admission. Staff interviews revealed that the facility had not yet obtained a Level 2 invalidation statement and had scheduled an appointment with a PASRR evaluator to address the issue. Resident 59, admitted with depression and panic disorder, was on anti-depressant and anti-anxiety medications. The Level 1 PASRR indicated a need for a Level 2 evaluation due to mood disorder and anxiety, but no such evaluation was found in the records. Staff acknowledged the oversight and planned to follow up with the PASRR coordinator. Resident 60, with bipolar disorder, anxiety, depression, and dementia, had a PASRR form indicating a Serious Mental Illness (SMI) but no Level 2 evaluation was conducted. Staff believed the resident's stability negated the need for further evaluation, contrary to guidelines. A state PASRR evaluator confirmed the requirement for a Level 2 evaluation when SMI indicators are present.
Incomplete Care Plan for Resident with Multiple Needs
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as Resident 60, who was admitted with diagnoses including a Stage 2 pressure ulcer, diabetes, and respiratory failure. The care plan lacked specific interventions for respiratory care, as it did not include monitoring for signs of hypoxia or administering oxygen therapy, despite the resident receiving oxygen via nasal cannula. Additionally, the care plan for skin integrity did not specify the type of wound, nor did it include interventions to prevent the wound from worsening or instructions on who to notify. The diabetes care plan was also incomplete, as it did not include interventions for managing hypoglycemia or hyperglycemia. Observations and interviews revealed that staff were unaware of the specific wound type and relied on a wound care nurse for dressing changes. The Kardex, a care directive for CNAs, did not mention the resident's pressure ulcer or provide guidance on care and monitoring. Interviews with staff indicated that the responsibility for updating the care plan lay with the Resident Care Manager, who reviewed it quarterly. However, the care plan was not updated to reflect the resident's current needs, leading to a lack of consistent interventions and placing the resident at risk for diminished quality of life.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure care plans were reviewed and revised for three residents, leading to a deficiency in care. Resident 13, who was initially admitted to the facility and later readmitted from the hospital, experienced a decline in activities of daily living (ADL) abilities and was on comfort care due to kidney failure. Despite these changes, Resident 13's care plan was not updated to reflect their current condition, including their refusal to get out of bed and the absence of wounds except for a vascular condition. The care plan contained outdated and duplicated information, such as goals for mobility and risk for rehospitalization, which were not revised to match the resident's current needs. Resident 2, a long-term resident, had not been wearing their lower dentures for a year due to poor fit, yet their care plan still indicated they wore full upper and lower dentures. Interviews with staff revealed that the care plan was not updated when the resident stopped wearing the lower dentures or when they were lost. This oversight in updating the care plan did not accurately reflect the resident's current dental status, potentially affecting their oral health and nutrition. Resident 28, admitted with a stroke affecting their left side, had a care plan that did not specify the location of their contracture and included interventions for limited physical mobility. Observations showed the resident participating in activities and able to move their left arm, hand, and fingers without resistance, contradicting the care plan's assessment. The care plan was not updated to reflect the resident's current functional status, as confirmed by evaluations showing no functional limitations due to contracture. The Director of Nursing Services acknowledged the expectation for care plans to be updated quarterly and with any change of condition, which was not met in these cases.
Failure to Provide Dentures Before Meals
Penalty
Summary
The facility failed to provide dentures to a resident prior to meals, which was necessary for their ability to chew food properly. The resident, who had severe cognitive impairment and functional limitations due to hemiplegia and hemiparesis following a stroke, was observed eating breakfast without dentures on multiple occasions. The resident's care plan and Kardex indicated that dentures should be provided in the morning, but this was not done, as evidenced by the Medication Administration Record not being signed off. The resident expressed difficulty chewing food without dentures, and it was noted that their lower dentures had been broken for over a week. Staff interviews revealed that the dentures were kept in the medication room overnight and were supposed to be given to the resident in the morning. However, due to a lack of communication and oversight, the new nursing assistant was not informed of the need to provide dentures before breakfast. The LPNs acknowledged that the dentures were not provided as required, and the resident was left to eat without them, impacting their ability to chew and enjoy their meals.
Failure to Address Resident's Hearing Deficit
Penalty
Summary
The facility failed to accurately assess and provide necessary interventions for a resident's hearing deficit, which was identified during a survey. Resident 12, who had intact cognitive function, reported difficulty hearing and expressed a desire to obtain hearing aids. Despite this, the facility staff did not assist the resident in accessing hearing services or making a referral for audiology evaluation. The resident's communication challenges were evident during interactions, as the surveyor had to increase the volume of speech for the resident to hear adequately. The facility's documentation and care planning processes were inadequate in addressing the resident's hearing needs. The admission assessment noted moderately impaired hearing, yet subsequent assessments and care plans did not reflect appropriate interventions. The Care Area Assessment (CAA) for communication was incomplete, lacking documentation on the cause of hearing loss and necessary interventions, such as assisting with obtaining hearing aids or adjusting communication methods. The care plan also failed to include specific strategies to mitigate the resident's hearing difficulties, such as reducing background noise or speaking distinctly. Interviews with facility staff revealed a lack of awareness and action regarding the resident's hearing needs. Staff members acknowledged the resident's hearing impairment but did not take steps to facilitate access to hearing aids or audiology services. The MDS coordinator admitted to using prepopulated interventions without tailoring them to the resident's specific needs, resulting in a care plan that did not adequately address the resident's communication deficit. This oversight placed the resident at risk of decreased quality of life due to unaddressed hearing issues.
Failure to Develop Comprehensive Dementia Care Plan
Penalty
Summary
The facility failed to develop a comprehensive dementia care plan for Resident 48, who was diagnosed with dementia, anxiety, and depression. The care plan did not address the resident's significant mental and psychosocial needs, nor did it establish personalized and achievable goals or identify interventions to promote a person-centered environment. The only policy in place was related to staff education on dementia, and there was no documentation of a detailed assessment of the resident's dementia or effective interventions for their behaviors. Resident 48 was admitted with moderate cognitive impairment and exhibited behaviors such as agitation and yelling out, which were documented over numerous shifts. Despite these behaviors, the care plan only included the administration of psychotropic medications like Quetiapine and Risperidone, without any non-pharmacological interventions. The resident's behavior of calling out was not addressed in the care plan, and there was no evidence of a psychiatric consult as indicated in the care plan. Observations and interviews revealed that Resident 48 frequently called out because their needs were not being met, such as wanting to get up in a chair or call their daughter. The resident expressed frustration that staff did not respond to their call light, leading them to yell out instead. The lack of a comprehensive care plan and appropriate interventions for Resident 48's behaviors resulted in unmet psychosocial needs and increased distress for both the resident and their roommate.
Failure to Ensure Residents are Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 60 and Resident 48, were free from unnecessary psychotropic medications. For Resident 60, the facility did not have a valid diagnosis for the use of Divalproex Sodium, which was prescribed for seizures despite no documented history of seizures. The medication was actually being used for mood stabilization related to bipolar disorder, but this was not accurately reflected in the medical records. Additionally, there was no monitoring for adverse side effects or behaviors related to the medication, which is a requirement for psychotropic drugs. Resident 48 was admitted with multiple diagnoses, including encephalopathy and dementia with behavioral disturbances. The facility administered Quetiapine, an antipsychotic medication, without proper documentation of the specific situations or indications for its use. The medication was initially prescribed as needed for agitation but was later increased to a regular nightly dose and then to twice daily without documented justification. The facility also failed to conduct necessary evaluations, such as a PASRR Level 2 evaluation or a psychiatric consult, to assess the resident's behavioral health needs. The facility's care plan for Resident 48 lacked specific interventions for managing behaviors such as calling out and agitation, relying instead on administering psychotropic medications. Interviews with staff revealed a lack of understanding and documentation regarding the resident's behaviors and the rationale for the use of antipsychotic medications. The facility did not adequately assess or address the resident's needs, goals, and comorbid conditions, nor did it implement non-pharmacological interventions as required.
Failure to Coordinate Dental Services for Resident
Penalty
Summary
The facility failed to ensure proper coordination of dental services for a resident, identified as Resident 17, who had missing and broken teeth. This deficiency was identified through interviews and record reviews, which revealed that despite multiple requests and referrals for dental care, there was a lack of follow-up and coordination. Resident 17, who was admitted with conditions including diabetes mellitus type two and arthropathic psoriasis, expressed the need for dental care to address missing teeth and a failing filling. The dental hygienist's consultation reports from December 2023 and June 2024 indicated the resident's need for a dentist referral, yet there was a delay in scheduling and coordinating these services. The progress notes from June 2023 to October 2024 showed several instances where the resident requested dental care, but there were gaps in follow-up and communication. Although a referral was made in June 2023, and the resident was seen by a dentist in August 2024, there were missed opportunities for timely intervention. Interviews with staff revealed a lack of clear communication and documentation regarding the scheduling of dental appointments, with the unit coordinator and resident's representative playing roles in the process. The Director of Nursing Services acknowledged the difficulty in finding dentists for residents with limited mobility, highlighting a systemic issue in coordinating dental care for residents.
Failure to Ensure Orderly Discharge for Residents
Penalty
Summary
The facility failed to ensure an orderly discharge for two residents, leading to potential unmet care needs. Resident 5, who had a cognitive communication deficit, was discharged without any documentation regarding follow-up physician care. The discharge summary form for Resident 5 was left blank in sections that should have included the primary care provider's contact information and whether an appointment had been made or needed to be scheduled. This lack of information could have hindered the resident's ability to receive necessary post-discharge medical care. Similarly, Resident 2, who had a cognitive communication deficit and a pressure ulcer, was discharged without proper documentation or instructions for ongoing care. The discharge summary for Resident 2 did not include information about the treatment of their buttocks skin cellulitis or follow-up physician care. Despite having specific orders for skin care and needing follow-up for various medical conditions, the discharge summary lacked essential details such as physician names, addresses, phone numbers, and appointment information. Staff D, a Registered Nurse/Resident Care Manager, confirmed that no follow-up appointments were made for Resident 2 and that no skin care instructions were provided, further contributing to the deficiency.
Failure to Provide Recommended Nutritional Supplements
Penalty
Summary
The facility failed to provide nutritional supplements as recommended by the registered dietitian for two residents, leading to a risk of delayed wound healing. Resident 1, who was admitted with protein-calorie malnutrition, developed a Stage 3 pressure injury while in the facility. Despite the dietitian's recommendation for daily Prosource protein supplementation and No Added Sugar House Shakes three times a day, these orders were not implemented. Staff interviews revealed a communication breakdown and discrepancies in the Nutrition Assessment Recommendations, resulting in the resident not receiving the necessary supplements for wound healing. Resident 4, who had an unstageable pressure injury and end-stage renal disease requiring dialysis, was also affected by the facility's failure to follow the dietitian's recommendations. The dietitian had recommended Prosource 30 ml twice daily to aid in wound healing and meet increased nutritional needs due to dialysis. However, the resident only received Prosource once daily, as indicated by the Medication Administration Records. Staff interviews could not explain why the dietitian's recommendations were not fully implemented, highlighting a significant lapse in the facility's nutritional care processes.
Inaccurate Clinical Records for Wound Care
Penalty
Summary
The facility failed to ensure clinical records were complete and accurate for two residents reviewed for wound care. Resident 1, who developed a Stage 3 pressure injury on their right buttocks while in the facility, had a wound care recommendation from a Physician Assistant to change the dressing every seven days. However, the facility implemented a routine dressing change every three days instead. The Director of Nursing Services acknowledged the discrepancy but did not provide additional documentation to justify the deviation from the recommendation. Resident 3, who had a Stage 4 pressure injury, had a recommendation from the same Physician Assistant to use calcium alginate to fill the wound with each dressing change. Instead, the facility used Xeroform for each dressing change. The Assistant Director of Nursing Services stated that they had clarified the wound care order to continue using Xeroform but failed to document this clarification. These inaccuracies in clinical records placed residents at risk for unmet needs.
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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